- Email: [email protected]
Violence Exposure, Posttraumatic Stress, and Personality in Juvenile Delinquents
Violence Exposure, Posttraumatic Stress, and Personality in Juvenile Delinquents VLADISLAV V. RUCHKIN, M.D., PH.D., MARY SCHWAB-STONE, M.D., ROMAN KOPOSOV, M.D., ROBERT VERMEIREN, M.D., AND HANS STEINER, M.D. ABSTRACT Objective: To assess posttraumatic stress and its relationship to comorbid psychopathology, violence exposure, and personality traits in Russian male juvenile delinquents. Method: Posttraumatic stress and comorbid psychopathology were assessed by a semistructured psychiatric interview (Schedule for Affective Disorders and Schizophrenia for SchoolAge Children-Present and Lifetime Version) in 370 delinquent youths during winter-spring of 1999. In addition, violence exposure, personality, and psychopathology were assessed by self-reports. Results: Most delinquents reported some degree of posttraumatic stress: 156 subjects (42%) fulfilled partial criteria and 87 (25%) fulfilled full DSM-IV criteria for posttraumatic stress disorder (PTSD). Violence-related experiences (witnessing and victimization) were the most common types of trauma. Higher levels of posttraumatic stress were accompanied by higher rates of comorbid psychopathology, with the most striking differences occurring between the groups with full versus partial PTSD criteria. Violence exposure was related to temperamental behavior activation (novelty seeking), whereas PTSD symptom scores were predominantly related to behavior inhibition and poor coping (high harm avoidance and low self-directedness). Conclusions: Similar to findings from American samples, Russian juvenile delinquents represent a severely traumatized population, mainly due to high levels of violence exposure. Those with full PTSD are the most severely traumatized and have highest rates of psychopathology, as compared to those with no or partial PTSD, and they require the most clinical attention and rehabilitation. Both exposure to violence and levels of posttraumatic stress are related to personality traits, which influence degree of exposure and individual perception of stress. The latter should be considered in individualized approaches to rehabilitation. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(3):322–329. Key Words: delinquents, full and partial posttraumatic stress disorder, psychopathology, personality.
Research conducted over the past 20 years has demonstrated that a broad range of experiences, both natural and manmade, can have detrimental effects on children’s mental health. Traumatization in general tends to have cumulative effects (Breslau and Davis, 1987), often leading to a wide range of comorbid conditions (Breslau et al., 1991; Hubbard et al., 1995), with varying degrees of symptom Accepted September 17, 2001. Drs. Ruchkin and Schwab-Stone are with the Child Study Center, Yale University School of Medicine, New Haven, CT. Drs. Ruchkin and Koposov are also with the Institute of Psychiatry, Northern State Medical University, Arkhangelsk, Russia. Dr. Vermeiren is with the Middelheimhospital, University of Antwerp, Belgium. Dr. Steiner is with the Division of Child Psychiatry and Child Development, Stanford University School of Medicine, Stanford, CA. Supported in part by the CIES Fulbright grant 24142 to Dr. Ruchkin. The authors thank Donald J. Cohen, M.D., for his support and his comments on the manuscript. Correspondence to Dr. Ruchkin, Yale Child Study Center, 230 South Frontage Road, New Haven, CT 06520-7900; e-mail: [email protected]. 0890-8567/02/4103–0322䉷2002 by the American Academy of Child and Adolescent Psychiatry.
322
severity. There is also ongoing discussion about whether posttraumatic stress disorder (PTSD) symptoms occur on a continuum of frequency and severity, with “full” criteria representing an arbitrary cutoff point rather than a clinically meaningful dividing point (American Academy of Child and Adolescent Psychiatry, 1998; Terr, 1991). Given the same traumatic event, some people will be more likely to develop posttraumatic stress disorder than others and, conversely, certain individuals will be more likely than others to develop PTSD in different contexts (Breslau et al., 1998). Trauma response usually correlates with the degree of exposure, measured by both physical and emotional proximity (Pfefferbaum, 1997), and is modulated by premorbid personality traits (Schnur et al., 1993), which determine the individual’s perception of traumatic events and thus influence the severity of posttraumatic stress symptoms (Yehuda and McFarlane, 1995). Due to increased exploratory activity (novelty seeking), some people may experience higher levels of exposure to J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
potentially stressful situations (e.g., exposure to violence), as well as be prone to delinquent and other types of sensation-seeking behavior. At the same time, the magnitude of posttraumatic stress and other types of internalizing psychopathology appears to be related to the personality trait of behavioral inhibition (harm avoidance) (Cloninger et al., 1994; Ruchkin et al., 1998a,b). Recent research has documented that juvenile delinquents represent a highly traumatized group, with rates of posttraumatic stress approaching 30% (Carrion and Steiner, 2000; Cauffman et al., 1998; Steiner et al., 1997). Most report exposure to events, such as abuse and neglect, violence exposure, and sexual molestation (Steiner et al., 1997); some studies suggest that traumatization is a predisposing factor for the development of delinquent behavior (Finkelhor and Dziuba-Leatherman, 1994; Widom, 1989). Thus trauma is relevant to the study of delinquency for at least three reasons (Steiner et al., 1997). First, since child maltreatment is related to both posttraumatic stress and delinquency, these outcomes may co-occur. Second, fuller examination of the relationship between trauma and conduct disorder may lead to a better understanding of the interplay between PTSD and personality functions. Third, clarifying relationships between PTSD and delinquency may suggest the potential role of preexisting psychopathology and vulnerability for PTSD. On the basis of these findings, we hypothesized that incarcerated juvenile delinquents will have high rates of posttraumatic stress due to frequent past traumatization (Steiner et al., 1997). Delinquents with higher rates of PTSD symptomatology will have higher rates of violence exposure and comorbid psychopathology and will differ from other groups on personality dimensions. In particular, those with high behavior activation (high novelty seeking) will be exposed to more violence, which in turn will be related to higher rates of psychopathology. However, the development of psychopathological manifestations will be particularly related to high behavioral inhibition, low personal efficacy, and poor coping skills (high harm avoidance and low self-directedness). Finally, the severity of comorbid psychopathology will be largely determined by the severity of PTSD symptoms. METHOD Participants The study was approved by the institutional review board of the Northern State Medical University (Arkhangelsk, Russia). The delin-
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
quent subjects were recruited voluntarily from the approximately 300 male adolescents who were inmates in the only juvenile detention center in the Arkhangelsk region of Northern Russia, a catchment area with a population of 1.5 million. The population of the region is homogenous ethnically, i.e., 98% Ethnic Slavs. All delinquents were referred to this institution by court decision. Most delinquents had multiple convictions, which included property crimes (theft, car theft, etc.: 51%), violence-related crimes (e.g., fighting, robbery: 38%), and in some cases, rape/sexual violence (6%) or murder (5%). Generally, those institutionalized for theft had shown a repetitive pattern of stealing, with multiple convictions and referral to this facility occurring only after committing theft during parole. The mean length of sentence at the time of the study was 4.3 years. Age of the participants ranged from 14 to 19 years (mean = 16.4, SD = 0.9). Classical measures of socioeconomic status such as the HollingsheadRedlich 2-factor index cannot be used in Russia currently, as the country is in economic upheaval, and it is questionable whether the HR 2F would apply. In general, most subjects came from impoverished economic backgrounds with unemployed parents, debts, and financial distress; however, this is common given the current economic situation in Russia, where a large part of the population have incomes that barely cover the costs of food. All participants were informed about the voluntary and confidential nature of their participation. They were further assured that the institutional staff would not obtain any individualized information about their responses. In classroom settings, all potential participants were provided with detailed descriptive information about the study. Questions that arose were answered in detail. Eight subjects refused to participate because of unwillingness to provide any personal information. Posttraumatic stress and psychopathology were assessed through a semistructured psychiatric interview, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), which was conducted with 370 delinquent youths. Interviewers, who administered the K-SADS, were blind to the results of self-report measures. During the study some youths were released, whereas others entered the facility; thus the interviewed group appears to be larger than the total population of the institution at any one time. A subsample of 289 subjects also completed a set of self-reports. There were no age/psychopathology rates differences between the groups. Instruments Combined Psychiatric Diagnoses. The K-SADS-PL, a widely used semistructured psychiatric interview that has high interrater diagnostic reliability and was validated in extensive testing (Kaufman et al., 1997), was used to yield current and past diagnoses. To assign a psychiatric diagnosis, clinically significant, diagnosis-specific impairment had to be present. The interview was conducted by two psychiatrists who were blind to the results of self-reports. The interviewers received standard K-SADS training from the author of the instrument and determined the presence of diagnoses according to DSM-IV criteria (American Psychiatric Association, 1994). Semistructured Clinical Interview for PTSD. The PTSD module of the K-SADS-PL was administered. This module consists of a list of potentially traumatic events; if there is evidence of past trauma, 5 PTSD screen items are asked. When any are answered affirmatively, 14 additional items inquire about reexperiencing, persistent avoidance, and increased arousal, as well as functional impairment. To avoid overdiagnosing the subjects with regard to PTSD, conservative criteria were applied. Those receiving two or fewer threshold ratings on the screen interview were considered as the no PTSD group. Those who had at
323
RUCHKIN ET AL.
least three threshold ratings, but who did not fulfill full DSM-IV criteria for PTSD, were considered as the partial PTSD group. Measures of Psychopathology and Violence Exposure. In addition to the K-SADS-PL, several rating scales of psychopathology were administered. They included the Child Posttraumatic Stress Reaction Index (CPTS-RI) (Frederick, 1985; Pynoos et al., 1987), a 20-item scale designed to assess posttraumatic stress reactions of school-age children and adolescents that has been used in previous studies of Russian youths (Ruchkin et al., 1998b) (in the present study Cronbach α = .81), and the Youth Self-Report (Achenbach, 1991), a 112-item self-report questionnaire assessing internalizing (e.g., anxiety, depression) and externalizing (e.g., aggression, delinquent behavior) symptomatology, which was previously validated in a Russian general population sample (Carter et al., 1995) (in the present study Cronbach α ranged from .60 for Social Problems to .89 for Externalizing and Internalizing Problems). Witnessing and victimization were assessed by a slightly modified version of the Survey of Exposure to Community Violence (Richters and Martinez, 1993), which asks respondents whether they had witnessed or been victimized by eight types of violence (e.g., seen somebody/was beaten up or mugged, threatened with serious physical harm, etc). In the present sample Cronbach α was .65 for Victimization and .76 for Witnessing. Temperament and Character Inventory. The Temperament and Character Inventory (TCI) (Cloninger et al., 1994), based on Cloninger’s unified biosocial theory of personality (Cloninger, 1987), measures four temperament and three character dimensions. According to Cloninger’s theory, temperament dimensions are independent and largely genetically determined (Cloninger et al., 1994). Two scales for temperament related to the study hypothesis are used in the current study (harm avoidance and novelty seeking). Harm avoidance reflects a heritable bias in the inhibition or cessation of behaviors. Subjects who score high on harm avoidance are pessimistic, chronically worried, shy with strangers, and tense in unfamiliar situations. Novelty seeking is viewed as a tendency toward behavior activation in response to novel stimuli or cues. Subjects who score high on novelty seeking show high levels of exploratory behavior, impulsive decision-making, quick loss of temper, and active avoidance of frustration. Character is the second domain of personality, which is predominantly determined by socialization processes during the lifespan (Cloninger et al., 1994). It is described in terms of response biases related to different self-concepts, changing during the process of personal, social, moral and spiritual development. Self-directedness is related to the extent to which a person identifies the self as autonomous. An individual with a low level of self-directedness can be described as immature, unreliable, blaming, and inert, with poor coping skills and impulse control. Cooperativeness is related to the extent to which a person identifies himself or herself as an integral part of society. Those with low levels of cooperativeness are characterized as hostile, aggressive, and vengeful individuals, with deficits in empathy. Selftranscendence reflects the tendency to identify with the unity of all things. Individuals with a high level of self-transcendence find comfort in spiritual experiences and beliefs in supernatural power and often have magical thinking. Cloninger’s theory of personality and the TCI have been used and validated with adolescents, both in the United States (e.g., Wills et al., 1998) and other cultures (e.g., Kijima et al., 2000; Maggini et al., 2000), including Russia (Ruchkin et al., 1998a,c). In the present study, we used the short version of the TCI, with 125 items to be answered as true or false. Cronbach α values were .60 for novelty seeking, .67 for harm avoidance, .68 for self-directedness, .64 for cooperativeness, and .75 for self-transcendence (further psychometric data are available from the corresponding author [V.V.R.]).
324
Translation Translation of these scales into Russian followed established guidelines, including appropriate use of independent back-translations (Sartorius and Kuyken, 1994). Russian translations made by the first author (V.V.R.) were followed by discussion with monolingual colleagues. Finally, an official interpreter made independent backtranslations. The versions obtained were compared with originals, and inconsistencies were analyzed and corrected. The translation of the K-SADS-PL was made at the Department of Psychology, Moscow State University, following the above-mentioned procedure. Data Analysis The data were analyzed with the Statistical Package for Social Sciences (SPSS-10.0). Chi-square and analyses of variance (one-way ANOVA and UniANOVA) tests were used as appropriate to examine differences between the PTSD, partial PTSD and full PTSD subgroups. Pearson product-moment correlation and partial correlation coefficients were calculated between violence exposure scores and selfreported psychopathology and personality dimensions.
RESULTS Posttraumatic Stress: Interview Results
Of the 370 interviewed subjects, 19 did not report any traumatic events, 351 (96%) reported at least one potentially traumatic event, and, by definition, all of the PTSD positive youths reported such an event. Furthermore, 303 participants (82.3%) reported multiple events. The five most commonly reported events included witnessing domestic violence (240 subjects, 65%), confronting traumatic news (215 subjects, 58%), witnessing a violent crime (185 subjects, 50%), physical abuse (170 subjects, 46%), and being a victim of a violent crime (117 subjects, 32%). Only 8 participants reported sexual abuse. However, many of the inmates hold victims of sexual abuse in very low regard (Ruchkin et al., 1998b), thus potentially influencing willingness to report such events. For the 351 subject who reported at least one traumatic event, the rates of PTSD were as follows: 118 subjects (33.6%) reported no symptoms of PTSD; 146 (41.6%) fulfilled partial PTSD criteria; and 87 subjects (24.8%) fulfilled full criteria for PTSD. Other Types of Psychopathology
Table 1 shows the prevalence of the seven most common comorbid psychiatric diagnoses in the no PTSD, partial PTSD and full PTSD groups. The full PTSD group revealed significantly higher rates of most diagnoses than the two other groups. The partial PTSD group differed significantly from the no PTSD group only in rates of major depressive disorder and generalized anxiJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
TABLE 1 Prevalence of Comorbid Diagnoses in Delinquents With No PTSD, Partial PTSD, and Full PTSD Other Diagnosis
No PTSD
Major depression ab Separation anxiety bc General anxiety abc Past ADHD bc Conduct disorder b Alcohol abuse bc Drug abuse bc
4 5 4 12 80 60 25
(3.4) (4.2) (3.4) (10.2) (67.8) (50.8) (21.2)
Partial PTSD 17 10 18 17 107 77 34
Full PTSD
(11.6) (6.8) (12.3) (11.6) (73.3) (52.7) (23.3)
14 17 20 21 72 59 34
χ2 ( p)
Total
(16.1) (19.5) (23.0) (24.1) (82.8) (67.8) (39.1)
35 32 42 50 259 196 93
(10.0) (9.1) (12.0) (14.2) (73.8) (55.8) (26.5)
9.8 15.7 18.3 9.4 5.8 6.8 9.4
(.008) (.000) (.000) (.009) (.054) (.033) (.009)
Note: Values represent number (percent). In addition to all-groups comparisons, intergroup differences in the rates of diagnoses were assessed by separate analyses (2 ⫻ 2). The results of these calculations are shown by superscript letters: a significant difference between No PTSD and Partial PTSD; b significant difference between No PTSD and Full PTSD; c significant difference between Partial PTSD and Full PTSD. PTSD = posttraumatic stress disorder; ADHD = attention-deficit/hyperactivity disorder.
ety disorder. We found it particularly interesting that the full PTSD group also differed from the other groups in rates of retrospectively established diagnoses of separation anxiety disorder and past attention-deficit/hyperactivity disorder (no current diagnosis). Finally, using the rates of the seven most common diagnoses, a cumulative coefficient for psychopathology was created (no other diagnosis, one to two diagnoses, and three or more diagnoses). The full PTSD group revealed the highest rates of comorbid psychopathology (Table 2). On the self-report measures (289 subjects) most participants revealed mild to moderate levels of posttraumatic stress (measured by the CPTS-RI, scores from 12 to 39), and 52 subjects suffered from severe and very severe stress (scoring above 40; cut-off scores suggested by the original studies on the CPTS-RI, e.g., 22). The scores of CPTS-RI in this delinquent population were higher than those reported in the general youth population in this part of Russia (26.29 ± 13.39 in delinquents versus 18.09 ± 7.87 in the general population, F = 64.05, p < .001; general population results from Ruchkin et al., unpublished data, 1999). Levels of problem scores increased along with the level of PTSD. Participants with full PTSD reported higher rates of both internalizing and externalizing problems (Table 3) as compared with the other groups. In spite of the general tendency for problem scores
to increase with level of PTSD, most differences were obtained either between full and partial PTSD groups or between full and no PTSD groups. There were no significant differences between no PTSD and partial PTSD groups on any of problem scores. PTSD, Violence Exposure, and Personality
Violence exposure scores increased along with PTSD severity. There was also an increase in harm avoidance and self-transcendence and a decrease in self-directedness from the no PTSD to the full PTSD group (Table 3). Violence Exposure in Relation to Personality and Psychopathology
Because the level of posttraumatic stress may bias reporting and lead to reports of greater violence exposure, or distorted reports on personality, the CPTS-RI score was partialled out from the correlations between personality and violence exposure. Both witnessing and victimization appeared to be positively related to novelty seeking (r = 0.18, p < .01 and r = 0.14, p < .05, respectively) and negatively related to cooperativeness (r = –0.18, p < .01 and r = –0.19, p < .001, respectively). On the other hand, we were also interested in whether personality factors would still differ by PTSD group even after effects of violence exposure were controlled. In a
TABLE 2 Number of Comorbid Diagnoses in Delinquents With No PTSD, Partial PTSD, and Full PTSD No. of Other Diagnoses
No PTSD (n = 118)
Partial PTSD (n = 146)
Full PTSD (n = 87)
Total
0 1–2 3+
21 (17.8) 74 (62.7) 23 (19.5)
14 (9.6) 91 (62.3) 41 (28.1)
— 18 (20.7) 69 (79.3)
35 (10.0) 183 (52.1) 133 (37.9)
Note: Values represent number (percent). χ2 = 91.5 ( p = .000). PTSD = posttraumatic stress disorder.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
325
RUCHKIN ET AL.
TABLE 3 Violence Exposure, Problem Scores, and Personality Characteristics in Delinquents With No PTSD, Partial PTSD, and Full PTSD (One-Way Analysis of Variance) Variables
No PTSD
Partial PTSD
Full PTSD
Fdf , p
CPTS-RI
22.18 (11.90)
25.72 (12.11)
33.03 (11.82)
F2,285 = 17.42, p < .000bc
Witnessing Victimization
2.13 (2.08) 1.31 (1.49)
2.69 1.94
(2.29) (1.67)
3.12 2.12
(2.36) (1.89)
F2,293 = 4.37, p < .013b F2,293 = 6.24, p < .002ab
Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior
4.38 3.58 7.99 4.48 3.80 6.65 8.07 12.66
(2.45) (3.16) (5.46) (2.54) (2.93) (2.96) (3.82) (6.47)
5.17 (2.56) 4.36 (3.30) 10.47 (6.27) 4.84 (2.63) 4.06 (3.02) 7.12 (3.18) 8.57 (3.61) 13.03 (6.42)
6.03 5.32 12.96 5.73 4.99 8.48 8.65 14.72
(3.07) (3.50) (6.34) (2.65) (3.19) (3.29) (4.31) (6.94)
F2,287 = 8.18, p < .000b F2,287 = 5.85, p < .003b F2,287 = 14.54, p < .000abc F2,287 = 5.03, p < .007b F2,287 = 3.42, p < .034b F2,287 = 7.43, p < .001bc F2, 287 = .64, p < .530 F2,287 = 2.24, p < .109
Novelty seeking Harm avoidance Self-directedness Cooperativeness Self-transcendence
11.65 8.07 11.24 14.03 7.72
(2.97) (3.82) (3.96) (3.89) (3.20)
11.67 (2.75) 9.40 (3.62) 10.00 (3.62) 14.18 (3.81) 8.71 (3.31)
11.77 9.87 8.81 14.39 9.33
(2.78) (3.41) (3.81) (3.31) (3.47)
F2,299 = .45, p < .956 F2,299 = 6.33, p < .002ab F2,299 = 9.23, p < .000 ab F2,299 = .21, p < .813 F2,299 = 5.59, p < .004b
Note: PTSD = posttraumatic stress disorder; CPTS-RI = Child Posttraumatic Stress Reaction Index. a Significant difference between No PTSD and Partial PTSD. b Significant difference between No PTSD and Full PTSD. c Significant difference between Partial PTSD and Full PTSD.
series of univariate ANOVAs, witnessing and victimization were used as covariates in checking for the difference between PTSD groups on personality dimensions. Even after effects of violence exposure were controlled, the groups differed on harm avoidance (F = 3.68, p = .026) and selftranscendence (F = 4.17; p = .016), which were higher in the full PTSD group, as well as on self-directedness (F = 5.66, p = .004), which was lower. Finally, both witnessing and victimization significantly correlated with most problem scores of the Youth SelfReport (Pearson correlation coefficients, Table 4). However, when the CPTS-RI score was partialled out, these previously significant relationships did not reach significance levels (except for the relationships between violence exposure and aggressive and delinquent behaviors) (Table 4).
in levels of comorbid psychopathology in youths with full and partial PTSD diagnoses, which has rarely been examined in samples of youths and has not been studied in juvenile delinquents. Finally, the study provides an additional perspective on psychopathology in youths by demonstrating that personality traits are differentially related to youths’ behaviors and may potentially predispose them to the development of psychopathology. As demonstrated by these findings, most delinquents reported some degree of posttraumatic stress, and about one quarter fulfilled the DSM-IV criteria for PTSD. TABLE 4 Relationships Between Violence Exposure and YSR Problem Scores Witnessing Pearson
DISCUSSION
The novelty of this study lies in its cross-cultural approach to juvenile delinquency. The present study generally confirms previous findings of high rates of PTSD obtained in the studies of American incarcerated juvenile delinquents and their relationships to violence exposure (e.g., Steiner et al., 1997). These findings also reveal differences 326
Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior
Victimization
Partial
Pearson
Partial
0.13* 0.01 0.13* 0.04 0.10 –0.07 0.04 –0.08 0.17** 0.09 0.13* –0.01 0.21*** 0.16** 0.26*** 0.19***
0.19** 0.21** 0.21** 0.13* 0.16** 0.19** 0.24*** 0.29***
0.08 0.11 0.06 0.02 0.07 0.05 0.19*** 0.21***
* p < .05; ** p < .01; *** p < .001.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
Violence-related experiences were the most commonly reported types of psychological trauma, and higher PTSD scores were related to higher scores of violence exposure. Furthermore, posttraumatic stress was accompanied by a wide range of psychopathology/internalizing problems, with highest rates in the full PTSD group. Differences between the latter group and those without PTSD were minimal. Violence exposure was also related to novelty seeking, whereas PTSD scores were predominantly related to harm avoidance and low self-directedness. It is interesting that the relationships between violence exposure and internalizing problems became nonsignificant, when the level of PTSD was controlled for. An important practical question is whether children and adolescents who meet full diagnostic criteria for PTSD are different in some significant way from those who meet partial PTSD criteria (American Academy of Child and Adolescent Psychiatry, 1998). As found in the present study, the partial PTSD group had rates of psychopathology similar to those in the no PTSD group and had similar numbers of comorbid diagnoses (one or two). The main difference between these two groups was in the rates of major depressive disorder and generalized anxiety disorder. This finding by itself is clinically meaningful and implies a need for additional diagnostic efforts in the partial PTSD group, in which psychopathology would probably have remained underestimated unless specifically addressed. This is further supported by the finding of similar rates of self-reported problems in both groups. However, the full PTSD group revealed a wide range of comorbid diagnoses (generally more than three) and differed not only from the no PTSD group, but also from the partial PTSD group, in most diagnoses and in selfreported problems. The differences in separation anxiety, past attention-deficit/hyperactivity disorder and substance abuse not only further substantiate the findings from other studies, which report greater risk for posttraumatic stress in children with a preexisting psychiatric disorder or prior emotional vulnerabilities (Earls et al., 1988; Terr, 1991), but also imply a specific reactivity pattern to life events in certain individuals, which we will discuss further. Finally, these findings suggest that although PTSD symptoms represent a continuum of frequency and severity, the DSM-IV criteria for PTSD represent a clinically meaningful dividing point that designates those in particular need of intervention. Levels of posttraumatic stress among delinquents were significantly higher than in the general population but J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
were similar to those found in the U.S. sample of incarcerated delinquents (Steiner et al., 1997), which might be due to higher levels of violence exposure, and especially to its most severe forms, in delinquent youths. Increased behavior activation (high novelty seeking) may predispose youths to greater exposure to risky and violent situations. It has been found previously that youths who engage in antisocial behavior often have higher novelty seeking and lower cooperativeness (Nagoshi et al., 1992; Ruchkin et al., 1998c); thus the current findings may reflect the pathway by which personality factors, through antisocial activity, lead to increased violence exposure. These findings also indicate a relationship between posttraumatic stress and the temperamental pattern of behavior inhibition. Generally, high harm avoidance and low self-directedness reflect the tendency of the individual to be more fearful, nervous, and passive and to have low energy levels and poor coping skills, factors which make such youths especially sensitive to stressful life events. Also, high harm avoidance and low self-directedness have been shown to be related to various psychopathological manifestations (Cloninger et al., 1994) and internalizing problems in youths (Ruchkin et al., 1998a,b). Finally, inhibited temperamental patterns have recently been associated with a physiological pattern of resting right frontal EEG activation in children (Calkins et al., 1996; Fox et al., 1996), which, in adults, appears to be associated with a tendency to respond to stressful events with negative affect or depressive symptomatology (Davidson, 1992). Contrary to expectation, higher novelty seeking does not necessarily imply low harm avoidance, and in the present study harm avoidance and novelty seeking were unrelated. These traits can be present in various combinations, as suggested by Cloninger (Cloninger, 1987; Cloninger et al., 1994) in his typology of personality: high and low, high and high, etc. We thus suggest that increased exploratory activity may predispose an individual to greater violence exposure, whereas concurrent higher behavioral inhibition could lead to higher rates of psychopathology. It has been noted that temperament can affect how the consequences of traumatic experiences will unfold (Widom, 1989). For some, the consequences may show themselves in depression, conformity, and behavior inhibition, whereas, for others, aggressive tendencies may result. Our findings may indicate such tendencies. We suggest that high novelty seeking with low harm avoidance possibly leads to desensitization toward violence and possibly to persistent antisocial behavior, whereas high novelty seeking and 327
RUCHKIN ET AL.
high harm avoidance would increase sensitization to potentially traumatic experiences and consequently lead to higher rates of internalizing problems. We particularly emphasize the role of low self-directedness, which reflects psychological immaturity and poor coping and makes an individual more sensitive to environmental influences. Low self-directedness also reflects decreased social competence and low independence. Finally, a greater degree of violence exposure was related to higher problem scores. These findings are useful in several respects. First, in line with previous studies (Pynoos et al., 1987; Schwab-Stone et al., 1995, 1999), they demonstrate that higher rates of violence exposure are related to greater posttraumatic stress and other types of psychopathology. These results replicate, in a very different sample, the findings from our work with an American community sample (Schwab-Stone et al., 1995, 1999), in which degree of violence exposure was related to both externalizing and internalizing symptoms. Second, the correlations between symptoms and victimization were generally more significant than those with witnessing, implying the differences between witnessing an event and being a target and suggesting elevated risk for developing PTSD for the latter (McCloskey and Walker, 2000). Third, higher PTSD levels were accompanied by high rates of other types of psychopathology. An important finding is that the relationships between violence exposure and problem scores became nonsignificant (except for those with aggressive and delinquent behaviors) when the level of PTSD was partialled out. Thus comorbid symptoms may reflect different sides of the same entity, and the level of posttraumatic stress may account for most of the comorbidity. Given that stressful events lead to a diverse spectrum of psychopathological manifestations, these may reflect a specific type of reactivity related to personality traits, as discussed above. Finally, these findings also show that violence and victimization are related to aggressive and delinquent behavior independently of posttraumatic stress, which brings into question theories that traumatic events lead to aggressive and violent behavior through the development of PTSD. The generalizability of these findings might be questioned based on the cultural and juridical differences between delinquent populations in different countries. However, a recent analysis of trends of juvenile delinquency in Central and Eastern Europe (Asquith, 2001) reveals similarities in characteristics of juvenile delinquents in Russia and other European countries. In gen328
eral, during the last decade there has been a general increase in juvenile crime in most Central and Eastern European countries. Juvenile offenses are largely accounted for by property offenses, including theft of cars and other valuable objects. In recent years, the nature of theft behavior by juveniles has changed and become more organized, directed at peers and involving violence or the threat of violence. Juvenile delinquency represents primarily an urban male phenomenon that is directly related to rapid social and economic changes and can be understood to reflect changing familial and social factors (Asquith, 2001). Limitations
This work has the shortcomings of being cross-sectional in nature and of relying exclusively on self-report measures. Also, the findings are limited to a sample of incarcerated delinquent youths from the Russian North and should be replicated in other cultures. Clinical Implications
From the public health perspective, these findings support previous research findings that implicate violence exposure in the development of both externalizing and internalizing behaviors, a finding with meaning for public policy, especially primary prevention efforts for youths at risk. Understanding the distinctions between youths with full and partial PTSD has implications for treatment planning, such that children with full criteria should be given major clinical attention. In general, those with partial PTSD criteria may require less intervention and may differ in long-term prognosis. Environmental experiences, and particularly violence exposure, filtered through personality traits, may increase individual vulnerability to stress. Our findings also suggest that a wide range of psychopathology may be related to specific reactivity patterns to environmental stress and emphasize the importance of a focus on personality aspects in the treatment of traumatized delinquent youths. Finally, we know from other studies (Laor et al., 1997) that children at highest risk for developing PTSD also have mothers who are anxious and insecure (i.e., harm avoidant). The latter may imply a transgenerational transmission of such traits as harm avoidance, which in turn increases risk for the development of psychopathology in general and PTSD in particular. REFERENCES Achenbach TM (1991), Manual for the Youth Self-Report and 1991 Profile. Burlington: University of Vermont Department of Psychiatry
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
American Academy of Child and Adolescent Psychiatry (1998), Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry 37(10 suppl):4S–26S American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington, DC: American Psychiatric Association Asquith S (2001), Juvenile Justice and Juvenile Delinquency in Central and Eastern Europe: A Review. University of Glasgow, Centre for Europe’s Children (http://eurochild.gla.ac.uk/documents/coe/reports/juvenile_justice/jj&jd(1).htm) accessed 10/02/01 Breslau N, Davis GC (1987), Posttraumatic stress disorder: the etiologic specificity of wartime stressors. Am J Psychiatry 144:578–583 Breslau N, Davis GC, Andreski P, Peterson E (1991), Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48:216–222 Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998), Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 55:626–632 Calkins SD, Fox NA, Marshall TR (1996), Behavioral and physiological antecedents of inhibition in infancy. Child Dev 67:523–540 Carrion V, Steiner H (2000), Trauma and dissociation in delinquents. J Am Acad Child Adolesc Psychiatry 39:353–359 Carter AS, Grigorenko EL, Pauls DL (1995), A Russian adaptation of the Child Behavior Checklist: psychometric properties and associations with child and maternal affective symptomatology and family function. J Abnorm Child Psychol 23:661–684 Cauffman E, Feldman SS, Waterman J, Steiner H (1998), Posttraumatic stress disorder among incarcerated females. J Am Acad Child Adolesc Psychiatry 37:1209–1216 Cloninger CR (1987), A systematic method for clinical description and classification of personality variants. Arch Gen Psychiatry 44:573–588 Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD (1994), The Temperament and Character Inventory (TCI): A Guide to Its Development and Use. St Louis: Washington University, Center for Psychobiology of Personality (dbbs.wustl.edu/RIB/cloninger.html) Davidson RJ (1992), Emotion and affective style: hemispheric substrates. Psychol Sci 3:39–43 Earls F, Smith E, Reich W, Jung KG (1988), Investigating psychopathological consequences of a disaster in children: a pilot study incorporating a structured diagnostic interview. J Am Acad Child Adolesc Psychiatry 27:90–95 Finkelhor D, Dziuba-Leatherman J (1994), Victimization of children. Am Psychol 49:173–183 Fox NA, Schmidt LA, Calkins SD, Rubin KH, Coplan RJ (1996), The role of frontal activation in the regulation and dysregulation of social behavior during the preschool years. Dev Psychopathol 8:89–102 Frederick CJ (1985), Children traumatized by catastrophic situations. In: Posttraumatic Stress Disorder in Children, Eth S, Pynoos RS, eds. Washington, DC: American Psychiatric Press, pp 71–100 Hubbard J, Realmuto GM, Northwood AK, Masten AS (1995), Comorbidity of psychiatric diagnoses with posttraumatic stress disorder in survivors of childhood trauma. J Am Acad Child Adolesc Psychiatry 34:1167–1173 Kaufman J, Birmaher B, Brent D et al. (1997), Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
Kijima N, Tanaka E, Suzuki N, Higuchi H, Kitamura T (2000), Reliability and validity of the Japanese version of the Temperament and Character Inventory. Psychol Rep 86:1050–1058 Laor N, Wolmer L, Mayes LC, Gershon A, Weizman R, Cohen DJ (1997), Israeli preschool children under Scuds: a 30-month follow-up. J Am Acad Child Adolesc Psychiatry 36:349–356 Maggini C, Ampollini P, Marchesi C, Gariboldi S, Cloninger CR (2000), Relationships between Tridimensional Personality Questionnaire Dimensions and DSM-III-R personality traits in Italian adolescents. Compr Psychiatry 41:426–431 McCloskey LA, Walker M (2000), Posttraumatic stress in children exposed to family violence and single-event trauma. J Am Acad Child Adolesc Psychiatry 39:108–115 Nagoshi CT, Walter D, Muntaner C, Haertzen CA (1992), Validation of the Tridimensional Personality Questionnaire in a sample of male drug users. Pers Individ Dif 13:401–409 Pfefferbaum B (1997), Posttraumatic stress disorder in children: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 36:1503–1511 Pynoos R, Frederick C, Nader K (1987), Life threat and post-traumatic stress in school-age children. Arch Gen Psychiatry 44:1057–1063 Richters JE, Martinez P (1993), The NIMH community violence project, I: children as victims of and witnesses to violence. Psychiatry 56:7–21 Ruchkin V, Eisemann M, Cloninger CR (1998a), Behavior/emotional problems in male juvenile delinquents and controls in Russia: the role of personality traits. Acta Psychiatr Scand 98:231–236 Ruchkin V, Eisemann M, Hagglof B (1998b), Juvenile male rape victims: is the level of post-traumatic stress related to personality and parenting? Child Abuse Negl 9:889–899 Ruchkin V, Eisemann M, Hagglof B, Cloninger CR (1998c), Interrelations between temperament, character, and parental rearing in male delinquent adolescents in Northern Russia. Compr Psychiatry 39:225–230 Sartorius N, Kuyken W (1994), Translation of health status instruments. In: Quality of Life Assessment: International Perspectives, Orley J, Kuyken W, eds. Berlin-Heidelberg: Springer-Verlag, pp 3–18 Schnur PP, Friedman MJ, Rosenberg SD (1993), Preliminary MMPI scores as predictors of combat-related PTSD symptoms. Am J Psychiatry 150:479–483 Schwab-Stone M, Chen C, Greenberger E, Silver D, Lichtman J, Voyce C (1999), No safe haven, II: the effects of violence exposure on urban youth. J Am Acad Child Adolesc Psychiatry 38:359–367 Schwab-Stone ME, Ayers TS, Kasprow W et al. (1995), No safe haven: a study of violence exposure in an urban community. J Am Acad Child Adolesc Psychiatry 34:1343–1352 Steiner H, Garcia I, Matthews Z (1997), Posttraumatic stress disorder in incarcerated juvenile delinquents. J Am Acad Child Adolesc Psychiatry 36:357–365 Terr LC (1991), Childhood traumas: an outline and overview. Am J Psychiatry 148:10–20 Widom CS (1989), Does violence beget violence? A critical examination of the literature. Psychol Bull 106:3–28 Wills TA, Windle M, Cleary SD (1998), Temperament and novelty seeking in adolescent substance use: convergence of dimensions of temperament with constructs from Cloninger’s theory. J Pers Soc Psychol 74:387–406 Yehuda R, McFarlane AC (1995), Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. Am J Psychiatry 152:1705–1713
329
Research conducted over the past 20 years has demonstrated that a broad range of experiences, both natural and manmade, can have detrimental effects on children’s mental health. Traumatization in general tends to have cumulative effects (Breslau and Davis, 1987), often leading to a wide range of comorbid conditions (Breslau et al., 1991; Hubbard et al., 1995), with varying degrees of symptom Accepted September 17, 2001. Drs. Ruchkin and Schwab-Stone are with the Child Study Center, Yale University School of Medicine, New Haven, CT. Drs. Ruchkin and Koposov are also with the Institute of Psychiatry, Northern State Medical University, Arkhangelsk, Russia. Dr. Vermeiren is with the Middelheimhospital, University of Antwerp, Belgium. Dr. Steiner is with the Division of Child Psychiatry and Child Development, Stanford University School of Medicine, Stanford, CA. Supported in part by the CIES Fulbright grant 24142 to Dr. Ruchkin. The authors thank Donald J. Cohen, M.D., for his support and his comments on the manuscript. Correspondence to Dr. Ruchkin, Yale Child Study Center, 230 South Frontage Road, New Haven, CT 06520-7900; e-mail: [email protected]. 0890-8567/02/4103–0322䉷2002 by the American Academy of Child and Adolescent Psychiatry.
322
severity. There is also ongoing discussion about whether posttraumatic stress disorder (PTSD) symptoms occur on a continuum of frequency and severity, with “full” criteria representing an arbitrary cutoff point rather than a clinically meaningful dividing point (American Academy of Child and Adolescent Psychiatry, 1998; Terr, 1991). Given the same traumatic event, some people will be more likely to develop posttraumatic stress disorder than others and, conversely, certain individuals will be more likely than others to develop PTSD in different contexts (Breslau et al., 1998). Trauma response usually correlates with the degree of exposure, measured by both physical and emotional proximity (Pfefferbaum, 1997), and is modulated by premorbid personality traits (Schnur et al., 1993), which determine the individual’s perception of traumatic events and thus influence the severity of posttraumatic stress symptoms (Yehuda and McFarlane, 1995). Due to increased exploratory activity (novelty seeking), some people may experience higher levels of exposure to J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
potentially stressful situations (e.g., exposure to violence), as well as be prone to delinquent and other types of sensation-seeking behavior. At the same time, the magnitude of posttraumatic stress and other types of internalizing psychopathology appears to be related to the personality trait of behavioral inhibition (harm avoidance) (Cloninger et al., 1994; Ruchkin et al., 1998a,b). Recent research has documented that juvenile delinquents represent a highly traumatized group, with rates of posttraumatic stress approaching 30% (Carrion and Steiner, 2000; Cauffman et al., 1998; Steiner et al., 1997). Most report exposure to events, such as abuse and neglect, violence exposure, and sexual molestation (Steiner et al., 1997); some studies suggest that traumatization is a predisposing factor for the development of delinquent behavior (Finkelhor and Dziuba-Leatherman, 1994; Widom, 1989). Thus trauma is relevant to the study of delinquency for at least three reasons (Steiner et al., 1997). First, since child maltreatment is related to both posttraumatic stress and delinquency, these outcomes may co-occur. Second, fuller examination of the relationship between trauma and conduct disorder may lead to a better understanding of the interplay between PTSD and personality functions. Third, clarifying relationships between PTSD and delinquency may suggest the potential role of preexisting psychopathology and vulnerability for PTSD. On the basis of these findings, we hypothesized that incarcerated juvenile delinquents will have high rates of posttraumatic stress due to frequent past traumatization (Steiner et al., 1997). Delinquents with higher rates of PTSD symptomatology will have higher rates of violence exposure and comorbid psychopathology and will differ from other groups on personality dimensions. In particular, those with high behavior activation (high novelty seeking) will be exposed to more violence, which in turn will be related to higher rates of psychopathology. However, the development of psychopathological manifestations will be particularly related to high behavioral inhibition, low personal efficacy, and poor coping skills (high harm avoidance and low self-directedness). Finally, the severity of comorbid psychopathology will be largely determined by the severity of PTSD symptoms. METHOD Participants The study was approved by the institutional review board of the Northern State Medical University (Arkhangelsk, Russia). The delin-
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
quent subjects were recruited voluntarily from the approximately 300 male adolescents who were inmates in the only juvenile detention center in the Arkhangelsk region of Northern Russia, a catchment area with a population of 1.5 million. The population of the region is homogenous ethnically, i.e., 98% Ethnic Slavs. All delinquents were referred to this institution by court decision. Most delinquents had multiple convictions, which included property crimes (theft, car theft, etc.: 51%), violence-related crimes (e.g., fighting, robbery: 38%), and in some cases, rape/sexual violence (6%) or murder (5%). Generally, those institutionalized for theft had shown a repetitive pattern of stealing, with multiple convictions and referral to this facility occurring only after committing theft during parole. The mean length of sentence at the time of the study was 4.3 years. Age of the participants ranged from 14 to 19 years (mean = 16.4, SD = 0.9). Classical measures of socioeconomic status such as the HollingsheadRedlich 2-factor index cannot be used in Russia currently, as the country is in economic upheaval, and it is questionable whether the HR 2F would apply. In general, most subjects came from impoverished economic backgrounds with unemployed parents, debts, and financial distress; however, this is common given the current economic situation in Russia, where a large part of the population have incomes that barely cover the costs of food. All participants were informed about the voluntary and confidential nature of their participation. They were further assured that the institutional staff would not obtain any individualized information about their responses. In classroom settings, all potential participants were provided with detailed descriptive information about the study. Questions that arose were answered in detail. Eight subjects refused to participate because of unwillingness to provide any personal information. Posttraumatic stress and psychopathology were assessed through a semistructured psychiatric interview, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), which was conducted with 370 delinquent youths. Interviewers, who administered the K-SADS, were blind to the results of self-report measures. During the study some youths were released, whereas others entered the facility; thus the interviewed group appears to be larger than the total population of the institution at any one time. A subsample of 289 subjects also completed a set of self-reports. There were no age/psychopathology rates differences between the groups. Instruments Combined Psychiatric Diagnoses. The K-SADS-PL, a widely used semistructured psychiatric interview that has high interrater diagnostic reliability and was validated in extensive testing (Kaufman et al., 1997), was used to yield current and past diagnoses. To assign a psychiatric diagnosis, clinically significant, diagnosis-specific impairment had to be present. The interview was conducted by two psychiatrists who were blind to the results of self-reports. The interviewers received standard K-SADS training from the author of the instrument and determined the presence of diagnoses according to DSM-IV criteria (American Psychiatric Association, 1994). Semistructured Clinical Interview for PTSD. The PTSD module of the K-SADS-PL was administered. This module consists of a list of potentially traumatic events; if there is evidence of past trauma, 5 PTSD screen items are asked. When any are answered affirmatively, 14 additional items inquire about reexperiencing, persistent avoidance, and increased arousal, as well as functional impairment. To avoid overdiagnosing the subjects with regard to PTSD, conservative criteria were applied. Those receiving two or fewer threshold ratings on the screen interview were considered as the no PTSD group. Those who had at
323
RUCHKIN ET AL.
least three threshold ratings, but who did not fulfill full DSM-IV criteria for PTSD, were considered as the partial PTSD group. Measures of Psychopathology and Violence Exposure. In addition to the K-SADS-PL, several rating scales of psychopathology were administered. They included the Child Posttraumatic Stress Reaction Index (CPTS-RI) (Frederick, 1985; Pynoos et al., 1987), a 20-item scale designed to assess posttraumatic stress reactions of school-age children and adolescents that has been used in previous studies of Russian youths (Ruchkin et al., 1998b) (in the present study Cronbach α = .81), and the Youth Self-Report (Achenbach, 1991), a 112-item self-report questionnaire assessing internalizing (e.g., anxiety, depression) and externalizing (e.g., aggression, delinquent behavior) symptomatology, which was previously validated in a Russian general population sample (Carter et al., 1995) (in the present study Cronbach α ranged from .60 for Social Problems to .89 for Externalizing and Internalizing Problems). Witnessing and victimization were assessed by a slightly modified version of the Survey of Exposure to Community Violence (Richters and Martinez, 1993), which asks respondents whether they had witnessed or been victimized by eight types of violence (e.g., seen somebody/was beaten up or mugged, threatened with serious physical harm, etc). In the present sample Cronbach α was .65 for Victimization and .76 for Witnessing. Temperament and Character Inventory. The Temperament and Character Inventory (TCI) (Cloninger et al., 1994), based on Cloninger’s unified biosocial theory of personality (Cloninger, 1987), measures four temperament and three character dimensions. According to Cloninger’s theory, temperament dimensions are independent and largely genetically determined (Cloninger et al., 1994). Two scales for temperament related to the study hypothesis are used in the current study (harm avoidance and novelty seeking). Harm avoidance reflects a heritable bias in the inhibition or cessation of behaviors. Subjects who score high on harm avoidance are pessimistic, chronically worried, shy with strangers, and tense in unfamiliar situations. Novelty seeking is viewed as a tendency toward behavior activation in response to novel stimuli or cues. Subjects who score high on novelty seeking show high levels of exploratory behavior, impulsive decision-making, quick loss of temper, and active avoidance of frustration. Character is the second domain of personality, which is predominantly determined by socialization processes during the lifespan (Cloninger et al., 1994). It is described in terms of response biases related to different self-concepts, changing during the process of personal, social, moral and spiritual development. Self-directedness is related to the extent to which a person identifies the self as autonomous. An individual with a low level of self-directedness can be described as immature, unreliable, blaming, and inert, with poor coping skills and impulse control. Cooperativeness is related to the extent to which a person identifies himself or herself as an integral part of society. Those with low levels of cooperativeness are characterized as hostile, aggressive, and vengeful individuals, with deficits in empathy. Selftranscendence reflects the tendency to identify with the unity of all things. Individuals with a high level of self-transcendence find comfort in spiritual experiences and beliefs in supernatural power and often have magical thinking. Cloninger’s theory of personality and the TCI have been used and validated with adolescents, both in the United States (e.g., Wills et al., 1998) and other cultures (e.g., Kijima et al., 2000; Maggini et al., 2000), including Russia (Ruchkin et al., 1998a,c). In the present study, we used the short version of the TCI, with 125 items to be answered as true or false. Cronbach α values were .60 for novelty seeking, .67 for harm avoidance, .68 for self-directedness, .64 for cooperativeness, and .75 for self-transcendence (further psychometric data are available from the corresponding author [V.V.R.]).
324
Translation Translation of these scales into Russian followed established guidelines, including appropriate use of independent back-translations (Sartorius and Kuyken, 1994). Russian translations made by the first author (V.V.R.) were followed by discussion with monolingual colleagues. Finally, an official interpreter made independent backtranslations. The versions obtained were compared with originals, and inconsistencies were analyzed and corrected. The translation of the K-SADS-PL was made at the Department of Psychology, Moscow State University, following the above-mentioned procedure. Data Analysis The data were analyzed with the Statistical Package for Social Sciences (SPSS-10.0). Chi-square and analyses of variance (one-way ANOVA and UniANOVA) tests were used as appropriate to examine differences between the PTSD, partial PTSD and full PTSD subgroups. Pearson product-moment correlation and partial correlation coefficients were calculated between violence exposure scores and selfreported psychopathology and personality dimensions.
RESULTS Posttraumatic Stress: Interview Results
Of the 370 interviewed subjects, 19 did not report any traumatic events, 351 (96%) reported at least one potentially traumatic event, and, by definition, all of the PTSD positive youths reported such an event. Furthermore, 303 participants (82.3%) reported multiple events. The five most commonly reported events included witnessing domestic violence (240 subjects, 65%), confronting traumatic news (215 subjects, 58%), witnessing a violent crime (185 subjects, 50%), physical abuse (170 subjects, 46%), and being a victim of a violent crime (117 subjects, 32%). Only 8 participants reported sexual abuse. However, many of the inmates hold victims of sexual abuse in very low regard (Ruchkin et al., 1998b), thus potentially influencing willingness to report such events. For the 351 subject who reported at least one traumatic event, the rates of PTSD were as follows: 118 subjects (33.6%) reported no symptoms of PTSD; 146 (41.6%) fulfilled partial PTSD criteria; and 87 subjects (24.8%) fulfilled full criteria for PTSD. Other Types of Psychopathology
Table 1 shows the prevalence of the seven most common comorbid psychiatric diagnoses in the no PTSD, partial PTSD and full PTSD groups. The full PTSD group revealed significantly higher rates of most diagnoses than the two other groups. The partial PTSD group differed significantly from the no PTSD group only in rates of major depressive disorder and generalized anxiJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
TABLE 1 Prevalence of Comorbid Diagnoses in Delinquents With No PTSD, Partial PTSD, and Full PTSD Other Diagnosis
No PTSD
Major depression ab Separation anxiety bc General anxiety abc Past ADHD bc Conduct disorder b Alcohol abuse bc Drug abuse bc
4 5 4 12 80 60 25
(3.4) (4.2) (3.4) (10.2) (67.8) (50.8) (21.2)
Partial PTSD 17 10 18 17 107 77 34
Full PTSD
(11.6) (6.8) (12.3) (11.6) (73.3) (52.7) (23.3)
14 17 20 21 72 59 34
χ2 ( p)
Total
(16.1) (19.5) (23.0) (24.1) (82.8) (67.8) (39.1)
35 32 42 50 259 196 93
(10.0) (9.1) (12.0) (14.2) (73.8) (55.8) (26.5)
9.8 15.7 18.3 9.4 5.8 6.8 9.4
(.008) (.000) (.000) (.009) (.054) (.033) (.009)
Note: Values represent number (percent). In addition to all-groups comparisons, intergroup differences in the rates of diagnoses were assessed by separate analyses (2 ⫻ 2). The results of these calculations are shown by superscript letters: a significant difference between No PTSD and Partial PTSD; b significant difference between No PTSD and Full PTSD; c significant difference between Partial PTSD and Full PTSD. PTSD = posttraumatic stress disorder; ADHD = attention-deficit/hyperactivity disorder.
ety disorder. We found it particularly interesting that the full PTSD group also differed from the other groups in rates of retrospectively established diagnoses of separation anxiety disorder and past attention-deficit/hyperactivity disorder (no current diagnosis). Finally, using the rates of the seven most common diagnoses, a cumulative coefficient for psychopathology was created (no other diagnosis, one to two diagnoses, and three or more diagnoses). The full PTSD group revealed the highest rates of comorbid psychopathology (Table 2). On the self-report measures (289 subjects) most participants revealed mild to moderate levels of posttraumatic stress (measured by the CPTS-RI, scores from 12 to 39), and 52 subjects suffered from severe and very severe stress (scoring above 40; cut-off scores suggested by the original studies on the CPTS-RI, e.g., 22). The scores of CPTS-RI in this delinquent population were higher than those reported in the general youth population in this part of Russia (26.29 ± 13.39 in delinquents versus 18.09 ± 7.87 in the general population, F = 64.05, p < .001; general population results from Ruchkin et al., unpublished data, 1999). Levels of problem scores increased along with the level of PTSD. Participants with full PTSD reported higher rates of both internalizing and externalizing problems (Table 3) as compared with the other groups. In spite of the general tendency for problem scores
to increase with level of PTSD, most differences were obtained either between full and partial PTSD groups or between full and no PTSD groups. There were no significant differences between no PTSD and partial PTSD groups on any of problem scores. PTSD, Violence Exposure, and Personality
Violence exposure scores increased along with PTSD severity. There was also an increase in harm avoidance and self-transcendence and a decrease in self-directedness from the no PTSD to the full PTSD group (Table 3). Violence Exposure in Relation to Personality and Psychopathology
Because the level of posttraumatic stress may bias reporting and lead to reports of greater violence exposure, or distorted reports on personality, the CPTS-RI score was partialled out from the correlations between personality and violence exposure. Both witnessing and victimization appeared to be positively related to novelty seeking (r = 0.18, p < .01 and r = 0.14, p < .05, respectively) and negatively related to cooperativeness (r = –0.18, p < .01 and r = –0.19, p < .001, respectively). On the other hand, we were also interested in whether personality factors would still differ by PTSD group even after effects of violence exposure were controlled. In a
TABLE 2 Number of Comorbid Diagnoses in Delinquents With No PTSD, Partial PTSD, and Full PTSD No. of Other Diagnoses
No PTSD (n = 118)
Partial PTSD (n = 146)
Full PTSD (n = 87)
Total
0 1–2 3+
21 (17.8) 74 (62.7) 23 (19.5)
14 (9.6) 91 (62.3) 41 (28.1)
— 18 (20.7) 69 (79.3)
35 (10.0) 183 (52.1) 133 (37.9)
Note: Values represent number (percent). χ2 = 91.5 ( p = .000). PTSD = posttraumatic stress disorder.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
325
RUCHKIN ET AL.
TABLE 3 Violence Exposure, Problem Scores, and Personality Characteristics in Delinquents With No PTSD, Partial PTSD, and Full PTSD (One-Way Analysis of Variance) Variables
No PTSD
Partial PTSD
Full PTSD
Fdf , p
CPTS-RI
22.18 (11.90)
25.72 (12.11)
33.03 (11.82)
F2,285 = 17.42, p < .000bc
Witnessing Victimization
2.13 (2.08) 1.31 (1.49)
2.69 1.94
(2.29) (1.67)
3.12 2.12
(2.36) (1.89)
F2,293 = 4.37, p < .013b F2,293 = 6.24, p < .002ab
Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior
4.38 3.58 7.99 4.48 3.80 6.65 8.07 12.66
(2.45) (3.16) (5.46) (2.54) (2.93) (2.96) (3.82) (6.47)
5.17 (2.56) 4.36 (3.30) 10.47 (6.27) 4.84 (2.63) 4.06 (3.02) 7.12 (3.18) 8.57 (3.61) 13.03 (6.42)
6.03 5.32 12.96 5.73 4.99 8.48 8.65 14.72
(3.07) (3.50) (6.34) (2.65) (3.19) (3.29) (4.31) (6.94)
F2,287 = 8.18, p < .000b F2,287 = 5.85, p < .003b F2,287 = 14.54, p < .000abc F2,287 = 5.03, p < .007b F2,287 = 3.42, p < .034b F2,287 = 7.43, p < .001bc F2, 287 = .64, p < .530 F2,287 = 2.24, p < .109
Novelty seeking Harm avoidance Self-directedness Cooperativeness Self-transcendence
11.65 8.07 11.24 14.03 7.72
(2.97) (3.82) (3.96) (3.89) (3.20)
11.67 (2.75) 9.40 (3.62) 10.00 (3.62) 14.18 (3.81) 8.71 (3.31)
11.77 9.87 8.81 14.39 9.33
(2.78) (3.41) (3.81) (3.31) (3.47)
F2,299 = .45, p < .956 F2,299 = 6.33, p < .002ab F2,299 = 9.23, p < .000 ab F2,299 = .21, p < .813 F2,299 = 5.59, p < .004b
Note: PTSD = posttraumatic stress disorder; CPTS-RI = Child Posttraumatic Stress Reaction Index. a Significant difference between No PTSD and Partial PTSD. b Significant difference between No PTSD and Full PTSD. c Significant difference between Partial PTSD and Full PTSD.
series of univariate ANOVAs, witnessing and victimization were used as covariates in checking for the difference between PTSD groups on personality dimensions. Even after effects of violence exposure were controlled, the groups differed on harm avoidance (F = 3.68, p = .026) and selftranscendence (F = 4.17; p = .016), which were higher in the full PTSD group, as well as on self-directedness (F = 5.66, p = .004), which was lower. Finally, both witnessing and victimization significantly correlated with most problem scores of the Youth SelfReport (Pearson correlation coefficients, Table 4). However, when the CPTS-RI score was partialled out, these previously significant relationships did not reach significance levels (except for the relationships between violence exposure and aggressive and delinquent behaviors) (Table 4).
in levels of comorbid psychopathology in youths with full and partial PTSD diagnoses, which has rarely been examined in samples of youths and has not been studied in juvenile delinquents. Finally, the study provides an additional perspective on psychopathology in youths by demonstrating that personality traits are differentially related to youths’ behaviors and may potentially predispose them to the development of psychopathology. As demonstrated by these findings, most delinquents reported some degree of posttraumatic stress, and about one quarter fulfilled the DSM-IV criteria for PTSD. TABLE 4 Relationships Between Violence Exposure and YSR Problem Scores Witnessing Pearson
DISCUSSION
The novelty of this study lies in its cross-cultural approach to juvenile delinquency. The present study generally confirms previous findings of high rates of PTSD obtained in the studies of American incarcerated juvenile delinquents and their relationships to violence exposure (e.g., Steiner et al., 1997). These findings also reveal differences 326
Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior
Victimization
Partial
Pearson
Partial
0.13* 0.01 0.13* 0.04 0.10 –0.07 0.04 –0.08 0.17** 0.09 0.13* –0.01 0.21*** 0.16** 0.26*** 0.19***
0.19** 0.21** 0.21** 0.13* 0.16** 0.19** 0.24*** 0.29***
0.08 0.11 0.06 0.02 0.07 0.05 0.19*** 0.21***
* p < .05; ** p < .01; *** p < .001.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
Violence-related experiences were the most commonly reported types of psychological trauma, and higher PTSD scores were related to higher scores of violence exposure. Furthermore, posttraumatic stress was accompanied by a wide range of psychopathology/internalizing problems, with highest rates in the full PTSD group. Differences between the latter group and those without PTSD were minimal. Violence exposure was also related to novelty seeking, whereas PTSD scores were predominantly related to harm avoidance and low self-directedness. It is interesting that the relationships between violence exposure and internalizing problems became nonsignificant, when the level of PTSD was controlled for. An important practical question is whether children and adolescents who meet full diagnostic criteria for PTSD are different in some significant way from those who meet partial PTSD criteria (American Academy of Child and Adolescent Psychiatry, 1998). As found in the present study, the partial PTSD group had rates of psychopathology similar to those in the no PTSD group and had similar numbers of comorbid diagnoses (one or two). The main difference between these two groups was in the rates of major depressive disorder and generalized anxiety disorder. This finding by itself is clinically meaningful and implies a need for additional diagnostic efforts in the partial PTSD group, in which psychopathology would probably have remained underestimated unless specifically addressed. This is further supported by the finding of similar rates of self-reported problems in both groups. However, the full PTSD group revealed a wide range of comorbid diagnoses (generally more than three) and differed not only from the no PTSD group, but also from the partial PTSD group, in most diagnoses and in selfreported problems. The differences in separation anxiety, past attention-deficit/hyperactivity disorder and substance abuse not only further substantiate the findings from other studies, which report greater risk for posttraumatic stress in children with a preexisting psychiatric disorder or prior emotional vulnerabilities (Earls et al., 1988; Terr, 1991), but also imply a specific reactivity pattern to life events in certain individuals, which we will discuss further. Finally, these findings suggest that although PTSD symptoms represent a continuum of frequency and severity, the DSM-IV criteria for PTSD represent a clinically meaningful dividing point that designates those in particular need of intervention. Levels of posttraumatic stress among delinquents were significantly higher than in the general population but J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
were similar to those found in the U.S. sample of incarcerated delinquents (Steiner et al., 1997), which might be due to higher levels of violence exposure, and especially to its most severe forms, in delinquent youths. Increased behavior activation (high novelty seeking) may predispose youths to greater exposure to risky and violent situations. It has been found previously that youths who engage in antisocial behavior often have higher novelty seeking and lower cooperativeness (Nagoshi et al., 1992; Ruchkin et al., 1998c); thus the current findings may reflect the pathway by which personality factors, through antisocial activity, lead to increased violence exposure. These findings also indicate a relationship between posttraumatic stress and the temperamental pattern of behavior inhibition. Generally, high harm avoidance and low self-directedness reflect the tendency of the individual to be more fearful, nervous, and passive and to have low energy levels and poor coping skills, factors which make such youths especially sensitive to stressful life events. Also, high harm avoidance and low self-directedness have been shown to be related to various psychopathological manifestations (Cloninger et al., 1994) and internalizing problems in youths (Ruchkin et al., 1998a,b). Finally, inhibited temperamental patterns have recently been associated with a physiological pattern of resting right frontal EEG activation in children (Calkins et al., 1996; Fox et al., 1996), which, in adults, appears to be associated with a tendency to respond to stressful events with negative affect or depressive symptomatology (Davidson, 1992). Contrary to expectation, higher novelty seeking does not necessarily imply low harm avoidance, and in the present study harm avoidance and novelty seeking were unrelated. These traits can be present in various combinations, as suggested by Cloninger (Cloninger, 1987; Cloninger et al., 1994) in his typology of personality: high and low, high and high, etc. We thus suggest that increased exploratory activity may predispose an individual to greater violence exposure, whereas concurrent higher behavioral inhibition could lead to higher rates of psychopathology. It has been noted that temperament can affect how the consequences of traumatic experiences will unfold (Widom, 1989). For some, the consequences may show themselves in depression, conformity, and behavior inhibition, whereas, for others, aggressive tendencies may result. Our findings may indicate such tendencies. We suggest that high novelty seeking with low harm avoidance possibly leads to desensitization toward violence and possibly to persistent antisocial behavior, whereas high novelty seeking and 327
RUCHKIN ET AL.
high harm avoidance would increase sensitization to potentially traumatic experiences and consequently lead to higher rates of internalizing problems. We particularly emphasize the role of low self-directedness, which reflects psychological immaturity and poor coping and makes an individual more sensitive to environmental influences. Low self-directedness also reflects decreased social competence and low independence. Finally, a greater degree of violence exposure was related to higher problem scores. These findings are useful in several respects. First, in line with previous studies (Pynoos et al., 1987; Schwab-Stone et al., 1995, 1999), they demonstrate that higher rates of violence exposure are related to greater posttraumatic stress and other types of psychopathology. These results replicate, in a very different sample, the findings from our work with an American community sample (Schwab-Stone et al., 1995, 1999), in which degree of violence exposure was related to both externalizing and internalizing symptoms. Second, the correlations between symptoms and victimization were generally more significant than those with witnessing, implying the differences between witnessing an event and being a target and suggesting elevated risk for developing PTSD for the latter (McCloskey and Walker, 2000). Third, higher PTSD levels were accompanied by high rates of other types of psychopathology. An important finding is that the relationships between violence exposure and problem scores became nonsignificant (except for those with aggressive and delinquent behaviors) when the level of PTSD was partialled out. Thus comorbid symptoms may reflect different sides of the same entity, and the level of posttraumatic stress may account for most of the comorbidity. Given that stressful events lead to a diverse spectrum of psychopathological manifestations, these may reflect a specific type of reactivity related to personality traits, as discussed above. Finally, these findings also show that violence and victimization are related to aggressive and delinquent behavior independently of posttraumatic stress, which brings into question theories that traumatic events lead to aggressive and violent behavior through the development of PTSD. The generalizability of these findings might be questioned based on the cultural and juridical differences between delinquent populations in different countries. However, a recent analysis of trends of juvenile delinquency in Central and Eastern Europe (Asquith, 2001) reveals similarities in characteristics of juvenile delinquents in Russia and other European countries. In gen328
eral, during the last decade there has been a general increase in juvenile crime in most Central and Eastern European countries. Juvenile offenses are largely accounted for by property offenses, including theft of cars and other valuable objects. In recent years, the nature of theft behavior by juveniles has changed and become more organized, directed at peers and involving violence or the threat of violence. Juvenile delinquency represents primarily an urban male phenomenon that is directly related to rapid social and economic changes and can be understood to reflect changing familial and social factors (Asquith, 2001). Limitations
This work has the shortcomings of being cross-sectional in nature and of relying exclusively on self-report measures. Also, the findings are limited to a sample of incarcerated delinquent youths from the Russian North and should be replicated in other cultures. Clinical Implications
From the public health perspective, these findings support previous research findings that implicate violence exposure in the development of both externalizing and internalizing behaviors, a finding with meaning for public policy, especially primary prevention efforts for youths at risk. Understanding the distinctions between youths with full and partial PTSD has implications for treatment planning, such that children with full criteria should be given major clinical attention. In general, those with partial PTSD criteria may require less intervention and may differ in long-term prognosis. Environmental experiences, and particularly violence exposure, filtered through personality traits, may increase individual vulnerability to stress. Our findings also suggest that a wide range of psychopathology may be related to specific reactivity patterns to environmental stress and emphasize the importance of a focus on personality aspects in the treatment of traumatized delinquent youths. Finally, we know from other studies (Laor et al., 1997) that children at highest risk for developing PTSD also have mothers who are anxious and insecure (i.e., harm avoidant). The latter may imply a transgenerational transmission of such traits as harm avoidance, which in turn increases risk for the development of psychopathology in general and PTSD in particular. REFERENCES Achenbach TM (1991), Manual for the Youth Self-Report and 1991 Profile. Burlington: University of Vermont Department of Psychiatry
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
PTSD IN JUVENILE DELINQUENTS
American Academy of Child and Adolescent Psychiatry (1998), Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry 37(10 suppl):4S–26S American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington, DC: American Psychiatric Association Asquith S (2001), Juvenile Justice and Juvenile Delinquency in Central and Eastern Europe: A Review. University of Glasgow, Centre for Europe’s Children (http://eurochild.gla.ac.uk/documents/coe/reports/juvenile_justice/jj&jd(1).htm) accessed 10/02/01 Breslau N, Davis GC (1987), Posttraumatic stress disorder: the etiologic specificity of wartime stressors. Am J Psychiatry 144:578–583 Breslau N, Davis GC, Andreski P, Peterson E (1991), Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48:216–222 Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998), Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 55:626–632 Calkins SD, Fox NA, Marshall TR (1996), Behavioral and physiological antecedents of inhibition in infancy. Child Dev 67:523–540 Carrion V, Steiner H (2000), Trauma and dissociation in delinquents. J Am Acad Child Adolesc Psychiatry 39:353–359 Carter AS, Grigorenko EL, Pauls DL (1995), A Russian adaptation of the Child Behavior Checklist: psychometric properties and associations with child and maternal affective symptomatology and family function. J Abnorm Child Psychol 23:661–684 Cauffman E, Feldman SS, Waterman J, Steiner H (1998), Posttraumatic stress disorder among incarcerated females. J Am Acad Child Adolesc Psychiatry 37:1209–1216 Cloninger CR (1987), A systematic method for clinical description and classification of personality variants. Arch Gen Psychiatry 44:573–588 Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD (1994), The Temperament and Character Inventory (TCI): A Guide to Its Development and Use. St Louis: Washington University, Center for Psychobiology of Personality (dbbs.wustl.edu/RIB/cloninger.html) Davidson RJ (1992), Emotion and affective style: hemispheric substrates. Psychol Sci 3:39–43 Earls F, Smith E, Reich W, Jung KG (1988), Investigating psychopathological consequences of a disaster in children: a pilot study incorporating a structured diagnostic interview. J Am Acad Child Adolesc Psychiatry 27:90–95 Finkelhor D, Dziuba-Leatherman J (1994), Victimization of children. Am Psychol 49:173–183 Fox NA, Schmidt LA, Calkins SD, Rubin KH, Coplan RJ (1996), The role of frontal activation in the regulation and dysregulation of social behavior during the preschool years. Dev Psychopathol 8:89–102 Frederick CJ (1985), Children traumatized by catastrophic situations. In: Posttraumatic Stress Disorder in Children, Eth S, Pynoos RS, eds. Washington, DC: American Psychiatric Press, pp 71–100 Hubbard J, Realmuto GM, Northwood AK, Masten AS (1995), Comorbidity of psychiatric diagnoses with posttraumatic stress disorder in survivors of childhood trauma. J Am Acad Child Adolesc Psychiatry 34:1167–1173 Kaufman J, Birmaher B, Brent D et al. (1997), Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 3 , M A RC H 2 0 0 2
Kijima N, Tanaka E, Suzuki N, Higuchi H, Kitamura T (2000), Reliability and validity of the Japanese version of the Temperament and Character Inventory. Psychol Rep 86:1050–1058 Laor N, Wolmer L, Mayes LC, Gershon A, Weizman R, Cohen DJ (1997), Israeli preschool children under Scuds: a 30-month follow-up. J Am Acad Child Adolesc Psychiatry 36:349–356 Maggini C, Ampollini P, Marchesi C, Gariboldi S, Cloninger CR (2000), Relationships between Tridimensional Personality Questionnaire Dimensions and DSM-III-R personality traits in Italian adolescents. Compr Psychiatry 41:426–431 McCloskey LA, Walker M (2000), Posttraumatic stress in children exposed to family violence and single-event trauma. J Am Acad Child Adolesc Psychiatry 39:108–115 Nagoshi CT, Walter D, Muntaner C, Haertzen CA (1992), Validation of the Tridimensional Personality Questionnaire in a sample of male drug users. Pers Individ Dif 13:401–409 Pfefferbaum B (1997), Posttraumatic stress disorder in children: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 36:1503–1511 Pynoos R, Frederick C, Nader K (1987), Life threat and post-traumatic stress in school-age children. Arch Gen Psychiatry 44:1057–1063 Richters JE, Martinez P (1993), The NIMH community violence project, I: children as victims of and witnesses to violence. Psychiatry 56:7–21 Ruchkin V, Eisemann M, Cloninger CR (1998a), Behavior/emotional problems in male juvenile delinquents and controls in Russia: the role of personality traits. Acta Psychiatr Scand 98:231–236 Ruchkin V, Eisemann M, Hagglof B (1998b), Juvenile male rape victims: is the level of post-traumatic stress related to personality and parenting? Child Abuse Negl 9:889–899 Ruchkin V, Eisemann M, Hagglof B, Cloninger CR (1998c), Interrelations between temperament, character, and parental rearing in male delinquent adolescents in Northern Russia. Compr Psychiatry 39:225–230 Sartorius N, Kuyken W (1994), Translation of health status instruments. In: Quality of Life Assessment: International Perspectives, Orley J, Kuyken W, eds. Berlin-Heidelberg: Springer-Verlag, pp 3–18 Schnur PP, Friedman MJ, Rosenberg SD (1993), Preliminary MMPI scores as predictors of combat-related PTSD symptoms. Am J Psychiatry 150:479–483 Schwab-Stone M, Chen C, Greenberger E, Silver D, Lichtman J, Voyce C (1999), No safe haven, II: the effects of violence exposure on urban youth. J Am Acad Child Adolesc Psychiatry 38:359–367 Schwab-Stone ME, Ayers TS, Kasprow W et al. (1995), No safe haven: a study of violence exposure in an urban community. J Am Acad Child Adolesc Psychiatry 34:1343–1352 Steiner H, Garcia I, Matthews Z (1997), Posttraumatic stress disorder in incarcerated juvenile delinquents. J Am Acad Child Adolesc Psychiatry 36:357–365 Terr LC (1991), Childhood traumas: an outline and overview. Am J Psychiatry 148:10–20 Widom CS (1989), Does violence beget violence? A critical examination of the literature. Psychol Bull 106:3–28 Wills TA, Windle M, Cleary SD (1998), Temperament and novelty seeking in adolescent substance use: convergence of dimensions of temperament with constructs from Cloninger’s theory. J Pers Soc Psychol 74:387–406 Yehuda R, McFarlane AC (1995), Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. Am J Psychiatry 152:1705–1713
329