Trauma and Juvenile Delinquency : Theory, Research, and Interventions 9781317787679, 9780789019745

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Trauma and Juvenile Delinquency: Theory, Research, and Interventions

Trauma and Juvenile Delinquency: Theory, Research, and Interventions has been co-published simultaneously as Journal of Aggression, Maltreatment & Trauma, Volume 6, Number 1 (#11) 2002.

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Trauma and Juvenile Delinquency: Theory, Research, and Interventions Ricky Greenwald, PsyD Editor Trauma and Juvenile Delinquency: Theory, Research, and Interventions has been co-published simultaneously as Journal of Aggression, Maltreatment & Trauma, Volume 6, Number 1 (#11) 2002.

~ 1 Routledge ~~

Taylor & Francis Group New York London

First published by The Haworth Maltreatment & Trauma Press, 10 Alice Street, Binghamton, NY 13904-1580 USA The Haworth Maltreatment & Trauma Press is an imprint of The Haworth Press, Inc., 10 Alice Street, Binghamton, NY 13904-1580 USA. This edition published 2012 by Routledge Routledge Taylor & Francis Group 711 Third Avenue New York, NY 10017

Routledge Taylor & Francis Group 27 Church Road, Hove East Sussex BN3 2FA

Trauma and Juvenile Delinquency: Theory, Research, and Interventions has been co-published simultaneously as Journal of Aggression, Maltreatment & Trauma, Volume 6, Number 1(#11) 2002. © 2002 by The Haworth Press, Inc. All rights reserved. No part of this work may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, microfilm and recording, or by any information storage and retrieval system, without permission in writing from the publisher. The development, preparation, and publication of this work has been undertaken with great care. However, the publisher, employees, editors, and agents of The Haworth Press and all imprints of The Haworth Press, Inc., including The Haworth Medical Press® and The Pharmaceutical Products Press®, are not responsible for any errors contained herein or for consequences that may ensue from use of materials or information contained in this work. Opinions expressed by the author(s) are not necessarily those of The Haworth Press, Inc. Cover design by Anastasia Litwak

Library of Congress Cataloging-in-Publication Data Trauma and juvenile delinquency: theory, research, and interventions / Ricky Greenwald, editor. p. cm. “. . . has been co-published simultaneously as Journal of aggression, maltreatment & trauma, Volume 6, Number 1(#11) 2002.” Includes bibliographical references and index. ISBN 0-7890-1974-4 (alk. paper)–ISBN 0-7890-1975-2 (pbk.: alk. paper) 1. Juvenile delinquents–Psychology. 2. Conduct disorders in adolescence. 3. Psychic trauma. 4. Juvenile delinquents–Rehabilitation. I. Greenwald, Ricky. II. Journal of aggression, maltreatment & trauma. HV9069 .T788 2002 364.2ƍ4–dc21 2002006586

Trauma and Juvenile Delinquency: Theory, Research, and Interventions CONTENTS About the Contributors

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Foreword: Pathways from Childhood Trauma to Adolescent Violence and Delinquency James Garbarino

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Introduction Ricky Greenwald

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SECTION ONE: THEORY AND RESEARCH The Role of Trauma in Conduct Disorder Ricky Greenwald Traumatic Victimization in Childhood and Persistent Problems with Oppositional-Defiance Julian D. Ford Assessment of PTSD and Trauma Exposure in Adolescents Elana Newman Chaos and Trauma in the Lives of Adolescent Females with Antisocial Behavior and Delinquency Patricia Chamberlain Kevin J. Moore

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Violence Exposure and PTSD Among Delinquent Girls Jenifer Wood David W. Foy Carole A. Goguen Robert Pynoos C. Boyd James An Examination of the Relationships Between Violence Exposure, Posttraumatic Stress Symptomatology, and Delinquent Activity: An “Ecopathological” Model of Delinquent Behavior Among Incarcerated Adolescents Jenifer Wood David W. Foy Christopher Layne Robert Pynoos C. Boyd James Neurobiological Disturbances in Youth with Childhood Trauma and in Youth with Conduct Disorder Deborah S. Lipschitz Charles A. Morgan III Steven M. Southwick

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SECTION TWO: INTERVENTIONS Preliminary Development of Trauma-Focused Treatment Groups for Incarcerated Juvenile Offenders Robert A. McMackin Mary Beth Leisen Leslie Sattler Karen Krinsley David S. Riggs Cognitive Processing Therapy for Incarcerated Adolescents with PTSD Julia Ahrens Lillian Rexford

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A Controlled Study of Eye Movement Desensitization and Reprocessing (EMDR) for Boys with Conduct Problems Glenn B. Soberman Ricky Greenwald David L. Rule Motivation-Adaptive Skills-Trauma Resolution (MASTR) Therapy for Adolescents with Conduct Problems: An Open Trial Ricky Greenwald

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Conclusion Ricky Greenwald

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Index

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ABOUT THE EDITOR Ricky Greenwald, PsyD, is Assistant Clinical Professor of Psychiatry (Divisions of Traumatology and Child and Adolescent Psychiatry), and Director of Training for the Children After Trauma Care & Health (CATCH) Program at the Mount Sinai Medical Center in New York City. He recently served as Senior Psychologist of the Mokihana Project, a demonstration project providing mental health services through the public school system in Kauai, Hawaii. Dr. Greenwald, a clinical psychologist, has been working with children, adolescents, and their families since 1985. A leading authority and innovator on using EMDR with children and adolescents, Dr. Greenwald’s 1993 booklet, Using EMDR with Children was the first published standard of care on the subject. His 1999 book Eye Movement Desensitization and Reprocessing (EMDR) in Child and Adolescent Psychotherapy has been translated into German and Italian. Dr. Greenwald has served on the board of directors of the EMDR International Association and received their 1999 Outstanding Contribution and Service Award. Dr. Greenwald has published extensively on child and adolescent trauma assessment and treatment. He developed and validated a parent/child set of child trauma symptom measures, which have been translated into several languages. He also maintains a child trauma Web site, . His current research focus is on the role of trauma in conduct disorder. He is the developer of the MotivationAdaptive Skills-Trauma Resolution (MASTR) individual therapy protocol for youth with conduct disorder and is conducting treatment outcome research using MASTR with incarcerated juvenile delinquents at several New York State facilities.

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ABOUT THE CONTRIBUTORS Julia Ahrens, PhD, is the outpatient supervisor at Johnson County Mental Health Center, Olathe, Kansas. She has seven years experience working in correctional settings and is especially interested in treatment interventions with adolescents. Patricia Chamberlain, PhD, is Founder and Director of the Oregon Social Learning Center’s Treatment Foster Care programs that have served severely disturbed and chronically delinquent youth since 1983. The Oregon TFC model was selected as one of 10 empirically based violence prevention Blueprint programs in 1988 by the Office of Juvenile Justice and Delinquency Prevention, and the Colorado Center for the Study and Prevention of Violence. Julian D. Ford, PhD, is Director of Behavioral Health Outcomes Research and Co-Director of the Center for the Study of High Utilizers of Health Care in the Department of Psychiatry at the University of Connecticut Health Center. He formerly served as Deputy Executive Director of the Department of Veterans Affairs National Center for PTSD and on the faculty of the Dartmouth Medical School. David W. Foy received his PhD in clinical psychology from the University of Southern Mississippi and is currently Professor of Psychology in the Graduate School of Education and Psychology, Pepperdine University. He has conducted research in the areas of social skills training, alcoholism, and posttraumatic stress reactions among survivors of combat, spousal abuse, sexual abuse, and community violence. James Garbarino, PhD, is Co-Director of the Family Life Development Center and Elizabeth Lee Vincent Professor of Human Development at Cornell University in Ithaca, New York. Carole A. Goguen, PsyD, received her doctorate from Pepperdine University in 1998. Her principal interests are in community violence research and treatment of posttraumatic stress disorder, especially among severely mentally ill persons. She is currently Associate Director of Rexv

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search and Education at the Executive Division of the National Center for PTSD and Research Associate Professor at Dartmouth Medical School. Ricky Greenwald, PsyD, is Assistant Clinical Professor of Psychiatry in the Traumatic Stress Studies Program at Mount Sinai School of Medicine in New York. He is active in research on child/adolescent trauma assessment and treatment, and the role of trauma in disruptive behavior disorders. C. Boyd James, PhD, is Professor in the Department of History at Scripps College, Claremont University. Dr. James is Director of the Center for the Study of Violence and Social Change. Karen Krinsley, PhD, received her doctorate in Clinical Psychology from Rutgers University. She is a licensed psychologist working at the National Center for Posttraumatic Stress Disorder in the Boston VA Healthcare System. Christopher Layne received his PhD in clinical psychology from the University of California, Los Angeles, and is currently Assistant Professor of Psychology at Brigham Young University. Dr. Layne’s recent research focuses on the impact of community violence and war-related trauma on children and adolescents. Mary Beth Leisen, PhD, completed her doctorate at the University of Hawaii at Manoa in 1999 and did her internship and postdoctoral fellowship at the National Center for PTSD at the Boston VA Medical Center. She has published several articles on the measurement and treatment of trauma and PTSD. Deborah S. Lipschitz, MD, is Assistant Profesor of Psychiatry at the Yale University School of Medicine and Attending Psychiatrist at the Neuroscience Division of the National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT. Robert A. McMackin, EdD, is Director of Professional Services for Life Resources, Inc., in Braintree, Massachusetts; Program Director of the Shattuck Hospital Youth Service Program in Boston, Massachusetts; and a clinical instructor at Tufts University School of Medicine.

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Dr. McMackin has worked with adult and juvenile offenders for over 25 years. Kevin J. Moore, PhD, is Research Associate at the Oregon Social Learning Center (OSLC) and Clinical Director of OSLC Community Programs specializing in Treatment Foster Care (TFC) and Intensive Home-based services for families and children with severe behavioral and emotional disorders. He is Co-Director of a violent offender treatment program, and consults and trains nationally with organizations regarding TFC and community-based treatment of severely emotionally and behaviorally disturbed youths. Charles A. Morgan III, MD, is Associate Professor of Psychiatry at the Yale University School of Medicine and Director of the Anxiety/PTSD clinic at the Neuroscience Division of the National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT. Elana Newman, PhD, is a licensed clinical psychologist who teaches and conducts research at the University of Tulsa. Her current work is focused on assessment of PTSD in adults and children, research ethics related to conducting research on trauma-exposed adults and children, and the impact of trauma upon journalists. Dr. Newman has revised the Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV. Robert Pynoos, MD, MPH, is Professor of Psychiatry at the UCLA School of Medicine and the Director of the UCLA Trauma Psychiatry Service. He is past-president of the International Society for Traumatic Stress Studies and Co-Editor of Post-Traumatic Stress Disorder in Children. Lillian Rexford, MA, is a therapist employed at the Topeka Juvenile Correctional Facility, where she works with the highest risk clients. She has facilitated sex offender, sexual abuse, and trauma groups in prison. David S. Riggs, PhD, is Assistant Professor in the Department of Psychiatry at the University of Pennsylvania School of Medicine in Philadelphia. David L. Rule, PhD, is Director of Institutional Research and Program Development at St. Thomas Aquinas College, Sparkill, New York. He

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was previously a tenured Assistant Professor of educational psychology and Director of Graduate Educational Psychology at Marist College, Poughkeepsie, New York. Dr. Rule’s specializations are in psychological and educational research methodologies and statistics. Leslie Sattler, MSW, is Clinical Director of the Life Resources Community Leadership Program in Braintree, Massachusetts, and former Clinical Director of Pilgrim Center for Boys, also in Braintree. Ms. Sattler has worked with juvenile offenders for 13 years. Glenn B. Soberman, PhD, is a clinical psychologist currently working with delinquent adolescents at the Goshen Residential Center in Goshen, New York. He is also Adjunct Professor at Marist College in Poughkeepsie, New York. Steven M. Southwick, MD, is Professor of Psychiatry at the Yale University School of Medicine and Program Director of the Neuroscience Division of the National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT. Jenifer Wood received her PhD in clinical psychology from the University of California, Los Angeles, and is currently the Managing Director for the National Center for Child Traumatic Stress at the University of California, Los Angeles.

Foreword: Pathways from Childhood Trauma to Adolescent Violence and Delinquency James Garbarino

On numerous occasions over the last decade I have been asked to provide expert testimony in the cases of juveniles who have engaged in lethal violence. In these cases my job has been to explain to the jury how the accumulation of risk and the corresponding lack of developmental assets in the lives of these kids must be understood to make sense of their crimes. It is not an easy task. Our judgmental culture is often short on compassion for these violent teenagers, preferring retaliation, retribution, and preventive detention to the challenging task of personal transformation and redemption. I have tried to tell these stories and provide an intellectual framework for making sense of those stories in my work [most notably, my book Lost Boys: Why Our Sons Turn Violent and How We Can Save Them (Garbarino, 1999)]. One of the things I learned from listening to these “lost boys” is the central role of trauma in their lives. The main goal of my expert testimony is to establish the relevance of understanding the dynamic links between a youth’s prior experiences with violent trauma and his crimiJames Garbarino, PhD is Co-Director of the Family Life Development Center and Elizabeth Lee Vincent Professor of Human Development at Cornell University in Ithaca, New York. [Haworth co-indexing entry note]: “Foreword: “Pathways from Childhood Trauma to Adolescent Violence and Delinquency”.” Garbarino, James. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1(#11), 2002, pp. xxv-xxxi; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. xix-xxv. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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nal behavior. In attempting to do this I often feel inadequate to the task. Enter Ricky Greenwald and his colleagues. In this book they make a much needed and timely contribution to understanding the dynamic links between trauma and juvenile delinquency. In doing so, they are on firm ground, and they make the most of this opportunity. Understanding the effects of violence on children demands an interdisciplinary perspective, one that incorporates psychological, biological, sociological, anthropological, and historical insights within the context of a larger ecological model. Anchoring this issue is the fact that each year in the United States thousands of children and youth commit acts of lethal violence, half against others (murder) and half against themselves (suicide) (Centers for Disease Control, 1998). The numbers of children and youth who commit potentially lethal acts is, of course, many times greater, what with the tens of thousands of “serious assaults” and “suicide attempts” that take place each year involving minors. For each of these kids, and for the families, communities, and societies of which they are a part, this problem of violence constitutes a crisis. The current crisis of these kids is not historically new, however. Writing in Juvenile Justice Update in 1997, Robert Shepherd points out that the New York Times, 140 years ago, editorially bemoaned the fact that there was such an astonishingly large number of boy burglars, robbers and murderers, that decent men should be alarmed. He offered the following analysis from a child psychiatrist working in Manhattan for the Juvenile Court in the 1950s: “At first it comes as a shock to meet youngsters under 16 who rob at the point of a gun, push dope, rape and kill. I’ve seen boys of 7 so small they could barely clear the desk who had sold themselves to sex perverts. Others had shot out kids eyes or had clubbed or knifed them, just for the fun of it.” This statement is from an article entitled “Manhattan’s Child Criminals Are My Job” in the Saturday Evening Post of March 27, 1954. Recall that in the mid 19th century, the governor of New York had to call out the militia to deal with rampant youth gangs in New York City. But while there are historical dimensions to the current situation, there are features of the contemporary situation that are distinctive as well. For one thing, we must recognize that the magnitude of the problem is different today. There has been a seven-fold increase in per capita aggravated assault rates among youth in the United States since 1956 (“According to the FBI: U.S. Federal Bureau of Investigation,” 1997). Also, kids are being tried as adults and incarcerated correspondingly, in what seems like a macabre return to the medieval concepts of children

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as simply little adults. But the parallel is even more subject to documentation than that. The homicide rate in the city of Amsterdam in the year 1450 is estimated to have been 150 per hundred thousand population (Perry, Pollard, Blakley, Baker, & Vigillante, 1995). By 1850, when Amsterdam had been “civilized,” the rate dropped to two per hundred thousand. This rate might be taken as a kind of baseline for the minimum expectable homicide rate, the rate we find in most of the modern and relatively affluent countries in the world. But in the United States we continue to find rates of 20 per hundred thousand and in the most oppressed social environments within our society we find rates of 160 per hundred thousand population! Homicide rates provide only an imprecise indicator of the overall problem of violence in the lives of American children and youth, however, for behind each murder stand many non-lethal assaults. This ratio varies as a function of both medical trauma technology (which prevents assaults from becoming homicides) and weapons technology (which can increase or decrease the lethality of assaults). An example from Chicago illustrates this: The city’s homicide rate in 1973 and 1993 was approximately the same, and yet the rate of serious assault had increased approximately 400% during that period (Garbarino, Dubrow, Kostelny, & Pardo, 1992). Thus, the ratio of assaults to homicides increased substantially–from 100:1 in 1973 to 400:1 in 1993. Even despite the recent decline in those mid-1990s figures, the rates remain very high by international standards. Class, race, and gender exert important influences on exposure to community violence. The odds of being a homicide victim range from 1:21 for Black males, to 1:369 for white females–with white males at 1:131, and Black females at 1:104. Being an American itself is a risk factor (Bronfenbrenner, McClelland, Wethington, Moen, & Ceci, 1996). Having established this historical and social context, what next becomes clear is that understanding the effects of violence on children is very much a matter of recognizing the developmental links between early experiences of violence as a victim and later experiences of violence as a perpetrator. This developmental relationship exists both within the lives of individual children and across the generations in families. Research indicates that inside virtually every dangerously violent youth is an untreated traumatized child, a child with experiences of violent victimization, and that there is substantial cross-generational continuity in violence within families.

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Research has begun to illuminate the neurological processes that translate early trauma into later dangerous behavior through brain development and neurochemistry. Dodge, Pettitt, and Bates (1997) have further elaborated this link by documenting the adaptive processes that link the experience of violence as a young child to the development of a pattern of aggressive anti-social behavior as an elementary-school age child. Their research reveals that the problem comes when abused children develop four particular psychological adaptations (hypersensitivity to negative social cues, obliviousness to positive social cues, a readily accessible repertoire of aggressive behavior, and a belief that aggression is a successful strategy in social relations). Such children are seven times more likely than abused children who do not develop these patterns to end upon diagnosed with “conduct disorder” (chronic aggressive and anti-social behavior). Abused children who do not develop these patterns are no more likely that children in general to develop conduct disorder. This is highly significant because it is from the ranks of children with conduct disorder that most chronic violent delinquents come (about a third of such children emerge as chronic violent delinquents according to a variety of studies (Loeber & Farrington, 1998). Child abuse and community violence are rampant in the lives of kids who become violent and delinquent youth. This is one of the most important effects of violence on children. My own research illuminates these links through intensive, multiple interviews with boys involved in lethal violence, and highlights the importance of geographic concentrations of violence that create “war zone” like settings for children. These are the social settings in which the rates of child victimization are highest (with child maltreatment rates many times higher than in other neighborhoods) and from which most lethal youth violence comes. A conduct-disordered child from such a neighborhood is many times more likely to end up as a serious violent chronic delinquent than a conduct-disordered child from “the right side of the tracks.” Children living in neighborhoods that simulate “war zones” are exposed to high levels of violence. A survey of 6-10th graders in New Haven, Connecticut, revealed that 40% had witnessed at least one incident of violent crime within the previous 12 months. In three high-risk neighborhoods in Chicago, 17% of the elementary school age children had witnessed domestic violence, 31% had seen someone shot, and 84% had seen someone “beat up” (Bell, 1991). At the height of the youth violence epidemic in the mid 1990s, nearly 30% of the kids living in high crime neighborhoods of major metropolitan areas like Chicago

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had witnessed a homicide by the time they were 15 years old, and more than 70% had witnessed a serious assault (Bell, 1991). These figures are much more like the experience of kids in the war zones I have visited in other countries than they are of what we should expect for children, living in “peace.” A study in Washington, DC reported that 43% of the 5th and 6th graders had witnessed a mugging in a “moderately violent” neighborhood (Richters & Martinez, 1993). Children adapt to their perception of community safety in many important ways. One is their view of the future. A Harris poll of 6th to 12th graders in 1992 revealed that 35% worried they would not live to old age because they would be shot (Harris Associates, (1994). In our interviews with families living in public housing projects in Chicago I learned that virtually all the children had first-hand experiences with shooting by the time they were five years old. A six-year-old girl once said that her job was to find her two-year-old sister whenever the shooting started and get her to safety in the bathtub of their apartment. “The bathroom is the safest place,” she said. Interviews with school-age children and youth confirm that the “gun culture” is a potent factor in the life of children in diverse settings in the United States. When children understand that adults cannot protect them they are left with what we might call juvenile vigilantism, the impulse to protect themselves, to take up weapons and relationships that substitute for adult protection. This is evident in comments from children and youth such as, “If I join a gang I’m 50 percent safe. If I don’t join a gang I’m zero percent safe.” Adults don’t enter into the equation. The key to understanding the effects of living in a “war zone” is the recognition that these children do not simply face a single threat to development, a solitary risk factor. Rather, they face multiple risk factors, a fact of overarching importance in light of the cumulative effect of risk factors (Sameroff, Seifer, Barocas, Zax, & Greenspan, 1987). In the study by Sameroff et al. (1987), while the presence of one or two risk factors was generally manageable for children, the presence of three or more risk factors was associated with significant developmental impairment. These are the children of greatest concern to us, the children who face major accumulations of risk factors, and who are thus most at risk for the psychological effects of trauma due to violence. Psychologist Pat Tolan (1996) examined this phenomenon in detail in a Chicago-based study in which he asked the question, “What percent of kids are resilient if we measure resilience as neither requiring mental health intervention or remedial education?” When he asked that question and analyzed data from boys growing up in the most afflicted war

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zone neighborhoods of Chicago, living in abusive and impoverished families, contending with minority status in a racist society, and looked at these kids over a two year period, the answer was zero percent. None of the children by age 15 were resilient in Tolan’s terms (Tolan, 1996). This testifies to the effects of violence when they occur within a larger context of social and psychological risk accumulation. The relentless pressure imposed on kids who come from that nexus of community violence, family disruption and personal experience of trauma is uniformly overwhelming. As research on the impact of violence on children matures, it turns increasingly to studies of the conditions under which alternative pathways are taken by affected children. Why do some child victims become adolescent perpetrators while others do not? How can early intervention change these pathways? How significant are the neurobiological effects of early trauma? These and other questions will require many years of sustained research to address adequately. Ricky Greenwald and his colleagues have taken on this task, and their contribution is significant. REFERENCES Bell, C. (1991). Traumatic stress and children in danger. Journal of Health Care for the Poor and Underserved, 2 (1), 175-188. Bronfenbrenner, U., McClelland, P., Wethington, E., Moen, P., & Ceci, S. (1996). The State of Americans: This Generation and the Next. New York: Free Press. Centers for Disease Control and Prevention (1998). Youth Risk Behavior Surveillance-United States, 1997. Washington, DC: U.S. Department of Health and Human Services. Dodge, K. A., Pettit, G. S., & Bates, J. E. (1997). How the experience of early physical abuse leads children to become chronically aggressive. In C. Cicchetti & S. L. Toth (Eds.), Developmental Psychopathology: Developmental Perspectives on Trauma: Vol. 9. Theory, Research, and Intervention (pp. 263-288). Rochester, NY: University of Rochester Press. Garbarino, J. (1999). Lost boys: Why our sons turn violent and how we can save them. New York: Anchor Books. Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, P. (1992). Children in Danger; Coping with the Consequences of Community Violence. San Francisco: Jossey-Bass. Harris & Associates (1994). Metropolitan Life survey of the American teacher: Violence in America’s public schools. Part II. Metropolitan Life Insurance. New York, NY. Loeber, R., & Farrington, D. P. (1998). Serious and violent juvenile offenders. In R. Loeber & D. Farrington (Eds.), Serious and Violent Juvenile Offenders: Risk Factors and Successful Interventions. Thousand Oaks, CA: Sage.

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Perry, B., Pollard, R., Blakley, T., Baker, W., & Vigillante, D. (1995). Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain: how “states” become “traits.” Infant Mental Health Journal, 16, 271-289. Richters, J., & Martinez, P. (1993). The NIMH community violence project: Vol. 1. Children as victims of and as witnesses to violence. Psychiatry, 56: 7-21. Sameroff, A., Seifer, R., Barocas, R., Zax, M., & Greenspan, S. (1987). Intelligence quotient scores of 4-year-old children. Social Environmental Risk Factors. Pediatrics, 79, 343-350. Tolan, P. (1996). How resilient is the concept of resilience? Community Psychologist, 4, 12-15. U.S. Bureau of Investigation (1997). 1996 Uniform Crime Report. Washington, DC: U.S. Department of Justice.

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Introduction Ricky Greenwald

It has long been acknowledged that the life histories of juvenile delinquents do not tend to be pretty. Historically, this recognition has sometimes engendered sympathy for the youth, or alternately, the stance that hardship is no excuse for criminal behavior. One perspective might lead to a more supportive response, the other to a more punitive one. Neither response has been particularly helpful. Despite the widespread recognition of the prevalence of adverse life events in the histories of juvenile delinquents, none of the established approaches to management and treatment of juvenile delinquents has really taken into account the likely impact of trauma. In recent years, the study of trauma has burgeoned into a specialized field, and has become the focus of numerous professional organizations, peer-reviewed journals, and advanced degree programs. The study of trauma in juvenile delinquency has become more sophisticated, with an impressive literature now documenting the prevalence of both trauma exposure and post-traumatic symptomatology in juvenile delinquents. There has been an almost imperceptible shift in consciousness from mere acknowledgment of presence of trauma history to a growing recognition that post-traumatic symptoms probably contribute to the acting-out behavior of the juvenile delinquent. Yet, the traditional standard of care persists. It’s time for the next step, time to move from knowledge to understanding to action. The purpose of this volume is to focus attention on the role of trauma in juvenile delinquency by presenting the cutting [Haworth co-indexing entry note]: “Introduction.” Greenwald, Ricky. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1(#11), 2002, pp. 1-3; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 1-3. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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edge in theory, research, and interventions, and to provide direction for further study. Ultimately, we hope that this will lead both to a fuller understanding of the dynamics driving delinquent behavior, and to more effective prevention and intervention practices. The papers in this volume represent significant, if in some cases preliminary, steps towards these goals. The first section of the book is devoted to theory and research on the relationship between trauma and juvenile delinquency. Ricky Greenwald makes the case for trauma’s role in conduct disorder, and integrates trauma theory with existing models of the development and persistence of conduct disorder. Julian D. Ford presents a theory of trauma victim coping as central to the development of the oppositional-defiant core of antisocial behavior. Elana Newman reviews methodology for clinicaland research-oriented assessment of trauma exposure, post-traumatic symptoms, and PTSD in juvenile delinquent and related populations. Two different research teams (Patricia Chamberlain & Kevin J. Moore; Jenifer Wood, David W. Foy, Carole A. Goguen, Robert Pynoos, & C. Boyd James) present data on the understudied prevalence of trauma exposure and post-traumatic symptomatology among female juvenile delinquents. Jenifer Wood and colleagues (David W. Foy, Christopher Layne, Robert Pynoos, & C. Boyd James) present additional data supporting the relationship between exposure to violence, post-traumatic symptoms, and juvenile delinquency. Finally, Deborah S. Lipschitz, Charles A. Morgan III and Stephen M. Southwick review the neurobiological basis for the relationship between trauma and juvenile delinquency. The second section of the collection is devoted to empirically based trauma-focused interventions for juvenile delinquent and related populations. This is such new territory that we were unable to identify any trauma-focused family or milieu treatment approaches appropriate for inclusion. Robert A. McMackin and colleagues (Mary Beth Leisen, Leslie Sattler, Karen Krinsley, & David S. Riggs) describe the early development of a trauma-focused group treatment for incarcerated adolescent boys with significant trauma exposure. Julia Ahrens and Lillian Rexford report on a controlled study of Cognitive Processing Therapy targeting the post-traumatic symptoms of incarcerated adolescent boys with PTSD. Glenn B. Soberman and colleagues (Ricky Greenwald & David L. Rule) report on a controlled study of Eye Movement Desensitization and Reprocessing for adolescent boys in residential or day treatment for severe behavior problems. Finally, Ricky Greenwald reports on an open trial of a multi-component trauma-focused individual

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treatment approach for adolescents with severe school performance and discipline problems. This volume has benefitted from the support and contributions of a number of distinguished authors in this specialty area, with other papers coming from those newer to the field. The quality of the data herein varies considerably, being most robust in regards to the risk factor research. On the basis of these data and on theory from related areas, testable models are presented, which can guide further research. The outcome studies, while clearly preliminary, were each designed on the basis of empirically supported approaches, and then adapted to this population. Thus, these studies represent extensions of treatment research with related populations. While these theories and studies are far from definitive, they do break new and important ground.

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SECTION ONE: THEORY AND RESEARCH

The Role of Trauma in Conduct Disorder Ricky Greenwald

SUMMARY. Trauma is proposed as a key to understanding the development and persistence of conduct disorder, in conjunction with other contributing factors. Trauma history is ubiquitous in the conduct disordered population, and trauma effects can help to account for many features of conduct disorder, including lack of empathy, impulsivity, anger, acting-out, and resistance to treatment. The current standard of care fails to fully address trauma, which may partially explain the low success rate of extant treatment approaches. A trauma-informed perspective is introduced to current models of conduct disorder. Research, prevention, and treatment implications are discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.] Address correspondence to: Ricky Greenwald, PsyD, Box 1228, Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029 USA (E-mail: [email protected]). The author would like to thank Claude M. Chemtob, PhD, for his helpful comments on an earlier draft of this paper. [Haworth co-indexing entry note]: “The Role of Trauma in Conduct Disorder.” Greenwald, Ricky. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 5-23; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 5-23. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

KEYWORDS. Conduct problems, disruptive behavior disorder, violence, trauma therapy, juvenile delinquency, review, etiology, development, theory, treatment

Conduct disorder represents a fairly common pattern of impulsive and antisocial behavior (including, but not limited to, juvenile delinquency), entailing enormous cost to afflicted individuals, their victims, and society (Robins, 1981). We now know a lot about risk factors for the development of conduct disorder. These include: temperament, gender, low intelligence, ADHD, impulsivity, poor coping skills, social failure, parental psychopathology, inappropriate discipline, affiliation with deviant peers, and socioeconomic disadvantage (see Kazdin, 1995; Moffitt, 1993; Patterson, DeBaryshe, & Ramsey, 1989). We address these factors with a variety of treatment approaches, and do help some youth to be successful in socially acceptable ways. Unfortunately, there is as yet no treatment of choice for adolescents with conduct disorder, with even preferred approaches yielding only modest results (Kazdin, 1997b). This may be explained, at least in part, by our failure to address trauma’s contribution to conduct disorder. In this article, I review child/adolescent trauma prevalence and outcomes, with an emphasis on the conduct disorder population, and then propose a key role for trauma in the development and persistence of conduct disorder. I will discuss current treatment approaches in that light, and suggest avenues for further research. CHILD AND ADOLESCENT TRAUMA For present purposes, trauma will be defined as an event in which the child or adolescent experiences intense horror, fear, or pain, along with helplessness (Krystal, 1978). Typical examples include auto accidents, physical or sexual assault, and witnessing violence. However, there is considerable empirical support for the notion that major loss experiences have a trauma-like impact on children and adolescents (Newcorn & Strain, 1992), except that the hyperarousal response may not be present following a loss (Pynoos, 1990). Therefore, although this discussion will focus strictly on trauma, many of the points probably apply to a wider range of adverse life experiences to which conduct-disordered youth have been exposed.

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Prevalence of Trauma Exposure Some of the data on the prevalence of traumatic events in childhood are indirect and suggestive (e.g., counting a single type of trauma), yet persuasive and alarming (Finkelhor & Dziuba-Leatherman, 1994; Pynoos, 1990). Recent research has found very high incidence rates for prior experience of at least one Criterion A (major trauma) stressor (DSM-IV; American Psychiatric Association, 1994) among young adults, most of which presumably occurred during childhood or adolescence. For example, Riise, Corrigan, Uddo, and Sutker (1994) found an 85% incidence rate among a military population (only a minority of which were combat-related). Similarly, Vrana and Lauterbach (1994) found an 84% incidence rate among college students. Trauma during childhood and adolescence is now so common as to be normative (Ford et al., 1996; Greenwald & Rubin, 1999). Among disadvantaged urban youth, exposure to violence and other potentially traumatic events appears to be a regular occurrence (Campbell & Schwarz, 1996; Jenkins, 1995; Ozer & Weinstein, 1998; Singer, Anglin, Song, & Lunghofer, 1995), a consistent finding despite the under-reporting inherent in many study designs (Wolfer, 1997). Many risk factors for conduct disorder also constitute increased risk for trauma, such as exposure to negligent, coercive, pathological, and/or substanceabusing parents; and exposure to poverty-related violence and crime. Effects of Trauma Not all trauma experiences lead to post-traumatic stress reactions (although they may increase future vulnerability); and such reactions, when they do occur, can vary widely in severity and range of symptomatology (Fletcher, 1996; Giaconia et al., 1995). The ability of the individual to recover psychologically from trauma appears to be influenced by numerous factors, including temperament, personality/coping style, severity of exposure, frequency/chronicity of exposure, and post-trauma environmental factors (Fletcher, 1996). Children and adolescents subject to the unfavorable environments that put them at risk for conduct disorder are simultaneously at an increased risk for repeated trauma exposure, as well as non-supportive post-trauma environments; thus, they are at increased risk for post-traumatic stress symptoms. Trauma is experienced as scary, horrible, painful, and intolerable. The potentially overwhelming nature of the traumatic experience can lead to a failure to integrate, work through, or “get over” the memory.

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The associated imagery, affect, and cognition may intrude unchecked, outside the control or mediation of the normal, verbally encoded memory storage system (van der Kolk, 1987). Indeed, elements of the traumatic memory are liable to intrude, unless and until the memory has gone through the normal processing system. Thematically related stimuli may trigger the intrusion of trauma-related material, leading to over-reactivity in some areas. Trauma constitutes a violation of the victim’s sense of safety and belief in the world as a safe place. This can have the effect of re-orienting the victim from a complacent to a defensive posture. The post-traumatic “survival mode” orientation can become self-perpetuating through a dynamic of mutually reinforcing symptoms and responses (Chemtob, Roitblat, Hamada, Carlson, & Twentyman, 1988). In a state of heightened alertness and sensitivity to possible danger, minor or even neutral stimuli can be misinterpreted as threatening, leading to further arousal and defensive action, such as avoidance, withdrawal, or aggression. This, in turn, can lead to reinforcement of the perception of the world as a dangerous place, preventing recovery from the trauma. In other words, survival mode is perpetuated by the psychological experience of ongoing retraumatization. Classic examples include the combat veteran diving for cover when a balloon pops, and the physically abused child who perceives an accidental bump by a passing peer to be an assault. Even the intrusive memory itself can be perceived as threatening. The trauma victim may learn to live in a psychological “war zone” (Garbarino, 1999) and adjusts accordingly, while remaining ever vulnerable to the unprocessed memory elements. The effects of unintegrated traumatic experiences can thus become permanently established, potentially leading to a variety of post-traumatic symptoms, and forming the basis of many types of psychopathology (e.g., Brom, 1991; Conaway & Hansen, 1989; Famularo, Kinscherff, & Fenton, 1992; Flisher et al., 1997; Green, 1983; Kendall-Tackett, Williams, & Finkelhor, 1993; Terr, 1991; van der Kolk, 1987). The high rate of conduct disorder-related co-morbidity noted in the literature (Wierson, Forehand, & Frame, 1992), mainly affective disorders and substance abuse, may partially reflect trauma effects; although, one co-morbid condition does not cause the other, both may arise from common pathways, such as adverse living conditions (Fergusson, Lynskey, & Horwood, 1996) which also engender trauma. Trauma may also lead to lasting symptoms in lieu of any formal diagnosis (e.g., Cuffe et al., 1998; Giaconia et al., 1995). This confusing array

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of responses to traumatization may partially account for the field’s general failure to address trauma effects in conduct disorder. TRAUMA’S CONTRIBUTION TO CONDUCT DISORDER Although trauma effects can manifest in many ways, when combined with the other risk factors noted above, trauma may be integral to the development and persistence of conduct disorder. Certain key features of the disorder can be explained much more completely by considering the trauma contribution. Trauma can violate basic trust, disrupt attachment, and interfere with empathy (James, 1989), which may reduce inhibitions regarding crimes against others. Trauma can leave the victim in a perpetual state of alert; this sensitivity to threat can lead to a hostile attribution bias, leading, in turn, to impaired social competence and increased aggressive behaviors (Chemtob et al., 1988; Hartman & Burgess, 1993). Trauma can engender anger and violent acting out (Chemtob, Novaco, Hamada, Gross, & Smith, 1997). Trauma can create intolerable emotion, such as intense fear or sadness, sometimes leading to substance abuse (Clark, Lesnick, & Hegedus, 1997; Steward, 1996) and other high-risk activities (Hernandez, Lodico, & DiClemente, 1993). Trauma can diminish the sense of future (Fletcher, 1996; Terr, 1991), fostering an instant gratification orientation and precluding regard for delayed consequences or investment in the longterm. Trauma’s unintegrated imagery and intense emotional reactivity can lead to affect dysregulation, along with violent and destructive acting-out (van der Kolk et al., 1996). Trauma effects can last indefinitely and can become a primary focus around which personality and behavior are organized (Terr, 1991; van der Kolk et al., 1996). There is a considerable body of literature documenting the relationship between trauma/maltreatment and subsequent aggressive/criminal acting-out (see Malinosky-Rummell & Hansen, 1993; Widom, 1989). Prospective studies have identified trauma exposure as a significant risk factor for youth antisocial behavior (Herrenkohl, Egolf, & Herrenkohl, 1997; Luntz & Widom, 1994; Pakiz, Reinherz, & Giaconia, 1997; Rivera & Widom, 1990; Thornberry, 1994). Although not all traumatized youth become antisocial, studies of antisocial youth have found rates of self-reported trauma exposure ranging from 70% to 92% (Dembo, La Voie, Schmeidler, & Washburn, 1987; Lewis, Mallouh, & Webb, 1989; McMackin, Morrissey, Newman, Erwin, & Daley, 1998; Rivera & Widom, 1990; Steiner, Garcia, &

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Matthews, 1997). The trend of more recent studies reporting higher exposure rates may reflect improved methodology and/or higher rates of exposure for the more recent cohort. Although much of this research has focused on physical and sexual abuse, exposure to community violence is also a major concern. For example, Wood and colleagues (Wood, Foy, Layne, Pynoos, & James, this volume) reported that 57% of their sample of incarcerated adolescents had witnessed a murder, 17% had witnessed a suicide, and 72% had been shot or shot at. The effect of trauma exposure is not predetermined, and may be expressed in a range of symptom presentations. Antisocial youth have been found to have high rates of post-traumatic stress disorder (PTSD), ranging from 24% to 65% (Burton, Foy, Bwanausi, Johnson, & Moore, 1994; Cauffman, Feldman, Waterman, & Steiner, 1998; Doyle & Bauer, 1989; McMackin et al., 1998; Steiner et al., 1997; Watson, Kucala, Manifold, Juba, & Vassar, 1988; Wood, Foy, Layne et al., this volume). Since trauma exposure can lead to a range of problems in addition to PTSD (Giaconia et al., 1995; Kendall-Tackett, Williams, & Finkelhor, 1993), this represents a conservative estimate of trauma-related symptoms and functional impairment in this population. For example, Giaconia and colleagues found that girls in their large community sample were six times more likely to have PTSD than boys following trauma exposure; however, boys and girls experienced similar levels of dysfunction following trauma exposure, regardless of diagnostic status. It is even possible that in some cases conduct disorder is a direct expression of post-traumatic symptomatology. A study of combat veterans found that combat-related trauma predicted both PTSD symptomatology and antisocial behavior, making an additional contribution to the antisocial behavior beyond pre-morbid predictors (Resnick, Foy, Donahoe, & Miller, 1989). A study comparing adolescents with conduct disorder and adolescents with PTSD found equally severe behavioral symptoms in both groups (Atlas, DiScipio, Schwartz, & Sessoms, 1991). In another study, adolescents in residential treatment (diagnoses not specified) were indistinguishable from incarcerated adolescents by either psychological symptoms or behaviors (Cohen et al., 1990). However, since there are many possible psychological and behavioral outcomes to trauma (Giaconia et al., 1995; Kendall-Tackett, Williams, & Finkelhor, 1993), it is certain that other factors, such as ADHD, unfavorable environment, etc., are still very important in determining specific outcomes, such as antisocial behavior.

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TRAUMA IN DEVELOPMENTAL MODELS OF CONDUCT DISORDER Recognition of trauma’s possible role in the development and persistence of conduct disorder does not necessarily entail discarding prior models; rather, those models are enriched. Trauma can help to account for the dynamic underpinnings of the models, helping to explain why they work. In this light, two prominent models are briefly reviewed below. The Reinforcement for Coercive Behavior Model This model of conduct disorder posits that a pattern of ineffectual, combined with intermittently explosive discipline reinforces non-compliant and coercive rather than pro-social behaviors, because the child’s antisocial behaviors lead to positive outcomes, such as termination of aversive parental behavior and/or obtaining desired goods or privileges (Patterson, 1986). The child’s increasing reliance on non-compliant and coercive behaviors leads to increased parental rejection, peer rejection, school discipline problems, school underachievement, and failure to develop empathy via appropriate family and peer relations. In addition to failing to gain competence in prosocial interpersonal skills, such youth may become socially isolated and depressed. Later exposure to a deviant peer group provides in-group social acceptance along with training and reinforcement from peers for more serious antisocial behaviors (Patterson, DeBaryshe, & Ramsey, 1989). One plausible role for trauma within this model relates to the affect dysregulation and consequent acting-out, which is characteristic of many traumatized individuals (van der Kolk et al., 1996). Some research suggests that affect dysregulation may be as powerful a predictor of antisocial behavior as parental reinforcement for coercive behavior (Snyder, Schrepferman, & St. Peter, 1997). There may be a synergistic effect of mutual reinforcement between these two factors, in that children who are emotionally over-reactive are more likely to engage in confrontive, coercive, and non-compliant behaviors (Snyder et al., 1997), leading, in turn, to more parental reactivity and harshness (Lytton, 1990). This dynamic could also explain the recent finding that trauma exposure was higher among youth with oppositional defiant disorder (a common precursor to conduct disorder) than those with adjustment disorder or ADH/D, even after controlling for other risk factors (Ford et al., in press).

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Another plausible role for trauma relates to the question of just what is being reinforced when parents respond inappropriately to children’s non-compliant and coercive behaviors. In fact, many of the child’s antisocial behaviors lead to apparently negative consequences, such as verbal or physical abuse, rejection, or loss of privileges. There is some research to support the notion that, at least on some occasions, what is reinforcing is not that the child gets “what he wants” in some material sense, but that by forcing an ostensibly aversive parental response, he has turned a chaotic environment into a predictable one (Wahler & Dumas, 1986). Although a chaotic environment might be uncomfortable for many children, it would be particularly disconcerting for a traumatized child, who may view predictable punishment (or predictable “aversive” attention) as preferable to chaos. Trauma may also play a central role in the persistence of conduct disorder. Trauma-related hypersensitivity to threat (Chemtob et al., 1988) can lead to misinterpretation of social cues, heightened arousal and anger, and inappropriate aggression in the perceived cause of self-protection. This information processing style is consistent with the “hostile attribution bias” commonly noted among antisocial youth (e.g., Dodge & Frame, 1982) and its use increases as a result of increased feelings of vulnerability or threat (Dodge & Somberg, 1987). This information processing style is self-perpetuating because the perception of threat increases the likelihood of aggression, engendering hostility in others and thus confirming the perception of others as dangerous. Similarly, anger in traumatized youth may serve the function of dampening fear and thus be self-reinforcing (Novaco, 1976). Furthermore, trauma-related affect dysregulation may trigger reactivity to a variety of situations and stimuli perceived as thematically related to the trauma. A recent study found that situations triggering trauma-related helplessness, and to a lesser extent fear or horror, accounted for initiating 81% of the “offense cycle” patterns of a sample of adolescent sex offenders, according to therapist ratings (McMackin, LaFratta, & Litwin, 2000). While the acting-out behavior may provide immediate relief from the trauma-related thoughts and feelings, the consequences of that behavior often serve to confirm the negative lessons initially learned from the trauma, thus reinforcing reactivity and continued susceptibility to re-offending (see Figure 1). The Cumulative Risk Model The Cumulative Risk model (more accurately, an atheoretical, piecemeal approach to explanation) posits that the greater number of risk fac-

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FIGURE 1. Trauma-Informed Offense Cycle

Trauma History Example: Physical Abuse (Sense of danger; anger, helplessness) The negative consequences confirm lessons learned in the trauma history, thus increasing sensitivity to trigger situations. Trigger Situations Example: Disrespect from a Peer

Negative Consequences

Cognitive & Emotional Response

Example: Fight, School Expulsion

Example: “I’m in danger,” Angry, Helpless

Quick-Relief Behavior Example: Attack the Peer

(Intervention can occur at many points in the cycle, while the relevance of trauma is reiterated.)

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tors present, the greater the risk that conduct disorder will develop. These factors may have interactive and progressive effects. Trauma may play a role in several of the risk factors that have been identified as contributing to conduct disorder. For example, various aspects of temperament have been implicated as predictors to developing conduct disorder (Lytton, 1990; Newman & Wallace, 1993; Moffitt & Henry, 1989); however, what is identified as temperament in the cited studies may already reflect the pervasive effects of early trauma (Perry, Pollard, Blakley, Baker, & Vigilante, 1995). Attention Deficit/Hyperactive Disorder (ADHD), widely identified as a risk factor for conduct disorder (Jensen, Martin, & Cantwell, 1997), may sometimes actually represent mis-diagnosed PTSD (Cuffe, McCullough, & Pumariega, 1994; Friedman, Harper, Becker, Wilson, & Tinker, 1997). Learning and academic problems are another widely cited risk factor (Hinshaw, 1997); neuropsychological deficits impeding memory and learning have been linked to child maltreatment (Palmer, Frantz et al., 1999; Perry et al., 1995). Furthermore, traumatized child, adolescent, and young adult populations do worse than less traumatized controls on a variety of measures of intelligence and academic achievement (Garcia, Lauterbach, Pavlicek, Burns, & Sykes, 1999; Loiselle & Belicki, 1999; Palmer, Brinker, Nicolini, & Farrar, 1999). The deficits in cognitive processing of interpersonal cues noted in the literature (e.g., Dodge & Frame, 1982; Dodge & Somberg, 1987) may reflect the hostile attribution bias noted among some traumatized individuals who are hypersensitive to indicators of threat (Chemtob et al., 1988; Hartman & Burgess, 1993). Even parental harshness and rejection can be stimulated by a child’s volatility and noncompliance (Lytton, 1990)–again, the child’s misbehavior may reflect traumatization (Fletcher, 1996). In sum, the post-traumatic reaction is potentially so pervasive for some individuals that a variety of identified conduct disorder risk factors may be created, mimicked, and/or exacerbated as a result of trauma. TREATMENT ISSUES Despite the prevalence of trauma history and post-traumatic symptoms among adolescents with conduct disorder, treatment programs tend to address it only in a partial manner. Since trauma effects can be so powerful, this gap in treatment may leave the youth relatively imper-

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vious to the other elements of the treatment program. Until trauma effects are directly targeted and effectively addressed, success rates with this population may remain at the current level. Trauma treatment involves two general phases: establishing a sense of safety and working through the traumatic material (Cohen, Berliner, & March, 2000; James, 1989; Pynoos & Eth, 1986). Safety can be effectively addressed in many ways within a milieu treatment program for adolescents with conduct disorder. A range of physical and behavioral controls helps to maintain a sense of bodily safety. Positive relationships with individual staff members, as well as consistent rules and daily routine, help to foster a sense of emotional safety. In outpatient treatment, parent training contributes to environmental stability, predictability, and supportiveness, and has documented effectiveness, particularly with younger children (Kazdin, 1997a). Cognitive-behavioral training also contributes to safety, in that increased self-control allows for increased control over, and therefore, predictability of, the environment. For example, in a study of volatile veterans with PTSD, participation in an anger management group led to increased self-control as well as reduction of trauma symptoms that were apparently unrelated to the anger treatment (e.g., intrusive thoughts and images), whereas the routine care for PTSD did neither (Chemtob, Novaco, Hamada, & Gross, 1997). Although cognitive-behavioral interventions do show modest effectiveness with conduct-disordered youth (Kazdin, 1997b), posttraumatic symptomatology has not been tracked in these studies. Consistent with this trauma-informed perspective, Greenwood (1994) observed that the more effective residential programs for juvenile delinquents do feature cognitive-behavioral treatment as well as small, non-institutional settings in which a relatively secure and supportive environment can be provided. Unfortunately, current treatment approaches for conduct disorder do not address the working-through phase very well. In some programs there is at least an attempt to do this, whether individually or in group work, but it is unlikely to be very helpful. (In lieu of directly applicable studies, see Solomon, Gerrity, & Muff, 1992, for a discussion of treatment difficulties). First of all, the conduct disordered population is extremely resistant to even engaging in psychotherapy (Kazdin, Mazurick, & Bass, 1993; Sommers-Flanagan & Sommers-Flanagan, 1995). Traumatized youth may be strongly inclined to avoid close relationships, avoid reminders of the trauma, and avoid even temporary distress for a long-term treatment-related gain that they do not believe they will see. Secondly, even those who are willing to address the trauma in

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treatment typically make only limited progress toward actual resolution and symptom reduction. Clinical experience indicates that many who attempt to face their traumatic memories only get upset, leading to acting-out, negative consequences, and then increased resistance to treatment. The treatment methods used are potentially harmful, generally inadequate, and at best, inconsistently effective. However, preliminary reports of more successful trauma-focused treatment of conduct-disordered youth are beginning to emerge (e.g., Doyle & Bauer, 1989; Greenwald, this volume; Greenwald, Lundberg, & Smyth, 2001). CONCLUSION Further ascertaining the role of trauma in conduct disorder can be accomplished in several ways. Trauma-related assessment can be included in prospective studies of child/adolescent development. Archival studies and retrospective interviewing can also help to ascertain whether or not trauma history precedes, or even precipitates, conduct problems. Trauma history and symptoms can also be assessed at intake or at other points when youth with conduct disorder are identified and accessible. In these contexts it will be important not merely to assess for Criterion A events and PTSD (DSM-IV; APA, 1994), but for the full range of adverse life events and post-traumatic symptomatology, because trauma effects are of clinical and theoretical interest regardless of formal diagnosis. A more complete elaboration of this traumagenic model of conduct disorder will emerge from studying the interaction between traumatic exposure, post-traumatic symptoms, behavioral contingencies, and other identified contributors to conduct disorder. Since conduct disorder encompasses subtypes (e.g., Christian, Frick, Hill, Tyler, & Frazer, 1997; Moffitt, 1993; Sorensen & Johnson, 1996), these should be considered, as some of these may prove more trauma-related than others. Gender is also likely to be a variable of interest, given gender-related differences in behavioral expressions of psychopathology (Zahn-Waxler, 1993), higher rates of PTSD among incarcerated girls compared to incarcerated boys (Cauffman et al., 1998), and somewhat different developmental paths for male versus female juvenile delinquents (Wood, Foy, Gogeun, James, & Pynoos, 2001). Ultimately we should be able to describe the various typical developmental paths that result in conduct disorder, and to specify trauma’s possible contribution at critical points. Trauma-focused treatment approaches can also be tested, preferably systematic trauma treatments (e.g., Doyle & Bauer, 1989; Greenwald;

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this volume) rather than partial approaches, such as psycho-education or symptom management training. Since conduct disorder seems to be complex and multi-determined, a comprehensive approach including trauma treatment is likely to be more consistently effective than a stand-alone trauma treatment. In treatment outcome studies, both trauma symptoms and conduct disorder symptoms should be tracked to ascertain whether reduction in conduct disorder symptoms is indeed related to the trauma effects. Existing effective prevention approaches for conduct disorder (e.g., Zigler, Taussig, & Black, 1992) can be analyzed for impact on trauma-related issues, such as increased environmental stability and reduced risk of trauma exposure, as well as indices of post-traumatic symptomatology. Trauma prevention and treatment components can be added to early intervention/prevention approaches and evaluated for additional yield. Considering trauma may prove to be key to a more dynamic and comprehensive understanding of conduct disorder, leading to more effective prevention and treatment. Given the ubiquity of trauma in the histories of conduct disordered youth, with potentially profound and lasting effects, trauma may play a central role in the development and persistence of conduct disorder for a large subset–even a majority–of this population. Without negating other important components of prevention and treatment, it may be useful to consider trauma as an organizing principle informing prevention and treatment approaches. Effectively addressing trauma means that other potentially effective interventions may stand a better chance of success. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Atlas, J. A., DiScipio, W. J., Schwartz, R., & Sessoms, L. (1991). Symptom correlates among adolescents showing posttraumatic stress disorder versus conduct disorder. Psychological Reports, 69, 920-922. Brom, D. (1991). The prevalence of posttraumatic psychopathology in the general and the clinical population. Israel Journal of Psychiatry & Related Sciences, 28, 53-63. Burton, D., Foy, D., Bwanausi, C., Johnson, J., & Moore, L. (1994). The relationship between traumatic exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile offenders. Journal of Traumatic Stress, 7, 83-92. Campbell, C., & Schwarz, D. (1996). Prevalence and impact of exposure to interpersonal violence among suburban and urban middle school students. Pediatrics, 98, 396-402.

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Cauffman, E., Feldman, S. S., Waterman, J., & Steiner, H. (1998). Posttraumatic stress disorder among female juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1209-1216. Chemtob, C. M., Roitblat, H. L., Hamada, R. S., Carlson, J., & Twentyman, C. (1988). A cognitive action theory of posttraumatic stress disorder. Journal of Anxiety Disorders, 2, 253-275. Chemtob, C. M., Novaco, R. W., Hamada, R. S., & Gross, D. M. (1997). Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 65, 184-189. Chemtob, C. M., Novaco, R. W., Hamada, R. S., Gross, D. M., & Smith, G. A. (1997). Anger regulation deficits in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 10, 17-36. Christian, R. E., Frick, P. J., Hill, N. L., Tyler, L., & Frazer, D. R. (1997). Psychopathy and conduct problems in children: II. Implications for subtyping children with conduct problems. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 233-241. Clark, D. B., Lesnick, L., & Hegedus, A. M. (1997). Traumas and other adverse life events in adolescents with alcohol abuse and dependence. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1744-1751. Cohen, J. A., Berliner, L., & March, J. S. (2000). Treatment of children and adolescents. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 106-138). New York: Guilford. Cohen, R., Parmelee, D. X., Irwin, L., Weisz, J. R., Howard, P., Purcell, P., & Best, A. M. (1990). Characteristics of children and adolescents in a psychiatric hospital and a corrections facility. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 909-913. Conaway, L. P., & Hansen, D. J. (1989). Social behavior of physically abused and neglected children: A critical review. Clinical Psychology Review, 9, 627-652. Cuffe, S. P., Addy, C. L., Garrison, C. Z., Waller, J. L., Jackson, K. L., McKeown, R. E., & Chilappagari, S. (1998). Prevalence of PTSD in a community sample of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 147-154. Cuffe, S. P., McCullough, E. L., & Pumariega, A. J. (1994). Comorbidity of attention deficit hyperactivity disorder and post-traumatic stress disorder. Journal of Child and Family Studies, 3, 327-336. Dembo, R., La Voie, L., Schmeidler, J., & Washburn, M. (1987). The nature and correlates of psychological/emotional functioning among a sample of detained youth. Criminal Justice and Behavior, 14, 311-334. Dodge, K. A., & Frame, C. L. (1982). Social cognitive biases and deficits in aggressive boys. Child Development, 53, 620-635. Dodge, K. A., & Somberg, D. R. (1987). Hostile attributional biases among aggressive boys are exacerbated under conditions of threats to the self. Child Development, 58, 213-224. Doyle, J. S., & Bauer, S. K. (1989). Post-traumatic stress disorder in children: Its identification and treatment in a residential setting for emotionally disturbed youth. Journal of Traumatic Stress, 2, 275-288.

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Traumatic Victimization in Childhood and Persistent Problems with Oppositional-Defiance Julian D. Ford

SUMMARY. A number of studies suggest similarities between the psychosocial impairment caused by traumatic victimization and the “cascade” (Patterson, 1993) of problems experienced by youths with severe and persistent problems with oppositional-defiance. Evidence indicating that traumatic victimization may be a factor in disruptive behavior disorders is reviewed. A preliminary conceptual model is proposed as a basis for clinical and research hypothesis testing concerning the potential relationship between traumatic victimization and problematic oppositional-defiance. The model postulates a chronological sequence from (a) victimization in childhood, to (b) escalating dysregulation of emotion and social information processing (“survival coping”), to (c) severe and persistent problems with oppositional-defiance and overt or covert aggression which are compounded by post-traumatic symptoms (“victim coping”). Implications for diagnosis, prevention, treatment, and research are discussed. Address correspondence to: Julian D. Ford, PhD, Department of Psychiatry, MC6228, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030 (E-mail: [email protected]). The author gratefully acknowledges the contributions of the Dartmouth Child Psychiatry/National Center for PTSD research group to earlier versions of the paper presented at the 1997 and 1998 Meetings of the International Society for Traumatic Stress Studies. [Haworth co-indexing entry note]: “Traumatic Victimization in Childhood and Persistent Problems with Oppositional-Defiance.” Ford, Julian D. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 25-58; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 25-58. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Abuse, violence, disruptive behavior disorders, posttraumatic stress disorder

Traumatic victimization (e.g., physical abuse, domestic violence, community violence) occurs often in the lives of children (Boney-McCoy and Finkelhor, 1995). As a result, children (DeBellis et al., 1999a, 1999b; Merry & Andrews, 1994) and adolescents (Cauffman, Feldman, Waterman, & Steiner, 1998; Cuffe et al., 1998; Steiner, Garcia, & Matthews, 1997) may suffer major biological alterations and severe psychosocial impairment. These debilitating problems can persist into adulthood in the form of chronic post-traumatic stress disorder (PTSD), and other disorders of anxiety, mood, addiction, self-regulation, and interpersonal relatedness (Ford, 1999; Mullen, Martin, Anderson, Romans, & Herbison, 1996; Neumann, Houskamp, Pollock, & Briere, 1996; Zlotnick, 1999). Moreover, traumatic victimization may be a factor in the development of persistent problems with oppositional-defiance, aggression, and delinquency in youths (Dodge, Pettit, Bates, & Valente, 1995; Ford et al., 1999). I will review and attempt to integrate the research literatures concerning (a) the development of oppositional-defiance, and (b) the impact of traumatic victimization in childhood and adolescence. I will make the case that victimization and oppositionaldefiance involve similar breakdowns in the psychobiological capacities required to regulate emotions and process social information. TRAUMATIC VICTIMIZATION AND THE DISRUPTIVE BEHAVIOR DISORDERS IN CHILDHOOD AND ADOLESCENCE Disruptive behavior disorders affect up to 10% of all children and 33% of those referred for psychiatric care (Costello, Angold, Burns, Stangl et al., 1996; Lahey, Applegate, Barkley et al., 1994; Lahey, Applegate, McBurnett et al., 1994). Almost three in four children meeting criteria for attention deficit hyperactivity disorder (ADHD) and

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more than 90% with oppositional-defiant disorder (ODD) are considered severely emotionally disturbed in the family, school, peer, and legal domains (Angold & Costello, 1996). ADHD, ODD, and conduct disorder often involve worse psychosocial impairment than major depression or many other child psychiatric disorders (Costello, Angold, Burns, Erkanli et al., 1996). Twin studies indicate that ADHD, ODD, and related severe behavior problems of youth (e.g., conduct disorder [CD], substance abuse) are attributable to the combined and separate effects of genetic (Comings, 1997; O’Connor, McGuire, Reiss, Hetherington, & Plomin 1998; Slutske et al., 1997), shared (family) environmental (Lyons, 1996; O’Connor et al., 1998), and unique (individual) environmental (Slutske et al., 1998) factors. Of particular relevance, a recent review notes that the potential contributing environmental factors include “peer groups, school experiences, treatment by parents, and stressful or traumatic life events” (Slutske et al., 1998, p. 371, italics added). How might “traumatic life events” contribute to disruptive behavior disorders such as ADHD or ODD? Psychological trauma is defined by the American Psychiatric Association’s (1994) Diagnostic and Statistical Manual of Mental Disorders as exposure to an event involving “actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” such that “the person’s response involved intense fear, helplessness, or horror,” which “may be expressed instead by disorganized or agitated behavior” by a child (p. 209). Thus, psychological trauma involves an event that confronts the person with the reality or very real possibility of death, serious physical injury, or a physical violation (e.g., rape or incest). In addition, the person’s response must also be emotionally “intense.” Thus, psychological trauma is biologically and emotionally shocking, potentially altering a child’s body (e.g., DeBellis et al., 1999a, 1999b), and thus her or his most basic emotions and personality. Although many types of events may be psychologically traumatic, I will focus on a particular type of traumatic event: traumatic victimization. Victimization refers to the experience of being threatened or harmed intentionally by another person (e.g., sexual or physical abuse; violent assault or rape), and may include being exposed to violence by significant others as a witness (e.g., a child exposed to domestic or community violence suffered or perpetrated by older family members, peers, or neighbors). When the experience of victimization meets the DSM-IV (APA, 1994) criteria for dangerousness and emotional response, then the event(s) can be considered “traumatic victimization.” Unfortunately, traumatic victimization is highly prevalent:

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Half of all children or adolescents in the community (Boney-McCoy & Finkelhor, 1995; Cuffe et al., 1998) and two-thirds in psychiatric samples (Cauffman et al., 1998; Neumann et al., 1996; Steiner et al., 1997; Weaver & Clum, 1993; Weine, Becker, Levy, Edell, & McGlashan, 1997) are exposed to severe violence. When victimization occurs in childhood and adolescence, the sequelae can include a variety of often persistent and debilitating emotional and behavioral problems, including PTSD and other anxiety disorders (Fergusson, Horwood, & Lynskey, 1996; Lynskey & Fergusson, 1997; Neumann et al., 1996), depression and suicidality (Fergusson et al., 1996; Kaplan et al., 1998; Lipschitz et al., 1999; Lynskey & Fergusson, 1997), addictions (Brady, Dansky, Sonne, & Saladin, 1998; Epstein, Saunders, Kilpatrick, & Resnick, 1998; Fergusson et al., 1996; Kaplan et al., 1998; Lynskey & Fergusson, 1997), and eating disorders (Neumann et al., 1996; Welch & Fairburn, 1996). In addition, several studies suggest that traumatic victimization is associated with ODD (Flisher et al., 1997; Merry & Andrews, 1994) and CD (Cauffman et al., 1998; Fergusson et al., 1996; Kaplan et al., 1998; Lynskey & Fergusson, 1997; Steiner et al., 1997). The evidence linking trauma or PTSD and ADHD is weaker: Three studies suggest ADHD is associated with trauma or PTSD (Cuffe, McCullough, & Pumariega, 1994; Famularo, Fenton, Kinscherff, & Augustyn, 1996; Merry & Andrews, 1994), but two studies find PTSD or trauma to be unrelated to ADHD (McLeer, Callaghan, Henry, & Wallen, 1994; Wozniak et al., 1999). Ford et al. (2000) note that several PTSD symptoms parallel the features of ODD and CD. For example, when trauma is intrusively re-experienced a child may react angrily or defiantly as well as with fear or anxiety. PTSD’s persistent avoidance of trauma reminders may take the form of an oppositional refusal to engage in certain activities or to follow rules, especially if it is expressed with the intense anger or irritability, which also is a hallmark of PTSD. What may seem to be callous indifference to the feelings or rights of peers or adults (commonly found in ODD or CD) may be a result of PTSD’s emotional numbing, social detachment, or hypervigilance. The resentful suspiciousness of ODD may arise from PTSD’s hypervigilance. These parallels between PTSD and ODD/CD raise the question of whether traumatic victimization could play a role in either ODD or CD. However, traumatic victimization is unlikely to be the primary cause of ODD or CD. Genetic influences are a major factor in ODD and CD (Lahey, Waldman, & McBurnett, 1999), and are implicated in the etiology of PTSD (True, 1993). Also, environmental factors other than trau-

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matic victimization are likely to contribute to the development of PTSD, as well as to ODD and CD. Two environmental factors which have been implicated in the development of childhood PTSD (Cuffe et al., 1998; Neumann et al., 1996) also are involved in the etiology of ODD and CD (Clark, 1998; Lahey et al., 1999; Langbehn, Cadoret, Yates, Troughton, & Stewart, 1998): a family history of mental illness or substance abuse (“family psychopathology”) and severe interpersonal discord in the parent-child relationship or the family (“family conflict”). Family psychopathology and family conflict can create severe stress and distress, and may also cause (or be the products of) traumatic victimization. How might traumatic victimization play a role in family conflict and psychopathology? Recent studies suggest that children whose families are troubled by psychopathology (Neumann et al., 1996) or conflict (Boney-McCoy & Finkelhor, 1996) often experience traumatic victimization either within or outside the family. Studies also indicate that traumatic victimization has a greater (adverse) impact on youths’ extreme emotional problems (e.g., PTSD, suicide) than either family psychopathology or conflict (Kilpatrick & Williams, 1998; Wagner, 1997). In some cases, traumatic victimization actually may be the vehicle by which family psychopathology or conflict cause behavioral and emotional problems. For instance, family psychopathology or conflict may directly lead to traumatic victimization in the form of aggressive, impulsive, or otherwise abusive or severely neglectful behaviors directed at a child (Banyard, 1999; Chaffin, Kelleher, & Hollenberg, 1996; Chan, 1994). Alternately, living with severe family psychopathology or conflict may indirectly teach children that abuse, neglect, or domestic violence is normal, acceptable, or even desirable. Such modeling and social reinforcement of potentially traumatic behavior in a family can lead children to imitate or tolerate victimization behaviors not only in the family but also in their peer or community relationships (Cauffman et al., 1998; Chaffin et al., 1996; Steiner et al., 1997). Traumatic victimization inside the family (Feiring, Taska, & Lewis, 1998; Morrison & Clavenna-Valleroy, 1998) or in non-family relationships (Overstreet, Dempsey, Graham, & Moely, 1999) also may compromise the already poor levels of social support in families with severe psychopathology or conflict. Social support within a family can buffer against the ill effects of family psychopathology or conflict on children’s behavioral health (Compas, Connor, & Wadsworth, 1997; Lahey et al., 1999). If victimization interferes with or leads to compromised family support, children may be more vulnerable to the adverse effects of fam-

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ily psychopathology or conflict. Thus, the harm to a child’s emotional or behavioral health caused by family psychopathology or conflict may be due in part to traumatic victimization rather than simply to the general ill effects of living in a disturbed or conflictual family. Therefore, while not assuming that traumatic victimization causes childhood behavior disorders, it is important to explore how traumatic victimization could contribute to these debilitating disorders. Ford et al. (1999) recently found that more than three in four children in outpatient psychiatric treatment for ODD had been traumatically victimized. By comparison, fewer than one in three children with ADHD or adjustment disorders had been traumatically victimized. Further analyses of these data (Ford et al., 2000) suggested that the “PTSD” symptoms of children with ADHD were primarily hyperarousal symptoms, such as problems with irritability or concentration that may actually be due to ADHD rather than to the effects of trauma or PTSD. Interestingly, Wozniak et al.’s (1999) prospective study of the association of ADHD with trauma and PTSD reported similar findings. Wozniak et al. found that children with ADHD were no more likely to be exposed to trauma or to develop PTSD than similar children who did not have ADHD. Exposure to trauma led children to be at risk for depression, but not for ADHD. Thus, although some children experience comorbid ADHD and PTSD (Cuffe et al., 1994; Famularo et al., 1996; Merry & Andrews, 1994), these two disorders appear to be relatively independent, and psychological trauma does not appear to play a role in the development of ADHD. However, children with ODD had high levels of symptoms that are characteristic of PTSD (i.e., fear-related problems with sleep, hypervigilance, and startle response). Ford et al. (2000) also found that children diagnosed with ODD had the most severe overall psychopathology and social impairment, which appeared to be explained primarily by their PTSD symptoms. Also, PTSD symptoms had a negative impact on psychosocial impairment, regardless of whether the child was experiencing other emotional problems (e.g., depression, anxiety), and regardless of the child’s age, gender, and family functioning (e.g., socioeconomic status, history of psychopathology, parent-child conflict). Ford et al. (2000) concluded that PTSD can worsen the emotional and behavioral problems experienced by children with ODD. Ford et al. also found that the only type of trauma that was particularly likely to occur for children with ODD was traumatic victimization. Children with ODD did encounter traumatic accidents, injuries, illnesses, and losses that were not the result of abuse or other forms of intentional harm, but they were no

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more likely to have had such “nonvictimization” traumas than the children who were not diagnosed with ODD. Thus, Ford et al. concluded that children in treatment for ODD: (1) were likely to have been traumatically victimized, and (2) were affected by specific post-traumatic symptoms that appeared to be due specifically to having been traumatically victimized. It is not clear at this point whether (and to what extent) traumatic victimization causes, exacerbates, or results from problems with oppositional-defiance. Many children who experience victimization do not develop problems with oppositional-defiance either in childhood (Fletcher, 1996) or as adults (Follette, Polusny, Bechtle, & Naugle, 1996). Prospective research assessing children repeatedly over many years is needed to document when and under what conditions they experience traumatic victimization and problematic oppositional-defiance. If victimization is found to precede oppositional-defiance, studies can test the causal impact of traumatic victimization (along with other potential causal factors). If oppositional-defiance is already present when victimization occurs, studies may still reveal that trauma worsens the subsequent problems with oppositional-defiance–and, it is also possible that oppositional-defiance could cause traumatic victimization (e.g., aggressive and defiant behavior may elicit trauma in the form of violent punishment or physical assault). In either case, it is necessary to determine if other factors that can cause or co-occur with victimization (e.g., family psychopathology or conflict) are a cause of oppositionaldefiance. To begin to sort out these possibilities, I will consider first the central role of oppositional-defiance in the origins and course of childhood disruptive behavior disorders. Then I will discuss how traumatic victimization may play a role in the development and exacerbation of oppositional-defiance. ORIGINS AND COURSE OF THE DISRUPTIVE BEHAVIOR DISORDERS OF CHILDHOOD ADHD, ODD, and CD appear to be distinct (although often co-occurring; Jensen, Martin, & Cantwell, 1997) syndromes (Langbehn et al., 1998). ADHD involves problems in maintaining attention (i.e., “inattention”) or managing impulsive behavior (i.e., “hyperactivity”) that are thought to be due to a neuropsychological deficiency in basic

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cognitive skills for processing information (Barkley, 1997; Faraone, Biederman, Mennin, Russell, & Tsuang, 1997; Faraone, Biederman, Weber & Russell, 1998). ODD involves pervasive indifference, negativity, or outright hostility toward others in the form of defiant resistance (August, Realmuto, Joyce, & Hektner, 1999; Lahey, Applegate, Barkley et al., 1994; Rey & Walter, 1999). CD involves aggressive violations of social rules, norms, or laws in the form of delinquency, cruelty, or criminal behavior (August et al., 1999; Lahey, Waldman, & McBurnett, 1999). Beginning from birth, different developmental pathways lead to ADHD, ODD and CD (Girourard et al., 1998; Nagin & Tremblay, 1999; Speltz, DeKlyen, & Greenberg, 1999). These developmental pathways reflect the influence of genetics (e.g., parent and child temperament; Lahey et al., 1999), family environment (Girouard et al., 1998), and a child’s resultant psychological capacities (e.g., verbal deficits characterize ADHD, while nonverbal deficits characterize ODD; Girouard et al., 1998). Although any disruptive behavior disorder can be debilitating, those characterized by impulsivity, oppositionality, or aggression tend to be most chronic and severe (Lahey, Waldman, & McBurnett, 1999). The inattentive form of ADHD (Nolan, Volpe, Gadow, & Sprafkin, 1999) is substantially worsened by the addition of impulsivity and hyperactivity (Faraone et al., 1998; Nolan et al., 1999). When ODD or CD co-occurs with ADHD, the result is often severe family conflict, social isolation, school failure, and anxiety or mood disorders (Angold & Costello, 1996; August et al., 1999; Biederman, Faraone, Milberger, Jetton et al., 1996; Faraone et al., 1997; Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997; O’Connor et al., 1998; Slutske et al., 1997; Speltz, McClellan, DeKlyen, & Jones, 1999). How then do disruptive behavior disorders become complex, severe, and chronic? Problems with oppositional-defiance and/or aggression in early childhood appear to set in motion what Patterson (1993) describes as a “cascade of impairment” in childhood and adolescence (see also Matthys, Cuperus, & Van Engeland, 1999; Speltz, McClellan et al., 1999). The “cascade” takes the form of a vicious cycle: In addition to frustrating other people by being inattentive or impulsive, a child who is defiant and/or aggressive will tend to alienate significant others. The child is likely to feel rejected or demoralized by people’s negative or avoidant reactions. As a result, the child may intensify the oppositional-defiance and/or aggression, as well as affiliating with peers and participating in activities that encourage violence or delinquency. Parents, peers, and teachers are likely to feel progres-

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sively more frustrated and hopeless, leading to reduced positive social contacts and supervision, and an escalation of “out-of-control” acts. In a series of studies, Patterson (1993) identified boys who had, by grade three or four, “failed in two fundamentally important tasks, peer relations and academic skills” (p. 916) as a result of oppositional-defiance. Over the next five years of childhood and early adolescence, these boys tended to develop a “cascade” of increasingly debilitating emotional, social, and behavioral problems, which included: (a) severe depressive symptoms, (b) engagement with a “deviant” peer group, (c) “wandering” with no monitoring by adults and little or no regard for family or school rules or curfews, (d) substance use, (e) truancy, and ultimately, (f) a police record and the beginning of potentially lifelong trouble with the law. By age 13, many of these boys were viewed by their families, schools, and communities as incorrigibly delinquent. These boys are both “architects” and “victims” of escalating problems with failure, alienation, despair, and deviance (Patterson, 1993). What begins as severe problems with attention (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997) or oppositional defiance (Taylor, Chadwick, Heptinstall, & Danckaerts, 1996) can escalate into a pernicious form of “aggressive delinquency” in adolescence (Magdol, Moffitt, Caspi, & Silva, 1998). Girls are less likely than boys to be diagnosed with ADHD, ODD, or CD (Lahey, Applegate, Barkley et al., 1994; Lahey, Applegate, McBurnett et al., 1994; Nolan et al., 1999), but nevertheless may develop severe problems with oppositional-defiance (Rey & Walter, 1999) and aggression (Cauffman et al., 1998). Consistent with socioculturally based differences in the sex role socialization of girls and boys, girls are more likely than boys to admit to anxiety or depression (Compas et al., 1997). Girls whose temperament (Lahey et al., 1999) or problematic early attachment experiences (Lyons-Ruth, Easterbrook, & Cibelli, 1997; Speltz et al., 1999) place them at risk for oppositional-defiance may react primarily inwardly with anxiety, depression, bodily distress, or social isolation (Egger, Costello, Erklani, & Angold, 1999; Feiring, Taska, & Lewis, 1999; Lipschitz et al., 1999). Although girls sometimes express oppositional-defiance in the more stereotypically male form of overt defiance or aggression (Cauffman et al., 1998; Rey & Walter, 1999), they often suppress aggression (McFayden-Ketchum, Bates, Dodge, & Pettit, 1996). Although overt aggression certainly can be a significant problem for girls, the opposite extreme of withdrawal, and turning fear, hurt, and anger inward can lead to equally problematic “covert” forms of oppositional-defiance–or example, irritable avoid-

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ance of interaction with parents or teachers (Rey & Walter, 1999). For at least some girls, what is conventionally viewed as “aggressiveness” may be the precursor of healthy assertiveness (Protinsky & Gilkey, 1996). Suppression of aggression may interfere with a girl’s development of assertive social competence later in childhood or in adolescence (Fagot & Leve, 1998), potentially leading to “internalized” problems with anxiety, depression, somatization, or eating disorders as passive expressions of defiance or aggression. Therefore, the negative cascade model may apply to girls as well as to boys (although this has not been definitively demonstrated). Several related research studies indicate that girls who have problems with oppositional-defiance in early childhood are at high risk for: (a) self-devaluation (Fagot & Leve, 1998), (b) anxiety and depression (Lipman, Bennett, Racine, Mazumdar, & Offord, 1998), (c) suicidality (Wannan & Fombone, 1998), (d) conflict in the family and school due to rule-breaking, truancy, and curfew violations (Zoccolillo, Tremblay, & Vitaro, 1996), (e) teen substance abuse (Brown, Gleghorn, Schuckit, Myers, & Mott, 1996), and (f) adult criminality, addiction, violent relationships, and psychiatric disorders (Pajer, 1998). As with boys, oppositional-defiance is a red flag for severe impairment in girls. Interestingly, oppositional-defiance may take a more “covert” or “internalized” form for some boys as well as for girls. Nagin and Tremblay (1999) found that many boys experienced a trajectory from problematic aggression to “overt delinquency” (e.g., physical violence), but boys who were characterized by oppositionality rather than aggression developed problems with what they describe as “covert delinquency” (e.g., theft). In addition to sometimes taking a more “covert” form, oppositional-defiance also may precipitate or exacerbate severe internalizing disorders, such as mood or anxiety disorders (Compas et al., 1997; Lipman et al., 1998; Nagin & Tremblay, 1999; Wannan & Fombone, 1998), somatoform disorders (Egger et al., 1999), or mixed internalizing-and-externalizing disorders (e.g., bipolar illness; Biederman, Faraone et al., 1997). For example, if ADHD is complicated by oppositional-defiance and/or aggression, the risk of major depression (Zoccolillo, 1992) or juvenile onset mania (Faraone et al., 1997) increases substantially. Externalizing (e.g., ODD, CD) and internalizing (e.g., depression, anxiety) disorders are distinct yet frequently comorbid (Biederman, Milberger, Faraone, Kiely et al., 1995; Biederman, Mick, & Faraone, 1998; Clark et al., 1997; Geller, Biederman, Griffin, Jones, & Lefkowitz, 1996; Jensen et al., 1997). Similarly, substance abuse often co-occurs with ADHD (Biederman,

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Wilens et al., 1997; Milberger, Biederman, Faraone, Chen, & Jones, 1997), ODD (Kessler et al., 1997), and CD (Kessler et al., 1997; Milberger et al., 1997). ADHD can worsen substance abuse: Adults who had ADHD in childhood are at risk for substance use disorders that escalate from alcohol abuse to psychoactive substance abuse (Biederman, Wilens, Mick, Faraone, & Spencer, 1998). It should be noted that it is problematic oppositional-defiance that is linked to the worst chronicity and impairment of both internalizing (Biederman, Faraone, Milberger, Curtis et al., 1995) and addictive (Biederman, Wilens et al., 1997) disorders. HOW DOES OPPOSITIONAL-DEFIANCE DISRUPT CHILDREN’S (AND FAMILIES’) LIVES? How then does oppositional-defiance come to be a severe problem? Lahey et al. (1999) summarize an extensive research literature, and conclude that the best answer is a bad “fit” between a child’s inborn temperament and his or her parents’ (a) temperaments, (b) emotional or psychiatric problems, and (c) behavioral capacities, lifestyle, and parenting style. Children who are temperamentally oppositional, uncaring, and avoidant tend to be difficult to get along with, as has been discussed already. However, if parents are able to help the child to redirect oppositionality and avoidance toward more prosocial forms of assertion, and to develop empathy for and interest in others, these temperamental traits need not become severe problems. On the other hand, if parents themselves are temperamentally oppositional, uncaring, or avoidant, they may not be able to respond well to their child’s temperament. Such parents are likely to role model antisocial, aggressive, addictive, or avoidant ways of dealing with relationships, responsibilities, and stress. Because of strong genetic influences, parents and children often have similar temperaments (Kagan, 1994). Thus, temperamentally oppositional, uncaring, and avoidant children are particularly likely to have parents with similar temperaments. When this occurs, the child’s temperament brings out “the worst” in the parent, and vice versa, leading to the vicious cycle of harsh, neglectful, oppositional-defiant, or aggressive parent-child interactions (Patterson, 1993). Thus, genetic heritage plays a substantial role in setting the stage for problematic parenting and for parent-child interactions that model and reinforce oppositional-defiance. Nevertheless, how children adaptively or maladaptively express their inborn temperaments ultimately is the

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result of social learning that is influenced, but not completely predetermined, by genetics. Oppositional-defiance can be taught (inadvertently or intentionally) by parents who consistently express themselves in a harsh, critical, uncaring, or avoidant manner. Even a temperamentally cooperative and sociable child can learn to be oppositional-defiant if this is the model and norm in her or his family. Yet, some temperamentally vulnerable children who live with angry, troubled, or neglectful parents and associate with delinquent peers do not develop severe oppositional-defiance. What might make the difference? One possibility is that traumatic victimization may play a part in determining whether a child is able to develop prosocial ways of dealing with life’s challenges versus becoming problematically oppositional-defiant. THE IMPRINT OF TRAUMATIC VICTIMIZATION: FROM SURVIVING TRAUMA TO COPING AS A VICTIM It should be noted that oppositional-defiance is not a problem for all children who have experienced traumatic victimization. Many traumatically victimized children suffer primarily from “internalizing” problems (e.g., anxiety, depression), and not from disruptive behavior disorders or overt oppositional-defiance (Cuffe et al., 1998). By the same token, many youths with ODD have not been physically abused or otherwise traumatically victimized (Dodge, Lochman, Harnish, Bates, & Pettit, 1997). However, when traumatic victimization takes the form of coercive, cruel, violent, or severely neglectful parenting, childcare, or role modeling by family members or other significant individuals, a child may learn to use oppositional-defiance as a self-protective avoidance or counter-reaction. The child may feel so terrified that s/he or someone else will get killed or terribly injured, so helpless to stop the violence or cruelty, and so motivated to use the “power” that anger, defiance, and aggression seem to provide, that s/he might feel impelled to resist with active or passive oppositional-defiance. What is happening to a child who responds to traumatic victimization with oppositional-defiance? Research suggests that severe oppositional-defiance involves a fundamental dysregulation of emotion and information processing (Lahey et al., 1999; Pennington, & Ozonof, 1996). Children or youths with ODD and CD often are observed to experience dysregulated emotion in such forms as fits of rage, difficulty expressing or even feeling love or happiness, intense frustration, desperate anxiety, or inconsolable despair (Cauffman et al., 1998;

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Chorpita, Albano, & Barlow, 1998; Cicchetti & Toth, 1995; LyonsRuth et al., 1997; Milberger, Biederman, Faraone, Murphy, & Tsuang, 1995; Patterson, 1993; Weiss, Susser, & Catron, 1998). Their ability to organize and use information tends to be compromised in a variety of ways, including: (a) problems in maintaining concentration, (b) difficulty making sense of ordinary social cues, (c) a tendency to make negatively biased and rigidly stereotypic interpretations of others’ words and actions (e.g., habitually misreading neutral or positive facial expressions or vocal tones as hostile or demeaning), and (d) very limited knowledge of response options other than negative-resistant or aggressive actions (Cicchetti & Toth, 1995; Dodge et al., 1997; Milberger et al., 1995; Weiss et al., 1998; Zelli et al., 1999). For many children with ODD, emotion seems unmanageable or absent, and thinking tends to be simplistic, reactive, rigid, and dominated by defiance and aggression. As a result, persistently oppositional-defiant youths tend to have distorted views of self, peers, and relationships (e.g., low self-worth, expecting social interactions to be frustrating or hostile) and to have great difficulty in solving ordinary social problems (Dodge et al., 1997; Matthys, Cuperus, & Van Engeland, 1999). These impairments in emotion and social information processing are relevant because they closely parallel the emotional and cognitive dilemmas and deficiencies of children who have suffered traumatic victimization. Each child’s experience of victimization is unique, but many victimized children experience overwhelmingly disturbing emotions (e.g., anger, hyperarousal, flashbacks) or virtually no emotion at all (e.g., emotional numbing, dissociation). Many victimized children also have great difficulty with mental concentration and prosocial problem solving, seemingly preoccupied with inner thoughts (often as a result of intrusive trauma memories), unable to think carefully and creatively (often due to a preoccupation with fear or hypervigilance), angrily resistant or overtly defiant (as a result of anhedonia, social detachment, persistent irritability, and hypervigilance), and limited in their behavioral choices (often as a result of persistently avoiding even remote reminders of past trauma) (Ford et al., 1999, 2000). Let us examine how traumatic victimization may lead to many of the forms of dysregulated emotion and social information processing that are also characteristic of pervasive problems with oppositional-defiance. The Trauma Impact. Victimization initially is followed by an adaptive attempt to cope with or avoid traumatic exposure (Chaffin, Wherry, & Dykman, 1997), because the psychobiological overload caused by victimization (e.g., threat, violation, pain) is an intolerable condition that

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must somehow be tolerated. Despite these attempts, many children exposed to violence and/or abuse develop an acute form of PTSD that involves reenacting the trauma in symbolic (e.g., play, nightmares) or direct (e.g., sexual precocity, self-injury, aggression toward peers) ways, difficulty falling asleep, hypervigilance, an exaggerated startle response, and generalized anxiety, fears, and agitation (Famularo, Kinscherff, & Fenton, 1990; Merry & Andrews, 1994). Immediate post-traumatic symptoms closely parallel the transient intrusive reexperiencing, hyperarousal, and dissociative reactions characteristic of what has been described as an “acute stress disorder” (Daviss et al., 2000). Some acute stress disorder symptoms are the direct result of the psychobiological impact of trauma: primarily the relatively automatic symptoms caused by emotional and informational overload, such as flashbacks, intense anxiety and anger, and temporary lapses in attention or consciousness. However, other acute stress disorder symptoms reflect the child’s initial adaptive attempts to survive the danger by keeping emotions under control (e.g., emotional numbing), keeping social relationships focused on dealing with practical matters (e.g., social detachment), and preparing for and protecting against any additional threats (e.g., hypervigilance). At the moment of impact and in the immediate aftermath, surviving trauma requires significant alterations in both planful and automatic forms of regulating emotion and processing information. The processing of emotions and thoughts tends to be narrowly focused on self-protectively identifying further threats and opposing any potential source of harm. Some children respond immediately with defiance or aggression when victimized, possibly due to prior learning experiences, prior trauma, or a temperamental predisposition. Other victimized children who outwardly seem fearful rather than angry or aggressive may nevertheless develop a self-protective attitude of passive opposition that can escalate into overt oppositional defiance if, over time, they come to experience post-traumatic problems with irritability and hypervigilance. Survival Coping. Unfortunately, what begins as acute post-traumatic reactions becomes chronic symptoms of PTSD for as many as two in three victimized youths (Boney-McCoy & Finkelhor, 1996; Cauffman et al., 1998; Famularo et al., 1996; McLeer et al., 1994; Merry & Andrews, 1994; Steiner et al., 1997). PTSD can develop as a result of a variety of traumas that do not involve victimization (e.g., severe accidents). Children who suffer PTSD due to traumas that do not involve victimization tend to suffer from a dysregulation of emotion and information processing which reflects a preoccupation with fear.

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This dysregulation shows up in the form of being prone to being distracted by reminders of the trauma on even simple cognitive tasks (Moradi, Taghavi, Neshat-Doost, Yule, & Dalgleish, 1999). A similar fear-based interference with thinking was found with children who do not have PTSD but whose parents have PTSD (Moradi, Neshat-Doost, Taghavi, Yule, & Dalgleish, 1999). Although the trauma may be completely over (or may never have happened to them at all–only to their parents), these children’s emotions and thought processes reflect a fearful and hypervigilant concern with the possibility of severe danger. It is as if they view their lives as an almost constant effort to be prepared for, and to survive, the recurrence of traumatic danger. When PTSD is due to traumatic victimization, the dysregulation of emotion and information processing is exacerbated by several unique additional adversities. Victimization may involve a violation of the child’s body (e.g., rape) or grievous physical injury, which leave a lasting physical and emotional imprint in addition to the psychological imprint of fear. Victimization may be perpetrated by a trusted adult or caregiver, or in an ostensibly safe setting (e.g., home, school, neighborhood), such that the child experiences not only fear but also a sense of betrayal (Freyd, 1994). Victimization often occurs in a context of family psychopathology, severe parent-child or family conflict, or inadequate family emotional and instrumental support, leading to a belief that there is no safe place anywhere in life. Victimization may occur not just as a single incident or over a limited time frame, but on an ongoing basis for months or years. The combination of violation, betrayal, family dysfunction, and prolonged victimization greatly intensifies the emotional impact of the trauma: Fear is amplified and complicated by horror, despair, rage, or shame (Briere & Elliott, 1994; Neumann et al., 1996). These adverse features of victimization also can alter the child’s fundamental information processing: Rather than developing a flexible, curious, and open-minded style of optimistically engaging in and making sense of life experiences, the victimized child often adopts a closed, rigid, and pessimistic way of thinking dominated by generalized distrust, avoidance, and overt or covert resistance (Ackerman, Newton, McPherson, Jones, & Dykman, 1998; Brent et al., 1995; Briggs & Joyce, 1997; Deykin & Buka, 1997; Dodge et al., 1995; Lynskey & Fergusson, 1997; Mallah, 1997). While by no means all, or even most, survivors of victimization in childhood are abusive as adults, violence can be perpetuated inter-generationally (Widom, 1999). For example, men who batter their partners have been found to be more likely to have experienced paternal rejection, physical abuse, and an absence of ma-

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ternal warmth in childhood, compared to demographically similar nonabusive men (Dutton, Starzomski, & Ryan, 1996). These men often describe feeling like victims, even as they victimize their vulnerable significant others (Dutton et al., 1996). Recognizing victimization as a potential source of abusive behavior does not excuse such behavior, but may provide a basis for preventing or treating it more effectively. Victim Coping. The dysregulation of emotion and information processing caused by traumatic victimization can lead a child to adopt an unspoken belief that distrust and defiance (whether expressed as overt oppositionality or as covert resistance) are essential to protect against the harm caused by people or to cope with otherwise unmanageable emotions. Victimized children do not inevitably act, feel, or assume the identity of a victim (Chaffin et al., 1997). Over time, however, maintaining a survival-focused stance of distrustful and defiant hypervigilance is emotionally and mentally exhausting. Coping primarily to survive and endure for long periods of time, without more than temporary relief from victimization or from persistent post-traumatic symptoms, is exhausting and demoralizing. Prolonged exposure to traumatic victimization or persistent post-traumatic distress in childhood can result in lasting impairment in the body’s stress response systems (DeBellis et al., 1999a; Glod & Teicher, 1996; Lemieux & Coe, 1995), in the physiology of the brain (DeBellis et al., 1999b; Shin et al., 1999), and in the ability to process social information and deal with interpersonal conflict (Cicchetti & Toth, 1995; Dodge et al., 1995). Being a victim thus can seem to become an inescapable “life sentence”–kind of prison, torture, or even a living death–rather than a temporary dilemma to be survived until a “normal” life resumes. Such “victim coping” involves feeling emotionally numb and empty, spaced-out and disoriented, and unable to think clearly or logically (Nijenhuis, Spinhoven, Vanderlinden, van Dyck, & van der Hart, 1998). From the perspective of a victim, both victimization and persistent post-traumatic symptoms are inevitable, inescapable, and overwhelming. Victim coping is based on a generalized expectancy of not only danger and betrayal, but moreover, on the belief that one is irreversibly damaged and fundamentally unable to have control of one’s life (Bolstad & Zinbarg, 1997). This view of victim coping is consistent with studies showing that chronic post-traumatic impairment involves persistent and severe biological imbalances affecting social information processing and memory (Yehuda & Harvey, 1997). The result is severe problems with intrusive re-experiencing symptoms (Schooler, Dougall, &

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Baum, 1999), emotional numbing and social detachment (Foa, Riggs, & Gershuny, 1994), impaired information processing (McNally, 1998), and dissociation of self-awareness and consciousness (Famularo et al., 1990; Witvliet, 1997). In addition, these impairments often are accompanied by escalating problems with anger and aggression (Chemtob, Novaco, Hamada, Gross, & Smith, 1997), which take the form of passive or active oppositional-defiance. Victim coping may be a link between traumatic victimization and problems with oppositional-defiance, because victim coping and oppositional-defiance may have a common underlying psychological basis: problems with the processing of emotional and social information. SOCIAL/EMOTIONAL INFORMATION PROCESSING AS A LINK BETWEEN VICTIM COPING AND OPPOSITIONAL-DEFIANCE Traumatic victimization can profoundly alter how children process social information, and this can have a significant emotional impact. For example, Mallah (1997) showed that children who witnessed or were directly abused by family violence felt afraid and believed that violence was going to occur when they viewed a non-violent and emotionally neutral interaction between a man and a woman. Children’s basic emotional responses and cognitive expectations in relation to ordinary social interactions thus may be altered by traumatic victimization. Additionally, children who felt most fearful of violence had the worst symptoms of PTSD, disruptive and aggressive behavior, and problems at school and with peers. Similar adverse outcomes may occur due to exposure to parental rejection and destructive sibling conflict (Garcia, Shaw, Winslow, & Yaggi, 2000) or to community violence (Marans & Cohen, 1993). A study by Dodge et al. (1995) went an important step further by demonstrating a specific link between (a) abuse, (b) impaired social information processing, and (c) problematic oppositional-defiance and aggression. One in eight children from three communities were described by their mothers as having been exposed to physical abuse between birth and age five. Over a four year period between preschool and the third and fourth grades, abused children’s social information processing was shown to be distorted in several ways, including inaccurate “encoding” (i.e., focusing on irrelevant details or adding details that actually did not happen), expecting people to be hostile, choosing aggres-

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sive reactions to deal with social stressors, and viewing aggression positively. Abused children were also more likely than nonabused peers to be described by the third and fourth grade teachers as disruptive, oppositional, or aggressive. Although children from socioeconomically disadvantaged or high stress families, and children with difficult (i.e., oppositional) temperaments were particularly likely to have third and fourth grade behavior problems, it was the experience of abuse (and not family or temperament factors) that best accounted for disruptive, oppositional, and aggressive behavior. The link between abuse and behavior problems was largely due to two types of distortion in social information processing: distorted encoding and a predisposition toward aggressive actions. Although the roles of family psychopathology and conflict were not directly examined, the Dodge et al. (1995) study provides the best evidence to date that alterations in social information processing associated with traumatic victimization may account for children’s problems with oppositionality and aggression over and above the effects of the child’s temperament and the family’s stress and functioning. These social information processing problems are similar to the resentful and resigned coping style that has been found to be characteristic of the abused children who are most psychosocially impaired (Chaffin et al., 1997). Furthermore, these social information-processing problems have been shown to account for the link between oppositional-defiant beliefs and problems with actual aggressive behavior (Zelli, Dodge, Lochman, Laird, & Conduct Problems Prevention Research Group, 1999). In subsequent analyses, Dodge et al. (1997) identified a potential difference between the victim coping that may result from traumatic victimization versus a form of oppositional-defiance and aggression that is not linked to trauma. They found that physically abused children diagnosed with CD were more likely than nonabused children with CD to display early onset (i.e., in early childhood vs. in preadolescence) conduct problems as a result of reactive attempts to fight back against being blamed or rejected (rather than preplanned aggression or crimes) and impairments in social information processing. These findings suggest the existence of a subtype of CD that reflects a victim’s stance of reactive behavior and impaired social information processing, and that is specifically tied to traumatic victimization (Dodge et al., 1997). More recent studies provide additional support for the view that traumatic victimization alters how children process social information

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and thus can lead to victim coping in the form of passive or active oppositional-defiance. Lynch and Cicchetti (1998) found that abused children were more likely than other similar children to think of their nonabusive mothers as unavailable, untrustworthy, unloving, or unreliable. Thus, abuse can lead to a profound sense of betrayal that can develop into a very negative, and oppositional-defiant, attitude toward a primary caregiver. To compound the problem, maltreated children learn to associate feeling emotion with a sense of trauma and victimization. After reviewing an extensive collection of research studies, Pollak, Cicchetti, and Klorman (1998) conclude that abused children often learn to be profoundly distrustful of, and resistant to, their own emotions. For example, what a nonabused child might experience as unpleasant, but transient anger or frustration might seem to an abused child to be a feeling of intolerable and overwhelming rage, hatred, or suicidality. Thus, abused children can become convinced that both close relationships and one’s own emotions cause awful harm. In that frame of mind, the abused child may succumb to anxiety and depression (Weine, Becker, Levy, Edell, & McGlashan, 1997) but alternately, she or he may develop a persistent attitude of oppositional-defiance as a defense against feeling betrayed in close relationships or vulnerable to any emotion (Mulder, Beautrais, Joyce, & Fergusson, 1998). IMPLICATIONS FOR PREVENTION AND TREATMENT Exposure of children to violent victimization is a public health problem that is increasingly recognized but not well understood or prevented. Although nationally the levels of reported incidents of violent victimization were reduced by as much as 20% between 1994 and 1997, youths remain at higher risk than any other age group (Rand, 1998). For example, in 1996 the rate of homicides annually was almost four times higher for youths than that for adults (15 versus 4 per 100,000; Bilchik, 1999). The most obvious manifestations, such as gang violence in the inner city and apparently random shootings in schools, highlight the terrible damage that traumatic victimization can cause in the lives of children, and the terror and loss with which their families and communities must grapple. These tragedies pose two critical issues for society at large and for the mental health professions: how to prevent violence, and how to identify, protect, and treat survivors of violence. Violence prevention programs tend to focus on building community partnerships among families, schools, law enforcement agencies, social

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service and public health agencies, and civic and business leaders (Bilchik, 1998; Sherman et al., 1998). Violence prevention initiatives are moving away from fear-based confrontation or vague “empowerment” methods (which do not seem to work; Sherman et al., 1998), toward teaching high-risk youth or adults (and their teachers, parents, law enforcement, and social service representatives) specific skills for anticipating and de-escalating conflict. For example, the Parents’ and Children Series (PACS) program for young (ages four to eight) conduct disordered children is a six-month intervention with documented efficacy (Webster-Stratton & Hammond, 1997) and effectiveness (Taylor, Schmidt, Pepler, & Hodgkins, 1998). The PACS has been shown to successfully reduce child conduct problems, enhance child selfmanagement, enhance parenting skills, reduce parent-child conflict, and develop positive parent-child relationships. Nevertheless, many children and adolescents are very difficult to help even with systematic and intensive prevention or treatment programs (Conduct Problems Prevention Research Group, 1999a, 1999b). These youths are so alienated and delinquent that they are trapped in what appears to be a self-imposed prison of rage, resignation, impulsivity, explosiveness, and indifference to the pain that they feel and the harm that they can cause to other persons. Without in any way excusing or justifying the harm caused by such youths’ deviant behavior, we must understand better this phenomenon if we are to do more than just wait for the next massacre, suicide, arrest, or hospitalization. Genetics, temperament, the parent-child (mis)fit, socioeconomic and ethnocultural adversities, and family psychopathology and conflict all must be taken into account in designing prevention programs for highrisk youths and their families, schools, and communities (Prinz & Connell, 1997; Ross, Blanc, McNeil, Eyberg, & Hembree-Kigin, 1998). In addition, these youths and their peers, parents, teachers, and community role models may benefit from learning how traumatic victimization can contribute to severe emotional and behavioral problems and what they can do together to prevent or recover from victimization. Clinically, recognizing that victimization may contribute to severe oppositional-defiance can provide several options for assessment and treatment that constructively address (and do not excuse or overlook) the harm done by violent or deviant behavior. Assessment of problems with emotional and social information processing can be done with an eye to identifying not only the genetic (e.g., family history, temperament) and social learning (e.g., family conflict, affiliation with a deviant peer group) factors contributing to oppositional-defiance, but also

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the child’s and family’s history of traumatic victimization, post-traumatic symptoms, and tendencies toward victim coping. If a history of victimization and persistent victim coping are detected, treatment may be most effective if it directly addresses the post-traumatic symptoms and victim coping, as well as the overtly disruptive behavior (Deblinger, Lippman, & Steer, 1996). This is more evident when an abused child presents with primary “internalizing” problems such as anxiety, depression, or social withdrawal (Fantuzzo et al., 1996). However, it may be equally important in treating children or adolescents with “externalizing” problems such as aggression or delinquency to provide the youth with opportunities to experience herself or himself as a survivor who can come to terms with trauma rather than remaining in a state of perpetual victim coping. By providing an empathic reframing of the youth’s externalizing and internalizing symptoms as desperate attempts to cope with the fallout of victimization, treatment also may be able to re-build the youth’s self-esteem, self-efficacy, and capacity to overcome disorganized attachments, and to develop positive attachments with peers, family, and adult role models (Cicchetti & Toth, 1995; Lyons-Ruth et al., 1997). This perspective also has implications for helping adult survivors of childhood victimization. The syndrome of “Disorders of Extreme Stress Not Otherwise Specified” (DESNOS; Herman, 1992) describes the dilemma of adult survivors of childhood victimization who experience difficulties that go beyond the anxiety, irritability, and hypervigilance of PTSD. Adult survivors may be preoccupied with shame, terrified of being abandoned or betrayed in relationships, consumed by rage, overwhelmed by impulses that are self-harmful or addictive, or prone to dissociation. These problems parallel many of the most problematic features of severe oppositional-defiance in childhood, and often are viewed simply as an irreparable personality disorder (Brodsky, Malone, Ellis, Dulit, & Mann, 1997; Prinz & Connell, 1997; Sabo, 1997) or end-stage addiction (Brady et al., 1998; Epstein et al., 1998). However, these impairments may reflect chronic victim coping, and may therefore be better understood as the lasting impact of traumatic victimization. DESNOS has been described by sufferers as living in a flood or firestorm of terrifying and humiliating emotions, thoughts, and impulses that never seem to go away, and that can only be endured by the stoic withdrawal or oppositional-defiance of victim coping (Ford, 1999). DESNOS thus involves severe dysregulation of both emotion and social information processing, and a distrust and oppositionality that has its origins in youth (Haviland, Sonne, & Woods, 1995; McClellan, Adams, Douglas, McCurrry, & Storck, 1995; Westen, Ludolph, Lerner,

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Ruffin, & Wiss, 1990) and can persist in adulthood (Allen, Coyne, & Huntoon, 1998; Cloitre, Scarvalone, & Difede, 1997; Ford, Fisher, & Larson, 1997). A finding by Ford and Kidd (1998) suggests that treatment of adult survivors of early childhood trauma who develop severe psychological and interpersonal problems may need to specifically address DESNOS in order to be effective. Ford and Kidd (1998) demonstrated that the strongest predictor of adult military veterans’ responsiveness to treatment for chronic PTSD was DESNOS, not whether the veteran had a history of trauma (including victimization) as a child. Thus, many adults with histories of severe trauma in childhood may respond quite favorably to existing psychological and psychiatric treatments for PTSD. However, those with DESNOS may require refined treatments that address not only stress and anxiety but also persistent problems in self-regulation and in relationships that appeared in the form of disordered conduct earlier in childhood or adolescence. It is important to remember that, as a result of factors such as gender (Webster-Stratton, 1996), different types of trauma exposure (Fletcher, 1996), or comorbidity in childhood (Biederman, Milberger, Faraone, Kiely et al., 1995) and adulthood (Duncan et al., 1996), these earlier problems with oppositionality may appear in the form of depression (Riggs, Baker, Mikulich, Young, & Crowley, 1995) or demoralization (Biederman, Mick, & Faraone, 1998) rather than or in addition to “externalizing” problems such as aggression or delinquency. It also may be worthwhile to investigate whether these debilitating problems can be prevented or ameliorated by interventions that address traumatic victimization, victim coping, and oppositional-defiance in childhood or adolescence. Adults with DESNOS tend to have experienced severe trauma in childhood, but not all adults who were traumatized as children suffer from DESNOS–and those who experienced horrific trauma in adulthood were particularly at risk for DESNOS (Ford, 1999). Thus, in addition to primary prevention efforts aimed at protecting children from trauma, it also is important to develop secondary prevention programs to protect adolescents and adults who experienced trauma as children from the adversity of additional trauma (Follette et al., 1996). IMPLICATIONS FOR RESEARCH An immediate priority for research is the inclusion of reliable and validated assessments of traumatic victimization and post-traumatic psychosocial impairment (Ford et al., 1999) in studies of the etiology (Lahey et al., 1999; Lyons-Ruth et al., 1997), course (August et al.,

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1999; Dodge et al., 1995), prevention (Conduct Problems Prevention Research Group, 1999a, 1999b), and treatment (Taylor et al., 1998; Webster-Stratton & Hammond, 1997) of oppositional defiance. Pioneering studies (e.g., Dodge et al., 1995; Lyons-Ruth et al., 1997) have demonstrated that traumatic victimization has a distinct and significant impact on persistent oppositional-defiance that is not merely an artifact of other more widely accepted risk factors (e.g., family history and conflict). These studies set several important precedents for future scientific investigations of traumatic victimization and oppositional-defiance. First, they use a prospective longitudinal research design. This means conducting a series of assessments (e.g., every year or every second year) with the same cohort of children and families from early in childhood through later childhood or even into adolescence. Although many prospective studies of the etiology and course of oppositional-defiance have been conducted (e.g., Lahey et al., 1999; Patterson, 1993), only the Dodge et al. (1995) and Lyons-Ruth et al. (1997) studies include traumatic victimization as a potential risk factor. Moreover, prospective studies of the etiology and course of post-traumatic impairment following traumatic victimization in early childhood are only beginning to be reported, with very little attention paid to the role of oppositional-defiance (Trickett, 1998). Prospective studies will be most informative if they begin the assessment of traumatic victimization, oppositional-defiance, and related risk and protective factors at or before birth, so that it will be possible to clearly observe the role of trauma and oppositional defiance at many successive points in the trajectories of the child’s, parents’ and family’s biopsychosocial development. Each time point offers the potential to better understand how traumatic victimization and oppositional-defiance unfold across the lifespan, and to determine both when they are intertwined and when they occur independently. Each observation also affords opportunities to examine other possible trajectories for children who are victimized (such as developing persistent anxiety or depression without any oppositional-defiant features), and to contrast the development of oppositional-defiant children who have versus have not been exposed to trauma. What we learn from longitudinal studies can provide a foundation for new intervention strategies to reduce the harm caused by victimization and conduct problems, and to facilitate positive development. Second, a related implication is the need for research to further clarify the role of emotion regulation and social information processing in both traumatic victimization and oppositional-defiance. Studies are needed to directly compare the self-regulatory and social-engagement

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problems caused by traumatic victimization with the emotion regulation and social information processing problems associated with oppositional-defiance. Similarities and differences can be discerned through careful observation of children who have definite histories of traumatic victimization but no problems with oppositional-defiance, children who have no histories of traumatic victimization but clearly documented problems with oppositional-defiance, children who have both problems, and children who have neither. Emotion regulation (Trickett, 1998), social information processing (Dodge et al., 1995), and the ability to form secure relational attachments (Lyons-Ruth et al., 1997) can be carefully and accurately assessed in a variety of relevant contexts (e.g., home, school, peer group), to determine how victimization and oppositional-defiance shape the most basic psychosocial capacities from earliest childhood, and to identify specific opportunities for enhancing these basic capacities through prevention and treatment. Ultimately, research is needed to evaluate the benefits (and costs) that accrue if prevention and treatment interventions for oppositional-defiance incorporate education and skills relevant to recovery from traumatic victimization, and, on the other hand, if interventions for child, adolescent, and adult survivors of traumatic victimization incorporate education and skills designed to modify the social information processing impairments caused by oppositional-defiance. Such studies also can help to empirically clarify for whom different approaches to prevention or treatment are best suited, with a long-term goal of developing a scientific and humane basis for matching each individual with the least costly and most helpful intervention. There is a long way to go before the harm done by traumatic victimization and persistent oppositional-defiance is eradicated or even widely ameliorated. However, research that considers the potential relationships between traumatic victimization and oppositional defiance offers new possibilities for a better understanding, and better approaches to prevention and treatment for these debilitating impediments to healthy biopsychosocial development. REFERENCES Ackerman, P., New 2ton, J., McPherson, W., Jones, J., & Dykman, R. (1998). Prevalence of posttraumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse and Neglect, 22, 759-774.

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Dodge, K., Lochman, J., Harnish, J., Bates, J., & Pettit, G. (1997). Reactive and proactive aggression in school children and psychiatrically impaired chronically assaultive youth. Journal of Abnormal Psychology, 106, 37-51. Dodge, K., Pettit, G., Bates, J., & Valente, E. (1995). Social information-processing patterns partially mediate the effect of early physical abuse on later conduct problems. Journal of Abnormal Psychology, 104, 632-643. Duncan, R., Saunders, B., Kilpatrick, D., Hanson, R., & Resnick, H. (1996). Childhood physical assault as a risk factor for PTSD, depression, and substance abuse. American Journal of Orthopsychiatry, 66, 437-448. Dutton, D., Starzomski, A., & Ryan, L. (1996). Antecedents of abusive personality and abusive behavior in wife assaulters. Journal of Family Violence, 11, 113-132. Egger, H., Costello, E. J., Erklani, A., & Angold, A. (1999). Somatic complaints and psychopathology in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 852-860. Epstein, J., Saunders, B., Kilpatrick, D., & Resnick, H. (1998). PTSD as a mediator between childhood rape and alcohol use in adult women. Child Abuse and Neglect, 22, 223-234. Fagot, B., & Leve, L. (1998). Teacher ratings of externalizing behavior at school entry for boys and girls: Similar early predictors and different correlates. Journal of Child Psychology and Psychiatry, 39, 555-566. Famularo, R., Fenton, T., Kinscherff, R., & Augustyn, M. (1996). Psychiatric comorbidity in childhood posttraumatic stress disorder. Child Abuse and Neglect, 20, 953-961. Famularo, R., Kinscherff, R., & Fenton, T. (1990). Symptom differences in acute and chronic presentation of childhood post-traumatic stress disorder. Child Abuse and Neglect, 14, 439-444. Fantuzzo, J., Sutton-Smith, B., Atkins, M., Meyers, R., Stevenson, H., Coolahan, K., Weiss, A., & Manz, P. (1996). Community-based resilient peer treatment of withdrawn maltreated preschool children. Journal of Consulting and Clinical Psychology, 64,1377-1386. Faraone, S., Biederman, J., Mennin, D., Russell, R., & Tsuang, M. (1997). Familial subtypes of attention deficit hyperactivity disorder. Journal of Child Psychology and Psychiatry, 39, 1045-1053. Faraone, S., Biederman, J., Wozniak, J., Mundy, E., Mennin, D., & O’Donnell, D. (1997). Is comorbidity with ADHD a marker for juvenile-onset mania? Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1046-1055. Feiring, C., Taska, L., & Lewis, M. (1998). Social support and children’s and adolescents’ adaptation to sexual abuse. Journal of Interpersonal Violence, 13, 240-260. Feiring, C., Taska, L., & Lewis, M. (1999). Age and gender differences in children’s and adolescents’ adaptation to sexual abuse. Child Abuse and Neglect, 23, 115-128. Fergusson, D., Horwood, L., & Lynskey, M. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood: II. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1365-1374. Fletcher, K. (1996). Childhood posttraumatic stress disorder. In E. Mash & R. Barkley (Eds.), Child psychopathology (pp. 242-276). New York: Guilford. Flisher, A. J., Kramer, R. A., Grosser, R. C., Alegria, M., Bird, H. R., Bourdon, K., Goodman, S., Greenwald, S., Horwitz, S., Moore, R., Narrow, W., & Hoven, C.

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Magdol, L., Moffitt, T., Caspi, A., & Silva, P. (1998). Developmental antecedents of partner abuse. Journal of Abnormal Psychology, 106, 375-389. Mallah, K. (1997). Children’s social information processing in family violence. Dissertation Abstracts International, 58B, 5128. Marans, S., & Cohen, D. (1993). Children and inner-city violence. In L. Leavitt & N. Fox (Eds.), The psychological effects of war and violence on children, (pp. 281-301). Hillsdale, NJ: Lawrence Erlbaum. Matthys, W., Cuperus, J., & Van Engeland, H. (1999). Deficient problem-solving in boys with ODD/CD, with ADHD, and with both disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 311-321. McClellan, J., Adams, J., Douglas, D., McCurrry, C., & Storck, M. (1995). Clinical characteristics related to severity of sexual abuse. Child Abuse and Neglect, 19, 1245-1254. McFayden-Ketchum, S., Bates, J., Dodge, K., & Pettit, G. (1996). Patterns of change in early childhood aggressive-disruptive behavior. Child Development, 67, 2417-2433. McLeer, S., Callaghan, M., Henry, D., & Wallen, J. (1994). Psychiatric disorders in sexually abused children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 313-319. McNally, R. (1998). Experimental approaches to cognitive abnormality in posttraumatic stress disorder. Clinical Psychology Review, 18, 971-982. Merry, S., & Andrews, L. (1994). Psychiatric status of sexually abused children 12 months after disclosure of abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 939-944. Milberger, S., Biederman, J., Faraone, S., Chen, L., & Jones, J. (1997). ADHD is associated with early initiation of cigarette smoking in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 37-44. Milberger, S., Biederman J., Faraone S., Murphy J., & Tsuang M. (1995). Attention deficit hyperactivity disorder and comorbid disorders: Issues of overlapping symptoms. American Journal of Psychiatry, 152, 1793-1799. Moradi, A., Neshat-Doost, H., Taghavi, R., Yule, W., & Dalgleish, T. (1999). Performance of children of adults with PTSD on the Stroop color-naming task. Journal of Traumatic Stress, 29, 663-671. Moradi, A., Taghavi, R., Neshat-Doost, H., Yule, W., & Dalgleish, T. (1999). Performance of children and adolescents with PTSD on the Stroop color-naming task. Journal of Child Psychology and Psychiatry, 29, 415-419. Morrison, N., & Clavenna-Valleroy, J. (1998). Perceptions of maternal support as related to self-concept and self-report of depression in sexually abused female adolescents. Journal of Child Sexual Abuse, 7, 23-40. Mulder, R., Beautrais, A., Joyce, P., & Fergusson, D. (1998). Relationship between dissociation, childhood sexual abuse, childhood physical abuse, and mental illness in a general population sample. American Journal of Psychiatry, 155, 806-811. Mullen, P., Martin, J., Anderson, J., Romans, S., & Herbison, G. P. (1996). The long-term impact of the physical, emotional, and sexual abuse of children: A community study. Child Abuse and Neglect, 20, 7-21. Nagin, D., & Tremblay, R. (1999). Trajectories of boy’s physical aggression, opposition, and hyperactivity on the path to physically violent and nonviolent juvenile delinquency. Child Development, 70, 1181-1196.

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Assessment of PTSD and Trauma Exposure in Adolescents Elana Newman

SUMMARY. Increasing evidence suggests that delinquent youth are at high risk for development of PTSD. This article reviews strategies for assessing PTSD among such adolescents. Integrating scientific and clinical approaches, the rationale and implementation of the multimodal assessment strategy for PTSD is reviewed. A brief overview of diagnostic challenges, clinical challenges, and the available structured and semi-structured interviews, self-report measures, and other means of assessing PTSD and trauma exposure are presented. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Assessment, sexual abuse, maltreatment, children, delinquency

The need to address Post-Traumatic Stress Disorder (PTSD) is often overlooked in the assessment and treatment of delinquent youth (McMackin, Morrissey, Newman, Erwin, & Daly, 1998). However, Address correspondence to: Elana Newman, PhD, Department of Psychology, University of Tulsa, 600 South College Avenue, Tulsa, OK 74104 (E-mail: elananewman@ utulsa.edu). [Haworth co-indexing entry note]: “Assessment of PTSD and Trauma Exposure in Adolescents.” Newman, Elana. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 59-77; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 59-77. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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it appears wise to routinely assess delinquent youth for PTSD since adolescents who exhibit delinquent behavior are likely to have experienced maltreatment, which is a risk factor for PTSD (Ford & Linney, 1995; Haapasalo & Kankkonen, 1997; Lutz & Widom, 1994; Malinosky-Rummell & Hansen, 1993; Rivera & Widom, 1990; Smith & Thornberry, 1995; Widom, 1989). Furthermore, the high co-morbidity of both conduct disorders and substance abuse with PTSD (e.g., Burket & Myers, 1995; Clark, Pollock, Bukstein, Mezzich, Bromberger, & Donovan, 1997; Clark, Smith, Neighbors, Skerlec, & Randall, 1994; Deykin & Buka, 1997) supports the need to routinely assess PTSD among youth with externalizing symptoms. Finally, there is direct evidence that some delinquent youth experience PTSD (Burton, Foy, Bwanausi, Johnson, & Moore, 1994; Erwin, Newman, McMackin, Morrissey, & Kaloupek, 2000; Steiner, Garcia, & Matthews, 1997). These factors suggest that the correct identification and classification of trauma-related PTSD symptoms enhances the probability that an appropriate treatment or rehabilitation plan can be designed to fit the unique needs of a particular youth. One of the basic tasks in assessing PTSD is to firmly establish the presence of specific symptoms of the disorder as defined by DSM-IV (APA, 1994) symptom and duration criteria. While this may seem an obvious assertion, in fact, researchers and clinicians may too readily assume that if a person was exposed to a traumatic stressor they must be experiencing PTSD. This is a mistaken assumption. Exposure to a potentially traumatic event is a risk factor for the development of numerous mental health problems, of which PTSD is just one possible outcome (e.g., Boney-McCoy & Finkelhor, 1995). Consequently, it is incumbent upon the clinician to examine exposed adolescents for all symptom criteria, including intrusions, numbing, avoidance, and hyperarousal within the specified time frame of one month (APA, 1987, 1994). Certainly, some trauma-exposed adolescents may exhibit several clinically significant PTSD symptoms, but not meet the DSM criteria. They may only have four of the five requisite symptoms. Alternatively, they may have five symptoms but the symptoms are not distributed across the three dimensions of intrusions, numbing/avoidance, and hyperarousal. For instance, a youth might be totally numb and avoidant without any intrusive symptomatology. Finally, it is theoretically possible that a youth may have all 17 symptoms, each at a subclinical threshold, but in combination, they create an overall deficit in functioning. In all these cases, the need to identify subclinical PTSD, or partial PTSD

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may be important for case disposition. Although there is no consensus on how to systematically define partial PTSD, it typically refers to individuals who never fully met criteria for PTSD, but at some time in life had experienced clinically significant symptoms of PTSD (Weiss et al., 1992). Although this review will focus upon assessment procedures for full PTSD, the same assessment approach can be used to assess partial PTSD. ASSESSMENT PROCESS Assessment of PTSD among adolescents, particularly delinquent youth, can be extremely challenging. Developmental, psychological, and situational factors may impede the process of establishing rapport, a necessary condition for a productive assessment session. In order to mitigate this potential, clinical suggestions regarding how to approach the assessment are reviewed in this section. Establishing Purpose and Process. It is important that the adolescent being assessed understands that the goal of assessment is to comprehensively understand as much as possible about his/her life experience including symptoms, behaviors, and thoughts. Adolescents need to know what information will and will not be shared with guardians. Such clarity is not only ethically mandated, but communicates respect for the youth by explicitly acknowledging his/her developmental ambivalence about autonomy and dependence on parental figures. Finally, other limits of confidentiality with respect to local laws, federal laws, and ensuing court cases need to be clearly communicated and documented, so that youth are aware and able to make choices about disclosure. If the youth’s state of mind and other circumstances allow, it is preferable to assess the youth alone without a guardian or family member present. Evidence has indicated that school-aged children and adolescents are likely to minimize or under-report symptomatology in the presence of their parents (Yule & Williams, 1990). Rapport Building and Clinician Demeanor. Since adolescents tend to be more suggestible and/or defensive when they perceive the interviewer to be authoritarian, unfriendly or intimidating (e.g., Lewis, Wilkins, Baker, & Woobey, 1995; Reed, 1996), interviewers should try to engender warmth through an egalitarian and friendly demeanor. Interviewers should demonstrate an overall interest in the youth, particularly with respect to understanding his/her psychological state. Interviewers need to communicate that no response is wrong, and that

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they are open to hearing any response. In addition, it may be helpful to have youth repeat their understanding of questions to assure that communication is effective. Evidence has shown that when younger respondents are able to ask for rephrasing and admit any lack of understanding, accuracy of responses increases (Saywitz & Synder, 1993). Hence it may be useful for older youth with communication delays to rephrase the interviewer’s questions or indicate confusion openly. The clinician’s behaviors and values can also affect an adolescent’s response style. Clinicians need to be cautious that a general negative or positive impression of the child, or response to a particular set of questions does not influence all the ratings of the adolescent’s behaviors. Careful information about each symptom should be collected. However, if a clinician believes the information gathered is exaggerated or minimized, it typically makes sense to wait and decide if one should communicate doubt later on when there is more information about the client’s credibility and demeanor, rather than directly confronting the client (Carlson, 1997). This is especially important when working with juvenile delinquents because strong feelings can potentially affect decision-making. For example, it may be difficult for the clinician to appreciate both the vulnerability and dangerousness of the adolescent simultaneously when assessing PTSD. Hence, it is important to evaluate the overall response style with as much information as possible before challenging a youth. In addition, some clinicians may avoid asking direct questions for fear of “traumatizing” the youth, fear of leading the child, or the interviewer’s own desire to avoid painful material. While these clinicians’ concerns are understandable, they can prevent important information from being obtained, which may harm the child in the long run. Most clinicians believe that if children are not asked specific questions about PTSD symptoms and the stressor, children and adolescents will not volunteer this information (Cohen et al., 1998). A balance of sensitivity, openness, and acceptance should guide trauma assessments and should be established based on the client’s unique characteristics, not the clinician’s biases. Safety. As in any clinical endeavor, supporting the client’s sense of safety is an integral part of the assessment process (Newman, Kaloupek, & Keane, 1997). Within the assessment, safety is a central concern because a thorough assessment of PTSD requires that an individual identify and describe traumatic memories, feelings, and symptoms, often with accompanying strong emotional reactions. Psy-

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chological safety, which includes trust in the clinician and an ability to communicate overwhelming feelings and reactions, can mitigate the potential that an assessment will increase self-destructive behavior (e.g., substance abuse, suicidal behavior, cutting behavior). The interviewer’s sensitivity in the structure and pacing of the process can foster this safe atmosphere. Most centrally, the clinician needs to remain supportive and neither over-react or under-react to the client’s experiences or symptoms (Carlson, 1997). This requires careful monitoring of one’s own responses and considering whether the client will interpret a remark as encouraging or discouraging him/her to communicate more about the topic at hand. Certainly, the interviewer should appear interested and responsive to the youth’s concerns. Other aspects of the interview may be helpful in facilitating the youth’s sense of control, such as offering the youth limited choices regarding breaks. At the conclusion of the interview, focusing on strengths of the person in coping with trauma may be helpful (Carlson, 1997). Children and adolescents appear to react positively to the assessment process if it is conducted with such respect and safeguards; however, caution is always warranted so that the clinician remains aware of and manages any child or adolescent’s potential adverse responses to the assessment process. Appropriate follow-up and safeguards can be implemented as needed. Co-Morbidity. Youth with PTSD may suffer from other disorders besides conduct disorder and substance abuse (mentioned previously). Among maltreated children, attention deficit hyperactivity disorder, anxiety disorders other than PTSD, brief psychotic disorder, reactive attachment disorder, and depression may be concurrent (Famularo, Fenton, Kinsheriff, & Augustyn, 1996). Hence, the use of a diagnostic interview which assesses all Axis I, and, if possible, all Axis II disorders will assist in the determination of co-morbid disorders. In addition, general standard psychometric assessments of psychopathology and distress can provide important information regarding co-morbid symptom severity. When assessing current co-morbid disorders, a careful lifetime history of the individual’s adjustment before and after traumatic events can provide evidence about the potentially complex interactions between PTSD and other psychiatric disorders. For example, substance abuse disorder in a traumatized individual may reflect an effort to self-medicate against intrusive thoughts and feelings, numbness, and psychological distress associated with PTSD. Comorbid disorders may also reflect pre-existing vulnerability.

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MULTI-MODAL ASSESSMENT APPROACH Multiple measures that use different formats and sources of information are recommended in assessing PTSD. Although there are several good measures for assessing PTSD, there is no one perfect measure that can function as a definitive indicator of PTSD. Different assessment formats have relative strengths and weaknesses. For example, an interviewer-administered assessment modality can increase the respondent’s comprehension by translating and rephrasing questions; however, the interview format can also decrease the accuracy of certain information that the respondent is uncomfortable revealing directly to another person. Secondly, multiple measures can be useful because respondents may have difficulty responding to a particular format, may experience fatigue during one testing occasion, or may demonstrate a response bias on a particular test. To understand more fully the psychometric advantages of multimethod assessment, definitions of terms relating to diagnostic performance may be useful. Diagnostic utility is the general extent to which a particular test index can accurately predict that a person belongs or does not belong in a specified category. Diagnostic utility is measured in terms of sensitivity, specificity, and efficiency. Sensitivity is the probability that the test score will correctly identify individuals with the diagnosis; specificity is the probability that the test score will correctly identify individuals without the diagnosis. Efficiency is the overall probability that true cases and non-cases will be categorized appropriately. Sensitivity, specificity, and efficiency are quantified as a percentage (0-100%) or, alternatively, as a number ranging from 0 to 1. Batteries of tests can be combined to maximize the predictive power of the entire assessment by incorporating measures with varying levels of specificity and sensitivity (for more detailed information, see Weathers, Keane, King, & King, 1997). It is advantageous to combine measures that can collectively offer high sensitivity and high specificity. For example, tests with especially high specificity may be valuable, independent of sensitivity, in order to efficiently screen out those who do not have PTSD. Likewise, tests that demonstrate excellent sensitivity can cast a broad net for possible cases, and additional assessment methods can then be applied to enhance specificity and overall efficiency. When selecting which measures to use, indices of sensitivity and sensitivity should be considered, as well as preference for wording and format. Unfortunately, this information is unavailable for most adolescent measures because few adolescent measures have undergone rigorous

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psychometric testing, although several studies are in progress. In the meantime, information about internal consistency, test-retest reliability, inter-rater reliability, and concurrent validity are the best available psychometric data to help guide decision-making. Although several research teams have used standardized adult measures successfully to assess PTSD in delinquents (e.g., Steiner et al., 1997), the use of measures designated for children and adolescents are preferable in most cases, unless an adolescent has clearly demonstrated cognitive and emotional functioning at an adult level. Trauma Exposure Adolescents may have experienced a wide range of stressful life experiences that meet the DSM criteria for PTSD above and beyond what is immediately brought to the clinician’s attention at the time of referral. Given that most traumatic events are associated with mental health problems (e.g., Boney-McCoy & Finkelhor, 1995), it is useful to conduct a comprehensive evaluation of lifetime exposure to various potentially traumatic life events. Ideally, a good measure assesses exposure to both life-threatening events (e.g., natural disasters, crimes, and violence) as well as to events such as sexual abuse and assault. The use of questions about such a wide range of events may reduce bias since it decreases the probability that an interviewer will selectively inquire about particular events that s/he suspects the child may have experienced. If time permits, the use of both a self-report and interview-based assessment is recommended because each format may influence selfdisclosure. In one study (Erwin et al., 2000), my colleagues and I discovered a fairly good correspondence between self-report and interview formats for learning about or assessing incarcerated adolescents’ exposure to potentially traumatic life events, with the exception of two striking discrepancies. Participants reported witnessing homicides more often in an interview and endorsed witnessing sexual assault (outside the home) more often on self-report forms. To help in selection of measures, Table 1 lists Criterion A measures, authors, format of measures, type of events assessed, and whether the measure helps determine both Criterion A1 (exposure) and A2 (appraisal of event). Apart from such measures, it is important to assess exactly what the patient recalls and what the patient (not the clinician) believes were the worst aspects of the traumatic event. After open-ended questioning, direct and behaviorally specific factual questions regarding the trauma can enhance accurate disclosure. For example, rather than ask if one

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TABLE 1. Measures for Assessing Trauma Exposure in Adolescents Instrument

Format

Event Type

Items

Crit. A1 & A2

Assessing Environments III (Berger et al., 1988)

Questionnaire–child

Family environment and abuse

190

No

Childhood Trauma Questionnaire (Bernstein et al., 1994)

Questionnaire–child

Maltreatment and abuse

70

No

Children’s Exposure to Community Violence (Ford, 1996)

Questionnaire–child

Community violence

19

No

Dimensions of Stressful Events (Fletcher, 1996b)

Interviewer based with parent or child

Dimensions of stressful events

Life Incidence of Traumatic Events–Student Form and Parent Form (Greenwald & Rubin, 1999)

Questionnaire– child and parent

Accidents, disasters, illness, divorce, physical and sexual abuse, robbery

16

Partially

Traumatic Events Questionnaire–Adolescent version and Therapist version (Lipschitz, 1996)

Questionnaire

Home violence, community violence, sexual and physical abuse

46

Partially

Any

15

Yes

Traumatic Events Screening Both Interview and self-report forms for Inventory children & parents (Rogers et al., 1996)

25 (general)

Partially

was battered, it is more effective to ask if one was “attacked, beaten, pinched, or hit by another.” Next, the clinician should systematically determine whether the events involved actual or threatened injury to oneself or others, and whether fear, horror, or helplessness were present at the time of the event or thereafter. For adolescents and children, agitated or disorganized behavior at the time is also accepted as meeting the DSM criteria. Useful questions for assessing such behavior on the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA; Newman & Ribbe, 1996) include: “Were you upset by how you acted at the time?” “What did other people say about how you were acting or feeling at the time?” (Newman et al., in press). The use of specific questions can help some children more readily report aspects of danger, because children exposed to high levels of traumatic threat often do not spontaneously report injury and threat in free recall formats. Since certain adolescents may have trouble admitting fear, it is sometimes useful to ask if his/her heart was beating really fast at the time. Similarly, rather than asking about helplessness, it may be helpful to ask if the child was concerned that s/he could not do anything about the event. This systematic assessment of fear, horror, helplessness, agita-

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tion, and disorganized behavior is especially important to supplement any measure that does not have Criterion A2 questions. Admittedly, it can be challenging to conduct a thorough Criterion A assessment among adolescents due to developmental issues. For example, it may be difficult to assess if certain sexual experiences are coercive or consensual. Furthermore, it is not uncommon for children and adolescents, when confronted with traumatic events, to minimize threat or use fantasy to cope with the event. At recall, some of these responses may be incorporated into the memory for the event and result in confusing reports (Pynoos, 1993). In addition, there is debate in the field as to whether the stressor criterion for children should be modified to better represent children’s responses to experiences. For example, would an event that is stressful, but not a trauma for adults, be considered a trauma for children? The necessity for modifying stressor criterion to adjust for differential stress thresholds based on developmental phases is unknown at this time. Finally, many delinquent youth have cognitive deficits that can impact their comprehension. The interviewer must be sensitive to insure that the youth properly understands all questions. Most youths easily understand the words “fear” and “helplessness” when trying to establish the severity of an event, but may have difficulty relating to the word “horror.” It should be remembered that only one of these three is required to meet the Criterion A standard. PTSD Interviews of Children/Adolescents A comprehensive structured or semi-structured interview instrument is recommended to ensure that all PTSD symptomatology is reviewed in detail. The semi-structured format has the particular advantage of providing organization and consistency while allowing interviewees to discuss their experiences using their own words and metaphors. On the part of the interviewer, clinical skill is required with respect to interpreting, clarifying, guiding, pacing, reflecting, and listening to responses during the interview. Likewise, clinical skill is needed to evaluate whether an individual might under- or over-report symptoms. These clinical hypotheses can be interpreted in the context of the other validity indices such as those in the Minnesota Multiphasic Personality Inventory-Adolescent (Butcher et al., 1992) or the Trauma Symptom Checklist for Children (Briere, 1996). Finally, attention to behavioral indices of PTSD, such as avoidance, hypervigilance, emotional detachment, and startle response to noises, can assist clinical decision-making.

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Table 2 is a list of currently available interviews designed to assess specifically and exclusively for PTSD. In addition, PTSD modules are included in various DSM-IV child-adolescent semi-structured interviews. These include the Anxiety Disorders Interview for DSM-IV Child Version (Albano & Silverman, 1996), the Child and Adolescent Psychiatric Assessment (CAPA; Angold et al., 1995), and the Diagnostic Interview Schedule for Children, (Costello, Edelbrock, Dulcan, Kalas, & Klaric, 1984). In addition, Praver and Pelcovitz (1996) have developed a PTSD measure that uses a cartoon-based method to assess PTSD symptoms and associated features in children ages 6-11 that has promising psychometric properties. Although designed for younger children, it may be useful for adolescents with delayed reading and communication skills. PTSD Self-Report Measures Self-report measures can be time efficient means to obtain information about an adolescent’s PTSD symptoms. In addition to serving as sources of data in a multi-modal assessment, self-report measures can be an efficient means to screen large groups to determine who needs further assessment. Nevertheless, reading difficulties, concentration problems, self-presentation issues, and test-taking biases can affect the TABLE 2. Interviews to Assess PTSD Instrument

Inter-Rater Reliability (kappa)

PTSD Symptom Sample Criteria Assessed

Number of Items

Clinician Administered PTSD Scale for Children and Adolescents (Nader et al., 1998; Newman & Ribbe, 1996)

In process

Yes & associated Delinquents, features pediatric accidents, various

34

Child PTSD Interview (Fletcher, 1996a)

.67

Yes & associated Various features

93

Child PTSD Inventory (Saigh, 1989)

In process

Yes

Rape, Kuwait children 60

Child Posttraumatic Stress Reaction Index (Frederick, Pynoos, & Nader, 1992)

.94-.97

No & associated features

Violence, disaster

20

UCLA PTSD Index for DSM-IV (Pynoos, Rodriguez, Steinberg, Stauber, & Frederick, 1998)

In process

Screening

Not specified

Three versions: Child: 26 Adolescent: 27 Adult: 22

UK = unknown

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quality of the data obtained. To counter some of these challenges, it can be useful to obtain a minimum reading level from the respondent to help choose what measure (child or adolescent) is most developmentally appropriate. This is especially important among delinquent youth who may appear quite mature, but may have educational, interpersonal, and psychological impairment (Brown, Kessel, Lourie, Ford, & Lipsitt, 1997; Silverman, Reinherz, & Giaconia, 1996; Warner & Weist, 1996). Table 3 lists self-report measures, authors, alpha coefficients, sample(s) tested, whether a DSM diagnosis can be determined, and total number of items. Parental Reports Although there is agreement that children are more reliable informants regarding internal states and symptoms than their parents are TABLE 3. Child and Adolescent PTSD Self-Report Measures Alpha

Sample

Dx

Child and Adolescent Trauma Survey (March et al., 1998)

.91

Fire

No

12

Childhood PTSD Reaction Index (Nader, 1996)

.88

Sniper attack, disasters

No

20

Child’s Reactions To Traumatic Events Scales (Jones, 1996 cited in Nader, 1997)

.72-.85

Hurricanes, fires

No

15

Child Report of PostTraumatic Symptoms (CROPS) (Greenwald & Rubin, 1999)

.91

Community sample

No

28

Impact of Events Scale (Dyregrov, Kuterovac, & Barath, 1996)

.71-.84

War, maritime disaster

No

13

Los Angeles Symptom Checklist (King, 1996)

.88-.94

Delinquent adolescents

Yes

43

Trauma Symptom Checklist for Children (Briere, 1996)

.58-.89

Non-clinical sample

No

54

My Worst Experience (Hyman, 1996)a

.68-.91

Sexual abuse, emotionally disturbed, school samples

Yes

100

When Bad Things Happen Scale (Fletcher, 1996c)

.92

Various samples, Israeli children

Yes

90

a

Information obtained from Nader (1997)

Number of Items

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TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

(e.g., Edelbrock, Costello, Dulcan, Kalas, & Conover, 1985), parents’ reports of observable behaviors provide meaningful information regarding observable and disruptive behaviors (e.g., Loeber, Green, & Lahey, 1990). While parents may underestimate their child’s difficulties (Nader, 1997), youth with PTSD also may have difficulty reporting on their condition due to denial, amnesia, avoidance, minimization, cognitive impairment, and communication difficulties. Therefore, collateral reports from a parent can provide valuable information, especially with respect to PTSD symptoms, such as behavioral re-enactments, angry behavior, hypervigilance, sleep difficulties, and startle responses. In addition, medical and school records may also provide important information. For example, difficulties in concentration could be corroborated by teachers’ report, and sleep difficulties may be noted in medical charts. These sources can serve to corroborate the patient’s report of PTSD symptoms and prior functioning. For instance, a dramatic change in school performance that coincides with trauma exposure can provide meaningful information. Furthermore, discrepancies between reports can help the evaluator understand the impact a traumatized person is having on others, and the ways in which the individual interprets personal symptoms and experiences. Table 4 lists parental report measures, type of measure, number of items, alpha coefficients, type of information obtained, and whether the measure yields a DSM diagnosis of PTSD. Acute Stress Disorder, Complex PTSD, and Related Problems Acute Stress Disorder (ASD) was added to the DSM-IV to address traumatic stress reactions within the first month of exposure to traumatic life events (APA, 1994). It includes several symptoms of PTSD (exposure to a traumatic event, symptoms of re-experiencing, avoidance, and arousal), but also requires three or more dissociative symptoms, defined as numbing, derealization, depersonalization, dissociative amnesia, and a reduction of awareness of one’s surroundings. Although there are no psychometrically validated standardized measures available for assessing Acute Stress Disorder in children or adolescents, several are undergoing development and testing. For example, the Stanford Acute Stress Reaction Questionnaire-Student Version (Seagraves et al., 1995) is undergoing testing and has some promising preliminary psychometrics (Lisa Butler, personal communication, April 27, 1999). In addition, the CAPS-CA can be adapted to assess for ASD, although it has yet to be tested psychometrically. Al-

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TABLE 4. Parental Reports of Criterion A and PTSD Symptoms Measure

Alpha

Items

DSM

Information

Childhood PTSD Reaction Interview Index (Frederick, Pynoos, & Nader, 1992) a

NR

Varies by version

No

PTSD symptoms & associated features

Interview

.94

78

Yes

PTSD & associated features

.93

28

No

PTSD & associated features

NR

19

Yes

Criterion A events

Childhood PTSD Interview–Parent Form (Fletcher, 1996a)

Format

Questionnaire Parent Report of Post-Traumatic Symptoms (PROPS) (Greenwald & Rubin, 1999) Traumatic Events Structured Interview– Parent Version (Rogers et al., 1996)

Interview

NR = not reported a Information obtained from Nader (1997)

ternatively, ASD can be assessed by combining validated measures of PTSD with validated measures of dissociation. For example, the Child Dissociative Checklist-Version 3 (CDC; Putnam, Helmers, & Trickett, 1993) and the Adolescent Dissociative Experiences Scale-Version 1 (A-DES; Armstrong, Putnam, Carlson, Libero, & Smith, 1997; Smith & Carlson, 1996) can provide information on dissociative symptoms. If these validated measures of dissociation were combined with previously mentioned PTSD measures, the ASD construct could be assessed. It is important to note that dissociation, especially in children, can be an important post traumatic response; readers specifically interested in understanding assessment and treatment of dissociation in children and adolescents can obtain more information from Putnam (1997). This review has emphasized using psychometric instruments to measure DSM criteria for PTSD. However, it is clear that traumatic events can profoundly affect other important aspects of functioning and can cause both children and adolescents to experience trouble in achieving developmental milestones. Given this reality, some researchers and clinicians have promoted the term “Complex PTSD” to refer to such difficulties. Complex PTSD refers to symptoms and behaviors that reflect the impact of traumatic experiences on self-regulation, self-definition, interpersonal functioning, and adaptational style. While not a recognized disorder, research and developmental theory support the notion

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that there is a complex syndrome resulting from the multiple dynamics and associated adaptations present in situations of interpersonal exploitation (e.g., Cole & Putnam, 1992; Kendall-Tackett, Williams, & Finkelhor, 1993). Thus far, there are two instruments that assess some of these issues in children and adolescents. The Trauma Symptom Checklist for Children (TSCC; Briere, 1996) (see Table 3) is a self-report measure that examines a broad spectrum of trauma-related symptoms including anxiety, depression, posttraumatic stress, sexual concerns, dissociation, and anger in children ages eight and older. Although it does not yield a DSM diagnosis of PTSD or other disorders, it measures various complex adaptations to trauma and has strong psychometric properties. In addition, the TSCC has two validity scales that examine the respondent’s tendencies to underreport or overreport symptoms, a rarity in PTSD assessment among children. In addition, the Children’s Impact of Traumatic Event Scales (Wolfe, Gentile, Michienzi, Sas, & Wolfe, 1991) is available to assess the impact of sexual abuse on children and adolescents. CONCLUSION Understanding the basic strategy and population specific issues for conducting assessments and choosing measures can assist clinical decision-making. The proliferation of child and adolescent measures to assess PTSD is an important advance in the field that will enhance our ability to identify trauma-related difficulties among delinquent youth. However, given the rapid advances in the field, it is recommended that the reader use this review as a starting point, and examine the recent literature for more updated information on each of these promising measures. By understanding the clinical and scientific issues related to designing and conducting PTSD assessments reviewed in this paper, clinicians will be able to design useful multi-modal batteries for their work with delinquent adolescents. REFERENCES Albano, A. M., & Silverman, W. (1996). Anxiety Disorders Interview Schedule for DSM-IV: Child Version. San Antonio, TX: Psychological Corporation. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.

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American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Angold, A., Prendergast, M., Cox, A., Harrington, R., Simonoff, E., & Rutter, M. (1995). The Child and Adolescent Psychiatric Assessment (CAPA). Psychological Medicine, 25, 739-753. Armstrong, J. G., Putnam, F. W., Carlson, E. B., Libero, D. Z., & Smith, S. R. (1997). Development and validation of a measure of adolescent dissociation: The Adolescent Dissociative Experiences Scale. Journal of Nervous & Mental Disease, 185, 491-497. Berger, A. M., Knutson, J. F., Mehm, J. G., & Perkins, K. A. (1988). The self-report of punitive childhood experiences of young adults and adolescents. Child Abuse and Neglect, 12, 251-262. Bernstein, D., Fink, L. A., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132-1136. Boney-McCoy, S., & Finkelhor, D. (1995). Psychosocial sequelae of violent victimization in a national youth sample. Journal of Consulting and Clinical Psychology, 63, 726-736. Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC). Odessa, FL: Psychological Assessment Resources. Brown, L. K., Kessel, S. M., Lourie, K. J., Ford, H. H., & Lipsitt, L. P. (1997). Influence of sexual abuse on HIV-related attitudes and behaviors in adolescent psychiatric inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 316-322. Burket, R. C., & Myers, W. C. (1995). Axis I and personality comorbidity in adolescents with conduct disorder. Bulletin of the American Academy of Psychiatry and the Law, 23, 73-82. Burton, D., Foy, D. W., Bwanausi, C., Johnson, J., & Moore, L. (1994). The relationship between traumatic exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile offenders. Journal of Traumatic Stress, 7, 83-93. Butcher, J. N., Williams, C. L., Graham, J. R., Archer, R. P., Tellegen, A., Ben-Porath, Y. S., & Kaemmer, B. (1992). Minnesota Multiphasic Personality Inventory-Adolescent. Minneapolis, MN: University of Minnesota Press. Carlson, E. B. (1997). Trauma assessments. New York: Guilford Press. Clark, D. B., Pollock, N., Bukstein, O. G., Mezzich, A. C., Bromberger, J. T., & Donovan, J. E. (1997). Gender and comorbid psychopathology in adolescents with alcohol dependence. Journal of the American Academy of Child Psychiatry, 36, 1195-1203. Clark, D. B., Smith, M. G., Neighbors, B. D., Skerlec, L. M., & Randall, J. (1994). Anxiety disorders in adolescence: Characteristics, prevalence, and comorbidities. Clinical Psychology Review, 14, 113-137. Cohen, J. A., Bernet, W., Dunne, J. E., Adair, M., Arnold, V., Benson, R. S., Bukstein, O., Kinlan, O., McClellan, J., Rue, J., & Sloan, E. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, Supplement, 4S-26S.

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Cole, P. M., & Putnam, F. W. (1992). Effect of incest on self and social functioning: A developing psychopathology perspective. Journal of Consulting and Clinical Psychology, 60, 174-184. Costello, A., Edelbrock, L., Dulcan, M., Kalas, R, & Klaric, S. (1984). Report on the NIMH Diagnostic Interview Schedule for Children (DISC). Washington, DC: National Institute of Mental Health. Deykin, E. Y., & Buka, S. L. (1997). Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents. American Journal of Psychiatry, 154, 752-757. Dyregrov, A., Kuterovac, G., & Barath, A. (1996). Factor analysis of the Impact of Events Scale with children in war. Scandinavian Journal of Psychology, 37, 339-350. Edelbrock, C., Costello, A. J., Dulcan, M. K., Kalas, R., & Conover, M. C. (1985). Age differences in the reliability of the psychiatric interview of the child. Child Development, 56, 265-275. Erwin, B. A., Newman, E., McMackin, R. A., Morrissey, C., & Kaloupek, D. G. (2000). Malevolent environmental factors, traumatic life events, and PTSD among criminally involved adolescents. Criminal Justice and Behavior, 27, 196-215. Famularo, R., Fenton, T., Kinsheriff, R., & Agustyn, M. (1996). Psychiatric co-morbidity in childhood post-traumatic stress disorder. Child Abuse and Neglect, 20, 953-961. Fletcher, K. E. (1996a). Psychometric review of Childhood PTSD Interview. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 87-92). Lutherville, MD: Sidran Press. Fletcher, K. E. (1996b). Psychometric review of Dimensions of Stressful Events (DOSE) Rating Scale. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 144-150). Lutherville, MD: Sidran Press. Fletcher, K. E. (1996c). Psychometric review of When Bad Things Happen Scale. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 435-437). Lutherville, MD: Sidran Press. Ford, J. (1996). Psychometric review of the Children’s Exposure to Community Violence. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 98-99). Lutherville, MD: Sidran Press. Ford, M. E., & Linney, J. A. (1995). Comparative analysis of juvenile sexual offenders, violent nonsexual offenders, and status offenders. Journal of Interpersonal Violence, 10, 56-70. Frederick, C. J., Pynoos, R., & Nader, K. (1992). Childhood PTS Reaction Index (Available from Pynoos, 300 Medical Plaza, Los Angeles, CA 90095-6968). Greenwald, R., & Rubin, A. (1999). Assessment of posttraumatic symptoms in children: Development and preliminary validation of parent and child scales. Research on Social Work Practice, 9, 61-75. Haapasalo, J., & Kankkonen, M. (1997). Self-reported childhood abuse among sex and violent offenders. Archives of Sexual Behavior, 26, 421-431. Hyman, I. A. (1996). Psychometric review of My Worst Experience and My Worst School Experience scale. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 212-213). Lutherville, MD: Sidran Press.

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Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164-180. King, L. A. (1996). Psychometric review of the Los Angeles Symptom Checklist (LASC). In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp.202-204). Lutherville, MD: Sidran Press. Lewis, C., Wilkins, R., Baker, L., & Woobey, A. (1995). “Is this man your daddy?” Suggestibility in children’s eyewitness identification of a family member. Child Abuse and Neglect, 19, 739-744. Lipschitz, D. S. (1996). Traumatic Events Questionnaire-Adolescent version. Unpublished measure. Loeber, R., Green, S.M., & Lahey B. B. (1990). Mental health professionals’ perception of the utility of children, mothers, and teachers as informants on childhood psychopathology. Journal of Clinical Child Psychology, 19, 136-143. Lutz, B. K., & Widom, C. S. (1994). Antisocial personality disorder in abused and neglected children grown up. American Journal of Psychiatry, 151, 670-674. Malinosky-Rummell, R., & Hansen, D. J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114, 68-79. March, J. S., Amaya-Jackson, L., Murray, M. C., & Schulte, A. (1998). Cognitive behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single incident stressor. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 585-93. McMackin, R. A., Morrissey, C., Newman, E., Erwin, B., & Daly, M. (1998). Perpetrator and victim: Understanding and managing the traumatized young offender. Corrections Management Quarterly, 2, 35-44. Nader, K. (1996). Psychometric review of Childhood PTSD Reaction Index (PTSD-RI). In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation. Lutherville, MD: Sidran Press. Nader, K. (1997). Assessing traumatic experiences in children. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD: A handbook for practitioners (pp. 291-348). New York: Guilford Press. Nader, K., Newman, E., Weathers, F. W., Kaloupek, D.G., Kriegler, J., Blake, D., & Pynoos, R.S. (1998). Clinician-Administered PTSD Scale for children and adolescents (CAPS-CA), a semi-structured interview for children with traumatic exposure. White River Junction, VT: National Center for PTSD. Newman, E., Kaloupek, D.G., & Keane, T.M. (1997). Assessment of PTSD in clinical and research settings. In B. van der Kolk, A. C. McFarlane, B., & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and the society (pp. 242-275). New York: Guilford Press. Newman, E., & Ribbe, D. (1996). Psychometric review of the Clinician Administered PTSD Scale for Children. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 108-114). Lutherville, MD: Sidran Press. Instrument available at http://www.dartmouth.edu./dms/ptsd/Assessment_Instruments.html Newman, E., Weathers, F., Nader, K., Kaloupek, D., Pynoos, R. S., Blake, D. D., & Kriegler, J. (in press). Clinician Administered PTSD Scale for Children and Adolescents for DSM-IV Manual. Los Angeles: Western Psychological Services.

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Praver, F., & Pelcovitz, D. (1996). Psychometric review of Angie/Andy Child Rating Scales: A Cartoon Based Measure for Post Traumatic Stress Responses to Chronic Interpersonal Abuse. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 65-70). Lutherville, MD: Sidran Press. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York: Guilford Press. Putnam, F. W., Helmers, K., & Trickett, P. K. (1993). Development, reliability, and validity of a child dissociation scale. Child Abuse and Neglect, 17, 731-741. Pynoos, R. S. (1993). Traumatic stress and developmental psychopathology in children and adolescents. In J. Oldman, M. Riba, & A. Tasman, (Eds.), Review of Psychiatry, 12, 205-238. Pynoos, R., Rodriguez, N., Stenberg, A., Stauber, M., & Frederick, C. (1998). UCLA PTSD Index for DSM-IV child version. Los Angeles: UCLA Trauma Psychiatry Service. Reed, L. D. (1996). Findings from research on children’s suggestibility and implications for conducting child interviews. Child Maltreatment, 1, 105-120. Rivera, B., & Widom, C. S. (1990). Childhood victimization and violent offending. Violence and Victims, 5, 19-35. Rogers, K., Ford, J., Racusin, C., Ellis, C., Thomas, J., Schiffman, J., Ribbe, D., Cone, P., Lukovits, M., & Edwards, J. (1996). Traumatic Events Screening Inventory (TESI). Available at . Saigh, P. A. (1989). The development and validation of the Children’s Posttraumatic Stress Disorder Inventory. International Journal of Special Education, 4, 75-84. Saywitz, K. J., & Snyder, L. (1993). Improving children’s testimony with preparation. In G. S. Goodman & B. L. Bottoms. Child victims, child witnesses: Understanding and improving testimony (pp. 117-146). New York: Guilford Press. Seagraves, J., Stein, S., Cardena, E., Classen, C., Koopman, C., & Spiegel, D. (1995). Stanford Acute Stress Reaction Questionnaire–Child’s Version. Unpublished instrument, Department of Psychiatry and Behavioral Sciences, Stanford University. Silverman, A. B., Reinherz, H. Z., & Giaconia, R. M. (1996). The long-term sequelae of child and adolescent abuse: A longitudinal community study. Child Abuse and Neglect, 20, 709-723. Smith, S. R., & Carlson, E. B. (1996). Reliability and validity of the Adolescent Dissociative Experiences Scale. Dissociation: Progress in the Dissociative Disorders, 9, 125-129. Smith, S., & Thornberry, T. P. (1995). The relationship between childhood maltreatment and adolescent involvement in delinquency. Criminology, 33, 451-481. Steiner, H., Garcia, I. G., & Matthews, Z. (1997). Posttraumatic stress disorder in incarcerated juvenile delinquents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 357-365. Warner, B. S., & Weist, M. D. (1996). Urban youth as witnesses to violence: Beginning assessment and treatment efforts. Journal of Youth and Adolescence, 25, 361-377. Weathers, F. W., Keane, T. M., King, L. A., & King, D. W. (1997). Psychometric theory in the development of posttraumatic stress disorder assessment tools. In J. P.

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Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD: A handbook for practitioners (pp. 98-135). New York: Guilford Press. Weiss, D. S., Marmar, C. R., Schlenger, W. E., Fairbank, J. A., Jordan, B. K., Hough, R. L., & Kulka, R. A. (1992). The prevalence of lifetime and partial post-traumatic stress disorder in Vietnam theatre veterans. Journal of Traumatic Stress, 5, 365-376. Widom, C. S. (1989). Does violence beget violence? A critical examination of the literature. Psychological Bulletin, 106, 3-28. Wolfe, V. V., Gentile, C., Michienzi, T., Sas, L., & Wolfe, D. A. (1991). The Children’s Impact of Traumatic Events Scales: A measure of post-sexual-abuse PTSD symptoms. Behavioral Assessment, 13, 359-383. Yule, W., & Williams, R. M. (1990). Post-traumatic stress reactions in children. Journal of Traumatic Stress, 3, 279-295.

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Chaos and Trauma in the Lives of Adolescent Females with Antisocial Behavior and Delinquency Patricia Chamberlain Kevin J. Moore

SUMMARY. Female adolescents entering the juvenile justice system have complex and serious problems in multiple areas of adjustment. Literature is reviewed on the prevalence and form of antisocial behavior in girls and on the long-term implications of such problems in adolescence. Risk factor characteristics, including family fragmentation, physical and sexual trauma, mental health problems, official arrest and self-report offending histories of a population of girls referred for out-of-home placement because of repeated and chronic juvenile offending are presented. In addition, with the exception of sexual trauma histories, these sample characteristics are compared to a similar sample of chronically offending boys. A treatment approach is described and pilot data are presented on its feasibility. Implications for

Address correspondence to: Patricia Chamberlain, Oregon Social Learning Center, 160 East 4th Avenue, Eugene, OR 97401 (E-mail: [email protected]). Support for this project was provided by Grants R01 MH 47458 and R01 MH 54257 from the Center for Studies of Violent Behavior and Traumatic Stress, National Institute of Mental Health (NIMH), and by Grant P50 MH 46690 from the Prevention Research Branch, NIMH. [Haworth co-indexing entry note]: “Chaos and Trauma in the Lives of Adolescent Females with Antisocial Behavior and Delinquency.” Chamberlain, Patricia, and Kevin J. Moore. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 79-108; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 79-108. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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designing empirically-based, gender-related treatment models are discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Girls’ juvenile justice, treatment foster care, randomized design, trauma, delinquency

It is widely acknowledged that adolescent females who are involved in the juvenile justice system are not treated comparably to their male counterparts (Bloom, 1998; Chesney-Lind, 1998). Several authors have noted that females in juvenile justice either tend to be ignored by the system or are dealt with more harshly for less serious crimes than boys (Chesney-Lind, 1999). There may be numerous reasons for this, including the perception that girls are criminal “lightweights” (Giordano & Cernkovich, 1997), the protective attitudes of social control agents in male-dominated juvenile justice systems (Schlossman & Cairns, 1991), or the characterization of girls as difficult to work with because they are emotionally demanding (e.g., have emotional hypocrisies; Zanarini & Gunderson, 1997). The result is that systems typically lack appropriate resources geared to the needs of girls. The idea that treatment for females should be gender specific and that male treatments are not adequate to address the unique needs of females is well accepted in clinical circles. However, the pathways to adolescent antisocial behavior in girls are not as well understood as they are in boys. Therefore, it is not surprising that theoretically grounded treatment models for antisocial behavior and related problems that consider gender are lacking. Understanding girls’ pathways to antisocial behavior is complicated by studies that indicate that the majority of boys who have severe and chronic problems with delinquency in adolescence have childhood histories of antisocial and aggressive behavior, whereas, for most seriously delinquent girls, antisocial behavior emerges for the first time during adolescence (Cohen, Cohen, Kasen, Velez, & Johnson, 1993). Other studies examining age of onset of conduct problems for boys and girls have found that first symptoms and less serious presentations appear at similar ages (reviewed in Keenan, Loeber, & Green, 1999). If the emergence of serious forms of antisocial behavior in early adolescence is more precipitous for girls than boys, this sudden onset could contribute to the lack of developmentally based treatment models for girls. We simply know less about factors that predict or protect against the devel-

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opment of severe conduct problems and delinquency for girls. Therefore, the position of juvenile justice interventionists is weakened when it comes to knowing what should be included in the design of developmentally grounded, gender relevant intervention models. Apparently, the juvenile justice system is not alone in this regard. There is evidence that girls are short-changed by other community service systems. They tend not to be referred to or make use of mental health, social service, or educational delivery service systems as often as boys. In fact, there is evidence that utilization rates for such services are lower for adolescent girls than for any other cohort (i.e., younger females, younger males, and adolescent males) (Offord, Boyle, & Racine, 1991). Caseau, Luckasson, and Kroth (1994) examined whether girls with mental health problems were under-identified in public schools as being SED (seriously emotionally disturbed, according to the Individuals with Disabilities education act IDEA:P.L.101-476). They found that girls were under represented in special education services, yet they were treated more often in private psychiatric hospitals. These authors suggested that the relatively high rate of psychiatric hospitalization for girls in their sample could be attributed to an overall denial of educational services to girls, especially services at an early stage of intervention. Although adolescent females use fewer services, in the juvenile justice system they are more likely than boys to be incarcerated for minor offenses (Chesney-Lind, 1988; Accoca & Dedel, 1998), even though they commit fewer and less serious offenses than males (Ageton & Elliott, 1978). Chesney-Lind’s review showed that despite the relatively minor nature of their offenses, more adolescent females than males end up in adult jails nationwide. In this article, we review research on the prevalence and form of severe antisocial behavior in females and discuss implications for their long-term adjustment into adulthood and motherhood. We report on the risk-factor profiles of girls we studied in the context of an ongoing clinical trial aimed at developing a treatment for severely antisocial girls referred from the juvenile justice system. We compare these risk-factor profiles to those of boys with similar juvenile justice backgrounds in order to highlight similarities and differences in the histories of trauma, mental health symptoms, and family risk factors for the girls and boys in our studies. We also focus on the fact that preliminary data on the girls in our study suggests that they have suffered even higher levels of all kinds of trauma and disruption than a comparable group of boys.

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Finally, we describe the modifications we have made to our intervention in an attempt to better serve girls. RESEARCH ON THE PREVALENCE AND FORM OF SEVERE ANTISOCIAL BEHAVIOR IN GIRLS Over the past two decades, results from epidemiologic studies have shown mixed results on the relative prevalence of severe conduct problems during adolescence for boys and girls (reviewed in Zoccolillo, 1993). A consistent finding (except in the Isle of Wight sample; Graham & Rutter, 1973) is that the high male to female ratio diminishes from preadolescence to adolescence. For example, findings from the Dunedin studies (Anderson, Williams, McGee, & Silva, 1987; McGee, Feehan, Williams, & Anderson, 1992) showed significant differences by gender in the prevalence of conduct problems at age 11 (i.e., girls = 1.9%; boys = 6.3%), but no differences at age 15. However, 15-year-old males and females differed in the rate of aggressive conduct problems (i.e., girls = 0%; boys = 3.1%). Zoccolillo (1993) raised the question of whether this finding, which is replicated elsewhere (e.g., Esser, Schmidt, & Woerner, 1990), is due to a later onset of conduct problems for females or to a lack of sensitivity of methods for detection of early symptoms in girls. Some studies have shown that the magnitude of sex differences in aggression depends on how aggression is defined. For example, when measures of conflict and aggression were administered to fourth graders, boys and girls reported equal rates of conflicts with peers. However, physical aggression was more common for boys, while snubbing and ignoring were more common for girls (Cairns & Cairns, 1994). In assessing developmental changes from fourth through ninth grades, Cairns, Cairns, Neckerman, Ferguson, and Gariepy (1989) found that rates of physical aggression declined for conflicts between boys, while social alienation and ostracism dramatically increased in conflicts between girls. Other studies have found no overall gender differences in aggressive behavior, except that boys tend to show more physical aggression and girls more verbal aggression (Hartup, 1974). Indirect aggression, which is not overt but rather delivered circuitously, appears to be more characteristic of girls than boys (Cairns, Cairns, Neckerman, Ferguson et al., 1989; Lagerspetz, Bjorkqvist, & Peltonen, 1988). Bjorkqvist and his group (e.g., Lagerspetz et al., 1988) were one of the first research groups to show that the social life of girls is more “ruthless and aggressive” (p. 412) than previous studies had

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suggested. More recently, Crick examined gender differences in the form of aggression by males and females in two studies (Crick, in press; Crick & Grotpeter, 1995). She assessed overt and “relational” forms of aggression in elementary school children. Overt aggression included physical and verbal aggression of the type typically studied. Relational aggression included exclusion, gossip, and collusion directed at relational bonds between friends. Using peer nominations, similar proportions of males and females were classified by their peers as nonaggressive (73% of boys; 78% of girls). However, boys and girls differed dramatically in how they expressed aggression; 15.6% of boys and only 0.4% of girls were classified exclusively as overtly aggressive, whereas 17.4% of girls and 2% of boys were classified exclusively as relationally aggressive. An additional 9% of boys and 4% of girls displayed both overt and relational aggression. Underwood (1995) examined whether nonverbal behaviors such as disdainful facial expressions, ignoring, and eye rolling would be perceived by children as hurtful. She compared the effects of these “socially aggressive” behaviors to physical aggression for 9-, 12-, and 15-year-olds. For all three age groups, mean ratings of hurtfulness for social aggression were greater for girls than boys. The findings support the notion that forms of aggression other than physical fighting and threats are salient for girls. Gender differences have been found both in the type of aggression expressed and in the interactional contexts in which they occur. Beginning in early childhood, boys are more likely to engage in roughand-tumble play, while girls typically play less physically in dyads. Sex-role prohibitions against physical aggression are stronger for females, and physically aggressive females are more disliked by peers than their male counterparts (Pepler, 1995). Yet, by adolescence physical aggression is not as rare among girls as one might expect. According to self-report data from the Ontario Child Health Study, 7% of girls (compared to 12% of boys) said they had physically attacked someone (Offord et al., 1991). Similarly, Cairns and his colleagues (Cairns, Cairns, Neckerman, Ferguson et al., 1989) found that 25% of seventh-grade girls and 12% of eleventh-grade girls admitted to engaging in physical fights with a female friend. These data on physical aggression are consistent with the notion that for girls, aggression tends to be expressed in close relationships rather than in the community at large (Pepler, in press). Although, in general, girls may be at lower risk for conduct problems than boys, those who are aggressive as adolescents are more

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likely than males to exhibit comorbid depression (Loeber & Keenan, 1994). Crick and Grotpeter (1995) found that, regardless of gender, relationally aggressive children were significantly more rejected by peers and reported more loneliness and depression. Relationally aggressive children demonstrated more hostile attributions to ambiguous social scenarios than did nonaggressive children and reported feeling more upset in these situations. Long-Term Implications of Severe Antisocial Behavior in Adolescence Several studies document that severe antisocial behavior in adolescence leads to extremely poor adult adjustment for females (e.g., Robins & Price, 1991; Zoccolillo & Rogers, 1991). Robins and her colleagues (Robbins, 1986; Robins & Price, 1991) have shown in several studies that while males who were antisocial adolescents are more likely to engage in criminal activities as adults, females are more at risk for diverse types of poor outcomes. For example, Robins and Price (1991) found that, regardless of other types of psychiatric problems, conduct problems in females predicted poor long-term outcomes, such as internalizing disorders, early pregnancy, and high use of social services. Along these same lines, Lewis, Yeager, Cobham-Portorreal, Showalter, and Anthony (1991) found that for a sample of incarcerated males and females, significantly fewer females had been re-arrested in adulthood (71% of females versus 95% of males). However, long-term outcomes in females were poor. Of 21 participants in the original sample, only six had completed high school, four were prostitutes, 19 had attempted suicide (with one success), 15 had serious drug problems, 13 were or had been involved in seriously violent relationships with men, and one had died of AIDS. Lewis et al. (1991) followed up on 159 females who had been committed to the California Youth Authority from 1961-1969, and who had been randomly assigned to incarceration or community treatment. Before assignment, they had an average of 4.6 arrests, and two-thirds of the sample was primarily status offenders. Following treatment, persistent offending continued (i.e., the treatment had no effect; mean arrests were 7.2), and the seriousness of their offenses increased. As adults, only 4% had no further arrests, 27% had at least two arrests, 40% had been arrested for crimes against persons, and 60% were incarcerated at least once during the period of the adult follow-up.

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Zoccolillo and Rogers (1991) examined long-term outcomes for 55 white, middle-class, adolescent females who had been hospitalized and who had severe conduct problems [i.e., they met the criteria for Conduct Disorder (DSM-IV; American Psychiatric Association, 1994)]. At 2-4 years post discharge, they found a mortality rate of 6% (twice the national rate), a 35% pregnancy rate (compared to an 8% state rate), and high school dropout rates that were significantly higher than the national average. Although many of these girls had comorbid emotional disorders, the authors concluded that it was the presence of severe conduct problems that determined their poor long-term prognosis. Several researchers have found a relationship between aggressive behavior during childhood and adolescent childbearing. Cairns, Cairns, and Neckerman (1989), for example, found that membership in an aggressive peer group in the seventh grade related to dropping out of school, which in turn related to adolescent childbearing. Further, twothirds of the adolescent mothers in that study were the girls considered to be “high risk” because of aggression, poor academic performance, and low socioeconomic status. Underwood, Kupersmidt, and Coie (1996) examined the frequency and timing of adolescent childbearing as a function of aggression and peer sociometric status. Peer nominations were made for status (i.e., popular, average, rejected, neglected, and controversial) and for aggression when girls were in the fourth grade. Eleven years later, county birth certificates were examined for the 79% of the original sample who still resided in the area. Half of the aggressive girls became mothers compared to 25% of the nonaggressive girls, F(1, 224) = 5.53, p < .05. Controversial girls (i.e., those who, in the fourth grade, were well liked by some peers and disliked by others) also had a 50% childbearing rate, which was significantly higher than for any other peer sociometric status group. In these analyses, aggression and controversial status were considered separately. There was only a 19% overlap between controversial and aggressive girls. Besides an elevated frequency of births, these investigators also found that both aggressive and controversial girls gave birth earlier and had more births than those in other groups. The Underwood et al. (1996) study identified two vulnerable subgroups of adolescent females: those who are aggressive and those who have controversial peer status. Controversial children have certain shared characteristics with aggressive children. Most importantly, both groups engage in antisocial and risk-taking behaviors and break rules (Coie & Dodge, 1988; Coie, Dodge, & Coppotelli, 1982). Capaldi (1991) found that similar factors contributed to boys’ engaging in early

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sexual intercourse. In Capaldi’s longitudinal study, levels of antisocial behavior and association with deviant peers during the fourth grade contributed to boys’ engaging in sexual intercourse by the ninth grade. Peer status and aggression may relate to adolescent motherhood because they both shape the social world in which the girls operate (Cairns, Cairns, & Neckerman, 1989), especially in terms of future friendship selection. Once an adolescent becomes a mother, she is at risk for multiple and cascading negative effects. At the very least, being a mother constrains her social, academic, and work opportunities. In numerous studies, adolescent motherhood has been associated with serious educational, financial, and relationship problems for teenage girls (Furstenberg, Brooks-Gunn, & Chase-Lansdale, 1989), and, in turn, with negative effects on psychological functioning (Kellam, Adams, Brown, & Ensiminger, 1992). The earlier adolescent mothers have their first child, the more negative the effects appear to be on the mother. For example, if mothers are 15 years or younger at the time they give birth, they complete one-and-a-half fewer years of schooling than those whose children are born in later adolescence (Hofferth & Moore, 1979). Problems for the Next Generation: Transmission of Trauma Children of adolescent mothers are at risk for negative outcomes. In particular, mothers with a history of severe antisocial behavior as adolescents put the next generation at risk in a multitude of ways. As adults, girls who have been antisocial as adolescents are more likely than non-antisocial girls to (1) affiliate with antisocial men (Quinton & Rutter, 1988), (2) be in violent, abusive relationships (Rosenbaum & O’Leary, 1981), (3) get divorced (Rosenbaum, 1989), (4) exhibit poor parenting skills (Capaldi & Patterson, 1991), and (5) have lower incomes and receive welfare (Robbins & Price, 1991). These and related outcomes result in a greatly increased risk for a child to behave in an aggressive and antisocial manner. For example, the Oregon Youth Study (Capaldi, 1991) has followed a sample of at-risk boys for 10 years, since they were in the fourth grade. In that sample, mothers who gave birth to their first child by age 20 were twice as likely to have study sons with early starting (before age 14) arrest records (35% vs. 18%). In their follow-up of institution-reared girls (n = 81) and boys (n = 90), Rutter and Quinton (1984) found that women who had experienced severe breakdowns in their own upbringing were more likely to have significant difficulties raising their own children, and an “appreciable

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minority” gave up care of their children to other people. In contrast, as adults, males who were institution-reared rarely had their children taken into care. The institution-reared girls were significantly more likely than controls (41% vs. 5%) to become teenage parents, whereas for males the difference was much smaller (8.9% for institution-reared vs. 2.45% for controls). Others have also found that abuse suffered when children are young is associated with higher levels of aggressive and antisocial behavior in adolescence, including increased teenage pregnancy rates and assaultive behavior (e.g., Herrenkohl, Egolf, & Herrenkohl, 1997; Pakiz, Reinherz, Giaconia, 1997). More broadly, there is evidence in the psychiatric literature that women with chronic and/or recurring problems tend to transmit problems to their offspring. There are two primary psychosocial mechanisms through which this transmission is hypothesized to occur. The first, documented in numerous studies, is that disturbed or deviant mothers are more likely to provide their children with poor parenting (Hare & Shaw, 1965; Keller et al., 1986; Lyons-Ruth, Zoll, Connell, & Grunebaum, 1989). The second is that such mothers tend to marry men who also have severe psychiatric, personality, or substance abuse problems (Merikangas & Spiker, 1982; Westen, Ludolph, Misle, Ruffins, & Block, 1990; Zoccolillo, Pickles, Quinton, & Rutter, 1992), and/or who are violent (Lewis et al., 1991). These findings in particular would appear to put children of these mothers at risk for the types of physical and sexual traumas found in our current study sample that we describe later in this article. This research also suggests that physical and sexual traumas increase the probability of the intergenerational transfer of abuse, trauma, and aggression. For example, Andrews, Brown, and Creasey (1990) found that daughters of mothers with chronic problems reported three times more early trauma experiences than those whose mothers had no disorder or only one mental health episode; and they were also subjected to physical and/or sexual abuse by their mothers’ partners significantly more often. On the other hand, selection of a non-deviant male partner has been shown to have a protective effect (Rutter & Quinton, 1984). In summary, the presence of psychiatric problems, including severe conduct problems in adolescent females, is increasingly recognized as a significant problem that is likely to have negative ramifications for their own adult adjustment (Robins & Price, 1991; Zoccolillo et al., 1992) and for the future adjustment of their offspring. The review presented above highlights the need for the development of effective treatments for adolescent girls who have severe antisocial behavior. This need, along with our commitment to the development of

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ecologically valid community-based treatment programs for youth with severe conduct and delinquency problems led to the development of the following treatment foster care program for adjudicated females. Adolescents with Severe Antisocial Behavior: Gender Differences in History and Treatment Response Background. Beginning in 1983, with funding from the Oregon State Corrections Division (Oregon Youth Authority; OYA), we developed and implemented a treatment foster care (TFC) model for youth with serious and chronic delinquency who are placed out of their homes by the courts. TFC is an alternative to group or residential care that uses well trained and supervised community families to provide placements and treatment in the context of a well coordinated, community based intervention strategy. The Oregon Social Learning Center TFC model has been described in detail in Chamberlain (1994) and Chamberlain and Mihalic (1998). Several studies with positive findings have been conducted on the efficacy of the model for various populations, including male juvenile offenders (Chamberlain & Reid, 1998), children leaving the state mental hospital (Chamberlain & Reid, 1991), seriously disturbed young children (Fisher, Ellis, & Chamberlain, 1999), and children in “regular” foster care (Chamberlain, Moreland, & Reid, 1992). Pilot Data (1985-1993). As were the majority of delinquency treatment models, our TFC program was developed based on intervention studies and longitudinal research on boys. However, beginning in the mid 1980s, we began receiving referrals for girls. To meet this community demand, we expanded the program to treat girls. Even though the girls were perceived as being less of a threat to the community than boys, foster parents and therapists report that they were, in many ways, more clinically challenging to treat than their male counterparts. In an attempt to understand the factors accounting for this perception, we examined 88 consecutive referrals of girls and boys to the program from the juvenile justice system (Chamberlain & Reid, 1994). Prior to intake, the 51 male participants had an average of 10.8 arrests (SD = 5.87) and the 37 females had an average of 8.43 arrests (SD = 4.12; p < .05). Significant gender differences were also found on age of first offense (males were younger) and on number of prior out-of-home placements (females had more). Females also had attempted suicide and had run away more frequently, while males had more felonies.

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The TFC treatment was equally effective in reducing arrests for boys and girls. On rates of status offenses, both girls and boys decreased over time, as they did on person-to-person crimes. On property crimes, both sexes dropped significantly, with boys showing a greater decrease in the rate of property crimes than girls. Program completion rates also showed no difference for boys and girls (i.e., 71% of males and 73% of females completed). This was a post hoc analysis, complete with all of the limitations associated with this type of retrospective approach. However, on major outcomes (arrests, program completion) relating to program goals, girls did as well as their male counterparts in TFC. Although this was a service program with no funded research component, clinically we were aware of differences that we wanted to explore using the limited types of data we had been able to collect. We examined the patterns of problem behavior demonstrated by girls and boys in their TFC homes. Data on problem behavior patterns were generated by the Parent Daily Report (PDR) checklist that was administered during treatment to TFC parents daily (M-F) by telephone. To compare initial levels of conduct problems, as well as the patterns over time, we examined the rate of foster-parent-reported problems for the first month (20 calls) and the sixth month (20 calls), which was typically the last month of placement. PDR has been used previously in treatment outcome (Dadds & McHugh, 1992) and longitudinal research (Patterson, Reid, & Dishion, 1992) to assess the presence of and changes in rates of conduct and emotional problems. A gender-by-time interaction was found (F = 8.7, df (1, 47) p = .005), indicating that boys began the program with higher daily rates of problem behaviors and these decreased over time, while girls had the opposite pattern: Their foster parents reported fewer problem behaviors at first and over time these increased. Whether girls “wore” more on the foster homes in which they were placed or became more aggressive and noncompliant over time in the home could not be determined from these data. We now hypothesize that in not targeting relational/social forms of aggression expression in these girls, we missed a key set of problem behaviors that compromised their relationships with their TFC parents, other socializing adults (e.g., therapists, teachers, and peers). The subtle nature of these behaviors coupled with our lack of an intervention strategy to help foster parents deal with them precluded inclusion of relational/social aggressive behaviors as treatment targets. Likewise, we did not target teaching girls alternative ways of expressing their con-

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cerns and anger that could help them maintain positive relationships with the adults who were attempting to help them. At any rate, these data were consistent with the perception by TFC parents and program staff that females were more difficult to treat than males. While girls might have benefited from TFC as much as boys in terms of reductions in arrest rates, we realized that we needed to reconceptualize and adapt aspects of our TFC model to be more responsive to the clinical needs of girls. Also, solid treatment effectiveness conclusions could not be drawn from the pilot study described above, since there was no control group, and the one-year follow-up period limited the examination long-term recidivism. In addition, previous research cited earlier (Robins & Price, 1991; Woodward & Fergusson, 1999; Zoccolillo & Rogers, 1991) suggests that for girls with antisocial and aggressive behavior there are other long-term outcomes that would be critical for a treatment program to impact (e.g., early pregnancy, shortened life span, continuing histories of trauma and abuse) if they were to be considered gender sensitive. Thus, in 1996, we began a study that is aimed at examining the histories and risk factors of girls in the juvenile justice system and the effectiveness of a TFC model modified to address the clinical needs of girls referred from juvenile justice. THE OREGON STUDY OF FEMALE DELINQUENCY PROCESSES AND OUTCOMES We are currently funded by the National Institute of Mental Health (MH54257) to conduct a clinical trial with adolescent females (ages 12-18) referred from the juvenile justice system. Girls are randomly assigned to one of two treatment conditions: Treatment Foster Care (TFC) or Group Care (GC). All participating girls have been screened by their local juvenile justice department staff and recommended for placement in out-of-home care due to severe and chronic delinquency. After girls are referred to the study, consent to participate is obtained from the girls and their guardians. Next, girls are assessed using a multi-method, multi-agent assessment strategy (i.e., different types of measures are gathered from a variety of reporters). We are focusing on several domains that are thought to influence girls’ long-term adjustment. These include: criminal behavior, mental health, history of trauma/abuse, parenting practices girls have experienced, educational history and level, substance use, sexual history, and relational aggression. After the

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baseline assessment, girls are placed in either TFC or GC (determined by random assignment). At this point, 42 girls have been enrolled in the study. Their characteristics and risk factors will be discussed next. Characteristics and Risk Factors of Study Participants Trauma and Abuse. To examine the history of trauma and abuse, we asked girls to complete the Assessing Environments III (AEIII; Berger, Knutson, Mehm, & Perkins, 1988) and the Lifetime Childhood Sexual Experiences questionnaire (Zaidi et al., 1991) and an adaptation of the Norris Traumatic Stress Schedule (Norris, 1990). The AEIII questionnaire was developed for use in studies investigating punitive childhood experiences of adolescents and adults. The Lifetime Childhood Sexual Experiences questionnaire was developed by for the National Center for Post-traumatic Stress Disorder (Zaidi et al., 1991); we have adapted it to a computer-based administration format. The AE-III is a widely used, standardized questionnaire used to measure disciplinary histories and abuse-related events during childhood. The AE-III is a true-false questionnaire that results in a number of sub-scales. All of the subscales have been found to have adequate test-retest reliability and internal consistency. We have adapted this measure to a self-administered, computer based questionnaire format. The Traumatic Stress Schedule was designed to determine the frequency and impact (i.e., perceived stress and posttraumatic stress disorder) of nine potentially traumatic events on individuals’ lives. Respondents answer a series of questions concerning impact after responding affirmatively to lead questions tapping whether an experience ever happened. It has been tested with demographically diverse populations (Norris, 1992). As expected, it is correlated with other measures of negative life events (e.g., losing a job and death in the family) (Degarmo & Leve, 2001). The Childhood Sexual Experience Questionnaire is a measure that collects a history of negative childhood sexual experiences using a grid with persons (potential perpetrators) along one axis and acts along the other. Due to the differences in state mandated reporting laws, we adapted this measure to accept simple “yes/no” answers for each of 14 different coercive events that may have happened to a youth at some point in her life. For any events that have happened, we ask one follow up question: “How old were you the first time that happened to you?” We have also adapted this measure to a self-administered, computer based questionnaire format.

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On the AEIII, we calculated the percentage of study girls who met the criteria for having been physically abused as defined by Berger et al. (1988). Compared to a sample of over 4500 college men and women, 64% of study girls met the Berger et al. criteria for physical abuse compared to 9% in the college sample. The responses to the Traumatic Stress Schedule shown in Table 1 indicated that, in addition to the abuse noted above, a significant percentage of the girls also had lifetime histories of other serious traumas, such as car accidents, fires, or being physically attacked or beaten. History of Childhood Sexual Experiences. Girls’ histories of sexual abuse were equally severe. We analyzed the percentage of girls who reported experiencing a series of 14 sexual acts from the Childhood Sexual Experiences Questionnaire (Zadi et al., 1991), their average age the first time they experienced the act, and the percentage of those who experienced each act who were under age 12 when it first occurred. The study girls reported that they had experienced an average of 4.28 forms of severe sexual abuse (e.g., various types of intercourse, posing for pornographic photographs) before the age of 12. In addition, the average age at which at least one of these sexual experiences occurred was 7.43 years. Family Instability. We examined girls’ histories of instability/transitions in parent figures. Beginning at their birth we asked them who (parent figures) they were living with, and then asked them to report any changes throughout their lives. We counted as a transition any time a parent figure came in or out of a girl’s home or when they were placed in the custody of another adult or in residential care. So, for example, if they were residing with their mother and father when they were born and then their father left (1) and mother’s new boyfriend moved in (2), that would be two parental transitions. If they were then placed in foster care (3), were returned to live with an aunt and uncle (4), and then the uncle left (5), a total of five transitions would be counted. At baseline, these girls had an average of 14 parental transitions, which was on average, about one parental transition for each year of their lives. Relational Aggression Table 2 shows girls’ rates of self-reported relational aggression in the last 24-hours involving caretakers, families, and friends. Table 2 also shows the girls’ experience of relational aggressive acts committed by their friends. These acts include, for example, trying to turn other friends against them and trying to keep them out of groups of friends.

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TABLE 1. Parental Report Lifetime Trauma (Norris) Percentage of girls (n = 42) Attacked or beaten

67 (N = 28)

Forced sex (youth report)*

40 (past year) (N = 17)

Serious car accident

26 (N = 11)

Injury or property damage from fire, severe weather, or disaster

14 (N = 6)

Other terrifying experience

93 (N= 38)

* This item is from the Lifetime Childhood Sexual Experiences Questionnaire

TABLE 2. Relational Aggression Incidents of relational aggression in the last 24 hours Percentage of girls (N= 46) Did not get along with a household member

28.3

Had a fight or disagreement with a caretaker

10.9

Ignored or stopped talking to caretaker

13.0

Had a fight or disagreement with a friend

28.9

Got angry

60.9

Committed at least one of the above forms of relational aggression

71.7

Number of friends who have committed acts of relational aggression Most or all of their friends have gotten mad at them and tried to get even by turning other friends against them

23.9

Most or all of their friends have gotten mad and ignored or stopped talking to them

28.3

Most or all of their friends have tried to keep certain people out of their groups of friends

17.4

At least a few friends committed at least one act of relational aggression

80.4

Most or all of their friends committed at least one act of relational aggression

37.0

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This baseline data suggests that the girls’ daily life is fraught with interpersonal conflict, relational aggression, and chaos. For example, 28% of the girls reported that they had a fight with a friend and 71.7% reported that they committed at least one form of relational aggression in the last 24 hours. Unfortunately, we did not collect comparable data from boys on the history of trauma, abuse, or relational aggression. We were, however, able to compare the boys’ sample on the parental transitions measure. The boys averaged four parental transitions as compared with the 14 reported above for the girls. Comparison of Risk Factors for Girls and Boys Referred from Juvenile Justice. We examined rates of parent criminality for study girls and compared the rates to those for parents of a group of boys who had also been referred by juvenile justice and who had participated in a parallel study at the Oregon Social Learning Center (OSLC) from 1990-1996 (Chamberlain & Reid, 1998). The two samples (girls and boys) were similar on age at referral (means: girls = 14.6 years; boys = 14.4 years) and on the percentage that had been adopted (girls, 8%; boys, 9%). Differences were found for rates of parents who had been convicted of a crime. Forty-three percent of girls’ mothers had been convicted of a crime, compared to 22% of boys’ mothers. Sixty-three percent of girls’ fathers had been convicted of a crime versus 22% of boys’ fathers. Both of these differences were significant at the p = .05 level (mothers X2 = 5.265, p = .02; fathers X2 = 8.75, p = .003). Seventy-five percent of the girls had at least one parent convicted of a crime as compared to 41% of the boys (X2 = 10.24, p = .001). The rates of out-of-home placements for girls and boys were examined, and again, a significant difference (t = 3.8, df = 39, p = .001) was found with girls averaging 3.9 previous out-of-home placements and boys averaging 1.3. Although we cannot compare the level of previous trauma or sexual experiences in our samples of male and female offenders, the data on parent criminality and rates of out-of-home placements suggest that girls who were referred from juvenile justice came from families that were extremely chaotic and distressed, even compared to the highly distressed families of juvenile justice-referred boys. For girls, the high rate of early sexual abuse and large number of parental transitions contributes to the picture of extreme instability, neglect, and abuse this group of girls has experienced. These data suggest that studies examining precursors to the development of antisocial behavior in girls would be remiss if they failed to look at the possible im-

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pact of multiple and sustained traumas, and lack of parental guidance and care on girls’ developmental trajectories. Mental Health Problems. Mental health problems were assessed through examination of the self-report of symptoms on the Brief Symptom Inventory (Derogatis & Spencer, 1982), where we compared scores on five scales for girls and boys. We also administered the DISC-2 Interview (Shaffer, Fisher, Piacentini, Schwab-Stone, & Wicks, 1989), which tracks girls’ mental health diagnoses using DSM-IV (American Psychiatric Association, 1994) criteria. In addition, we coded files to determine what percentage of girls and boys had made a documented suicide attempt. On this variable, we found a significant difference between girls and boys, with 64% of girls and 3% of boys having attempted suicide. Girls’ and boys’ scores on the five BSI scales reflected the same trend. In Table 3, we show the percentage of girls and boys in the two juvenile justice-referred samples who met clinical cut off criteria on five of the BSI scales. On every scale, more girls than boys report levels of symptoms that put them in the clinical range. DISC-2 data from girls confirm a high rate of endorsement of psychiatric symptoms; of the girls interviewed so far (n = 39), 53% of them have met criteria for three or more Axis 1 disorders based on the DSM-IV. This is clearly a highly distressed group of youngsters who have substantial mental health problems. Criminal and Antisocial Behavior. It is well documented in the literature that girls tend to commit fewer and less serious crimes than boys (Rutter, Giller, & Hagell, 1998). In our samples, males referred to a parallel study had 14 offenses prior to entering the study. The first 25 girls who entered the study had an average of 11 prior offenses (t = 1.54, df = 102, p = .126, n.s.). Interestingly, before entering the study boys had spent an average of 73 days in detention during the past year, whereas girls (with fewer offenses) spent an average of 81 days in detention during the past year. In addition to collecting data on official reports of criminal activity, we collected youth self-reports of criminal activities at regular intervals. Official reports are known to provide an underestimate of the volume and seriousness of criminal acts (Elliott & Voss, 1974) because only a small fraction of such acts are detected by the police, and different precincts and communities vary in terms of which offenses are written up and processed. A number of investigators agree that compared to official reports, self-reports better capture the actual nature, incidence, and frequency of juvenile offending (Capaldi & Patterson, 1996; Erickson & Empey, 1963). All girls in the ongoing study and boys from the previous study

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TABLE 3. Percent of Boys and Girls at Different Waves Meeting Clinical Cutoffs on the BSI Diagnosis

Boys at baseline (n = 79)

Girls at baseline + 3 mos. (n = 39)

5.1

75.3

11.4

61.5

Depression

7.6

38.5

Hostility

3.8

35.9

10.1

51.3

1.3

59.0

Somatization Anxiety

Paranoid/psychotic General Psychopathology

(Chamberlain & Reid, 1998) completed the Elliott Behavior Checklist (EBC; Elliott, Ageton, Huizinga, Knowles, & Canter, 1983), a confidential self-report of delinquency. Youth are asked how many times s/he engaged in any of the criminal behaviors during a specific time frame. Scores on three subscales are reported: General Delinquency, Index Offenses, and Felony Assaults. The EBC has demonstrated good psychometric properties (Elliott & Ageton, 1980; Elliott, Ageton, Huizinga, Knowles, & Canter, 1983; Elliott, Huizinga, & Ageton, 1985). In Table 4, scores for girls and boys on five EBC scales are listed. As can be seen, boys report committing more serious offenses (index offenses and felony assaults). We also examined boys’ and girls’ reports of how many of their friends engaged in delinquent behaviors. Youth were asked to report on a scale from 1 (none) to 5 (all) if their friends had committed a series of delinquent acts in the past 6 months. Table 5 shows that girls consistently rate their friends as being significantly more delinquent than do boys. Gender-Related Adaptations to the Oregon TFC Model Most theories of criminality are based largely on characteristics of, observations of, and social conditions affecting male offenders (Keenan et al., 1999). Historically, theories of female criminality have tended to be based on individual and pathological factors, whereas male crime has been explained by social and cultural factors (Bloom, 1998). During the past two decades, increasing attention has been paid to the possible

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TABLE 4. Self-Reported Delinquency: A Comparison of Adolescent Boys and Girls at Baseline Boys (n = 79) How many times in the last year…*

Mean

SD

Girls (n = 46) Mean

SD

Sig.

Subscale Index offenses

56.35

114.14

41.06

133.94

ns

Felony assault

12.99

34.23

6.33

15.82

ns

Hit another

57.06

101.27

32.41

85.63

ns

Total personal violence

70.05

116.16

38.74

88.50

.09

352.13

464.96

323.09

611.15

51.67

105.98

10.54

41.25

.003

Stole or tried to steal at school

5.06

17.48

.61

1.54

.027

Begged for money, things from strangers

7.06

25.05

38.39

103.36

.059

Been involved in gang fights

8.25

30.12

1.85

4.98

.068

59.37

115.95

29.78

69.87

.078

General Delinquency

ns

Individual Items Carried hidden weapon

Tried to steal something worth < $5

*Boys were asked about prior 6 months and girls were asked about the prior 12 months, so boys' scores were multiplied by 2. To handle extreme values (like shoplifting 999 times) each individual item score was capped at 365 (daily) prior to summing.

role of contextual (e.g., family, peer, systemic) factors in the development of female delinquency. There is now recognition that females in the juvenile justice system have multiple and complex needs in addition to controlling their criminal, antisocial, and often self-destructive behavior. Interventions need to be tailored to the specific problems and barriers to productive adjustment that these girls face. The Oregon TFC model attempts to provide girls with several basic program components plus individualized services and supports that address their specific needs. Basic program components are organized around the notion of providing girls with a safe, supportive, and stable family living environment. Because the girls we are working with have such severe histories of chaos and disruption, a primary treatment goal is to stabilize them and to stop the pattern of moving from one place-

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TABLE 5. A Comparison of the Peer Groups of Delinquent Boys and Girls* Boys (n = 79)

Girls (n = 46)

Mean

SD

Mean

SD

Sig.

Peers hit/threatened to hit someone

2.95

1.21

3.83

1.14

.000

Peers sold hard drugs

2.08

1.08

3.39

1.32

.000

Peers damaged something on purpose

2.80

1.11

3.86

1.19

.002

Peers sold or gave alcohol to other kids

2.62

1.18

3.26

1.27

.005

Peers got drunk once in a while

3.54

1.19

4.15

1.11

.006

Peers drove car without permission

2.23

1.00

2.83

1.34

.011

Peers cheated on school tests

2.79

1.35

3.28

1.35

.061

Peers stole something worth more than $50.00

2.61

1.13

3.00

1.17

.067

* The response categories for the items concerning number of peers who have engaged in the behavior in the last year are: 1 = none of them, 2 = very few, 3 = some, 4 = most, and 5 = all of them. Thus, high scores indicate a greater amount of deviant peers.

ment to the next, especially when placement changes are unplanned and are a reaction to a negative set of circumstances. Like their male counterparts referred from juvenile justice, girls enrolled in our TFC program have histories of chronic and severe delinquency and need to be well supervised by adults and separated from delinquent peers. They also seem to benefit from being given clear and teaching-oriented direction and mentorship by a positive female adult (e.g., the female TFC parent). The role of the female TFC parent is well defined in this regard. To help accomplish these treatment goals, program staff closely supervises TFC parents via daily telephone calls and weekly meetings. Special attention is given to interactional dynamics between the foster mother and girls in an attempt to head off escalating negative confrontations and the build-up of angry feelings that can potentially lead to a replication of the girl’s history of disrupted and abusive relationships with significant adults. For example, foster parents are trained to use specific verbal and physical interaction patterns and the girls are coached to use adult preferred social skills. We also consider it important to orient girls toward planning for their futures, given their tendency to have foreshortened views of their fu-

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tures (Greenwald, 2000; Terr, 1991) and their tendency to be preoccupied with relational chaos. Findings from the work of Rutter (1989) and others (Walsh, 1999) suggest that, for female adolescents, a planning orientation is protective against future antisocial behavior. In the TFC model, each girl works weekly with an individual therapist who is available to address issues of the girl’s choosing. The therapist introduces the notion of future planning and assists the girl to identify a plan and to take steps toward its actualization. In addition, the girl’s individual therapist helps her problem-solve around difficulties she may be encountering in the TFC home, in school, with peer relations, or in other situations. The individual therapist follows the girl’s agenda with regard to working on issues related to sexual and physical abuse and is very cautious to prevent the girls from becoming overwhelmed or feeling they are not in control of the pace. Clinically, we think it is unwise to direct girls to deal with these issues (particularly early in treatment/placement), given that doing so typically increases their levels of anxiety, stress, and behavioral and emotional modulation problems. We are well aware that this approach is somewhat controversial in that others believe that “trauma therapy” should occupy a large part of any treatment for these girls. This trauma focused approach is based on what we believe to be an overgeneralization of studies that have suggested good outcomes for children who have suffered single or specific traumatic events, and who had met appropriate developmental milestones prior to the experience of those traumatic events, and who are currently living in stable and supportive social-emotional environments. We are currently unaware of any randomized clinical trial that has shown positive outcomes from trauma-focused therapy with severely antisocial and multiply victimized girls. Careful pacing and caution around a therapeutic focus on abuse seems justified on several grounds. First, girls usually enter the TFC program with a high rate of antisocial behaviors and emotional volatility. This negative behavior places them at risk for relationship and placement disruptions. The foster home environments they are placed in typically have a difficult time decelerating this negative momentum. Therefore, because the girls generally have had such intense and chaotic histories right up to the moment of placement, there is a primary need for the main clinical priority to be helping them stabilize and get back on track developmentally. This approach is in line with the work of other clinical researchers working with severely traumatized adult women who present with behavioral and emotional instability. For example, Linehan (1993) advocates for the importance of stabilization

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and increasing behavioral skills as a first stage treatment target and for decreasing posttraumatic stress symptoms as a second stage target. Because of the number, different types, and intensity of traumatic events these girls have typically experienced, we have found that it is a difficult or unreasonable energy demand for adolescents to focus on exploring these traumas while also trying to accomplish current developmental tasks (e.g., learning to live in a family, getting along with others, going to school and studying, learning and performing age appropriate social skills). We believe that attempts to conduct focused trauma therapy before stabilizing girls and before targeting behaviors and emotional coping styles that help them avoid daily interpersonal and intrapersonal chaos and disruption is unwise and that doing so has the potential to actually increase their negative behavioral and emotional trajectories. Thus, the girls are encouraged to identify themes and topics to work on in the context of the individual therapy, but the undertaking of trauma work is only encouraged once a substantial period of stability has occurred and the girl has had some successes and experienced positive accomplishments. Family treatment is provided to girls’ biological (or adoptive) families to prepare for reunification, if that is the plan. The goal of family treatment is to help parents prepare for their girl’s return home, and specifically, to become more effective at supervising, encouraging, supporting, and following through with consequences with their youngster (i.e., providing a stable and predictable social-emotional environment). One mechanism for accomplishing this is to teach parents to use the point and level system that is part of the daily program in the TFC home. The first sessions are devoted to the family therapist assessing family strengths and areas for improvement. The family therapist tries to understand the barriers to effective parenting that have interfered with the parent-child relationship in the past. Parents are asked about and supported in their view of the evolution of the problem. Parents are encouraged by both the family therapist and case manager to have frequent contact with staff for updates on their daughter’s progress in the program. As the adults who know the child best, parents are asked for continual input into their child’s treatment. Parents are given both the family therapist’s and case manager’s 24-hour telephone numbers. Home visits are scheduled throughout the placement. The first visit is typically short (2-4 hours), followed by a daylong visit, and eventually weekend visits are arranged. Negative indicators for a home visit are if the parent is unable or unwilling to closely supervise the youth during

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the visit. In these instances, visits take place in the program offices or in another supervised setting. In TFC, girls attend public schools. Although school has been an area of major difficulty for many of them, we find that with close supervision and follow-through most girls can do surprisingly well in public school settings. To monitor in-school performance, attendance, and behavior, girls carry a school card that lists each class. For each class period, there is a place for teachers to rate the girl’s behavior as acceptable or unacceptable, to note whether homework has been completed, and to sign their names. The TFC parents collect school cards daily, and teacher ratings are converted into points earned or lost on the daily program. Program staff are on-call to remove youngsters from school should they become disruptive. In addition to these standard program features, we conduct school-based interventions, as needed. In summary, our treatment approach reflects recognition that girls with histories of severe trauma and disruption require a multi-component treatment approach that in some ways is more complex than what is typically required for boys in similar settings. The initial focus is on providing girls with a stable, safe living environment along with giving them emotional and practical support for coping with daily challenges. Once girls start to feel safe and successful in developmentally appropriate life tasks, our emphasis expands to include fostering a planning orientation that is aimed at countering these girls’ pessimistic life views and feelings of hopelessness. CONCLUSION The data presented in this article suggests that the developmental histories of the girls in this juvenile justice sample have experienced extreme and complex trauma. This history appears to put girls at risk for a pattern of daily behaviors that is filled with intra- and inter-personal chaos and relational/social aggression. When this chaotic and stressful daily life is coupled with a complex trauma history and includes delinquency and conduct problems, the clinical treatment task is quite complex. The Oregon Girls Study attempts to organize a treatment approach within a developmental model of female conduct problems. A better understanding of the developmental histories and gender differences in female conduct problems may lead to better defined and targeted treatments. For example, in our sample, most girls had already partici-

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pated in numerous programs that attempted to treat them for the symptoms of trauma and chaotic histories (e.g., sexual abuse, depression, PTSD, school problems, family problems, conduct problems, etc.), but few, if any, provided a comprehensive approach that focused on their behavioral problems and on increasing positive functioning in their daily lives. It is our experience that when daily functioning is ignored or under-treated, there can be a misuse and overuse of control procedures (i.e., medications, and in our sample, longer periods of incarceration) and an increasing perception that “nothing works.” Initial data from this longitudinal study is also commensurate with recent developmental work on girls’ aggression by others (e.g., Cairns & Cairns, 1994; Crick & Grotpeter, 1995; Pepler, 1995; Rutter, Quinton, & Hill, 1990; Underwood, Kupersmidt, & Coie, [in press]) in that adolescent female aggression is expressed differently than male aggression. Moreover, female aggression tends to be performed in interpersonal contexts (i.e., close personal relationships rather than the community at large). It is our opinion that until these recent developmental findings on the demographic and topographical differences between boys’ and girls’ aggression and conduct problems are better disseminated, many treatment agents and agents of social control will fail to identify these gender differences and will continue to label adolescent female aggression in other more mentalistic and less operationalized ways (e.g., “attitude” problems, mental health syndromes, “bad girls”). This lack of theoretical and developmental specificity is less likely to lead treatment agents toward interventions that focus on the present and are successful long term. This lack of specificity may also lead to the aforementioned perception of hopelessness and thus, to the selection of more restrictive and less contextualized interventions (e.g., incarceration, hospitalization) over that of less restrictive, community based psychosocial interventions such as TFC. As noted earlier, the social-interactional treatment strategies we use in TFC have been shown to reduce both male and female adolescent delinquency rates. However, our previous studies (e.g., Chamberlain & Reid, 1994) and the initial demographic data from our current study suggest that if the relational/social aggressive behaviors associated with the conduct disorders in girls are not directly treated, the girls will remain at risk for negative long-term interpersonal and developmental outcomes (e.g., adult mental health problems, early pregnancy, and poverty). These negative outcomes also include the transmission of trauma, aggression, mental health, and conduct problems intergenerationally. Thus, we are anxious to determine if

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our attempts to clinically alter a previously successful TFC model for boys to better understand and treat gender differences, such as relational aggression and other behavioral manifestations of traumatic childhoods (e.g., lack of future planning), will ultimately improve the life course trajectories of conduct disordered girls. REFERENCES Accoca, L., & Dedel, K. (1998). No place to hide: Understanding and meeting the needs of girls in the California Juvenile Justice System. San Francisco: National Council on Crime and Delinquency. Ageton, S. S., & Elliott, D. S. (1978). The incidence of delinquent behavior in a national probability sample of adolescents (Report No. 3). The National Youth Survey. Boulder, CO: Behavioral Research Institute. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anderson, J. C., Williams, S., McGee, R., & Silva, P. A. (1987). DSM-III disorders in preadolescent children. Archives of General Psychiatry, 44, 69-76. Andrews, B., Brown, G. W., & Creasey, L. (1990). Intergenerational links between psychiatric disorder in mothers and daughters: The role of parenting experiences. Journal of Child Psychology and Psychiatry, 31, 1115-1129. Berger, A. M., Knutson, J. D., Mehm, J. G., & Perkins, K. A. (1988). The self-report of punitive childhood experiences of young adults and adolescents. Child Abuse and Neglect, 12, 251-262. Bloom, M. (1998). Primary prevention and foster care. Children and Youth Services Review, 20, 667-696. Cairns, R. B., & Cairns, B. D. (1994). Lifelines and risks: Pathways of youth in our time. Cambridge, UK: Cambridge University Press. Cairns, R. B., Cairns, B. D., & Neckerman, H. J. (1989). Early school dropout: Configurations and determinants. Child Development, 60, 1437-1452. Cairns, R. B., Cairns, B. D., Neckerman, H. J., Ferguson, L. L., & Gariepy, J. L. (1989). Growth and aggression: I. Childhood to early adolescence. Developmental Psychology, 25, 320-330. Capaldi, D. M. (1991). The co-occurrence of conduct problems and depressive symptoms in early adolescent boys: I. Familial factors and general adjustment at Grade 6. Development and Psychopathology, 3, 277-300. Capaldi, D. M., & Patterson, G. R. (1991). Relation of parental transition to boys’ adjustment problems: I. A linear hypothesis. II. Mothers at risk for transitions and unskilled parenting. Developmental Psychology, 27, 489-504. Capaldi, D. M., & Patterson, G. R. (1996). Can violent offenders be distinguished from frequent offenders: Prediction from childhood to adolescence. Journal of Research in Crime and Delinquency, 33, 206-231.

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(Addendum to the Assessing Environment-III). National Center for PTSD and University of Iowa. Zanarini, M. C., & Gunderson, J. G. (1997). Differential diagnosis of antisocial and borderline personality disorders. In D. M. Stoff, J. Breiling, & J. D. Maser (Eds.), Handbook of antisocial behavior (pp. 83-91). New York: John Wiley & Sons. Zoccolillo, M. (1993). Gender and the development of conduct disorder. Development and Psychopathology, 5, 65-78. Zoccolillo, M., Pickles, A., Quinton, D., & Rutter, M. (1992). The outcome of childhood conduct disorder: Implications for defining adult personality disorder and conduct disorder. Psychological Medicine, 22, 1-16. Zoccolillo, M., & Rogers, K. (1991). Characteristics and outcome of hospitalized adolescent girls with conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 973-981.

Violence Exposure and PTSD Among Delinquent Girls Jenifer Wood David W. Foy Carole A. Goguen Robert Pynoos C. Boyd James

SUMMARY. This study focuses on the unique trauma histories of incarcerated girls. In particular, this study draws upon data obtained from 100 incarcerated adolescent girls, highlighting areas of similarity to and difference from incarcerated boys, including: overall levels of traumatic violence exposure, exposure to unique forms of traumatic violence, psychological symptomatology, and hypothesized trajectories of involvement in serious delinquent activity. In addition, a case example is presented to illustrate our hypotheses about the trajectories of adolescent girls’ involvement in serious delinquent behavior, as well as the prominent role of early trauma histories and repeat victimization in these trajectories. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.] Address correspondence to: Jenifer Wood, PhD, National Center for Child Traumatic Stress, University of California, Los Angeles, 11150 West Olympic Boulevard, Suite 770, Los Angeles, CA 90064 (E-mail: [email protected]). This research was supported by a grant from the California Wellness Foundation Violence Prevention Initiative and by Charles R. Drew University of Medicine and Science. [Haworth co-indexing entry note]: “Violence Exposure and PTSD Among Delinquent Girls.” Wood, Jenifer et al. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 109-126; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 109-126. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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KEYWORDS. Adolescence, community violence, dating violence, gender differences, juvenile justice, trauma, physical abuse, sexual abuse

GIRLS BEHIND BARS Despite falling crime rates, more young women are arrested and incarcerated in the United States today than ever before. On an average day, over 14,000 girls are detained in juvenile facilities (Gallagher, 1999). Nearly three-quarters of a million females below the age of 18 were arrested by the police in 1997 (Snyder, 1998), accounting for 26% of total juvenile arrests and 16% of arrests for violent crimes. Since 1993, the number of arrests among female adolescents has increased more for most offense types in comparison with males (Snyder, 1998). Between 1992 and 1996, female arrests for violent index crimes increased 25%, for example, with no recorded increase among males; property crime index offense arrests increased 21% among girls, in contrast to a 4% decrease among boys during this same time period (Budnick & Shields-Fletcher, 1998). According to Snyder (1998), arrests for aggravated assault among adolescent girls have increased 15% since 1993, in comparison to a 10% decrease among boys. Although arrests for drug abuse violations have increased markedly for both males and females, the rate of increase among girls (117%) is 1.5 times that of boys (78%) (Snyder, 1998). Antecedents and Trajectories of Involvement in Delinquent Activity Paralleling the growing number of girls at the extreme end of the continuum of aggressive and delinquent activity has been an increasing interest on the part of researchers and clinicians in understanding the antecedents and trajectories of such behavior. For example, investigators have recently begun to focus on the prevalence of conduct disorder and aggressive behaviors among girls.. Epidemiological research indicates that there are no sex differences in the prevalence of conduct disorder in adolescence, and, in fact, conduct disorder is one of the most common diagnoses among adolescent females (Zoccolillo, 1993). Investigators disagree, however, regarding whether or not there are sex differences in the symptoms or correlates of conduct disorder (ZahnWaxler, 1993). Some investigators have concluded that aggressive behavior in girls is typically interpersonal in nature and may be more

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strongly associated with deficits in social competence than boys’ more instrumental aggression (Crick & Dodge, 1994). While the literature has clearly established a set of pathways for boys’ involvement in delinquent behavior, many of these investigations did not include girls, nor did they make comparisons between the sexes. Much less is known about girls’ trajectories of involvement in delinquent behavior. Compas, Hinden, and Gerhardt (1995) outline five trajectories of adolescent development that reflect continuity or discontinuity between aggressiveness in childhood and delinquency in adolescence. They point out, for example, that delinquent or violent behavior in adolescence may be preceded by a pattern of aggressive behavior in childhood (the “stable maladaptive path”) or that adolescents’ behavior may “decline” during their teenage years as a result of increased life stressors, as well as the biologically-based changes of puberty. A decline during adolescence may be followed by “turnaround or recovery” in early adulthood or may continue to follow the stable maladaptive path. Compas et al. (1995) go on to suggest that males and females may differ in terms of these trajectories, with females being more likely to decline in adolescence and fail to recover; a significant proportion of males, they suggest, display continuity between aggressive behavior in childhood and delinquency in adolescence. Numerous investigations have revealed less consistency or stability in females’ aggressive behavior in comparison with males’ (see Tolan & Gorman-Smith, 1998). For example, Stattin and Magnusson (1989) did not find a relationship between girls’ aggression measured at age 10 and later officially recorded violent offenses. A great deal of previous research has investigated the question of whether family dysfunction (operationally defined in a number of ways) is more strongly associated with delinquent behavior among girls. Some investigators have found that mother-adolescent relationships are more conflictual in families of female delinquents; moreover, the fathers of female delinquents were more emotionally disturbed (Henggeler, Edwards, & Borduin, 1987). Henggeler and his colleagues found that the families of female delinquents tended to be more conflictual than those of males, and they speculated whether this difference was due to females being more susceptible to the disorganizing influence of family conflict, or to family reactivity to previously occurring female delinquent behavior. In support of the former interpretation, Jaycox and Repetti (1993) found that exposure to family conflict has a greater impact on girls’ emotional adjustment, specifically their perceived self competence. A comparison of incarcerated male and female

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adolescents found that the females, as a group, were more seriously impaired as a result of childhood histories of physical and sexual abuse (Lewis et al., 1991). Lewis and her colleagues felt that, in comparison with incarcerated male adolescents, the females were “an especially dysfunctional group” (p. 201). It also has been suggested that, while both male and female delinquents may have dysfunctional families, females’ may differ more strongly from non-delinquent females’ (Miller, 1979). In contrast, others have reported that the relationship between family dysfunction and delinquency is no stronger for females than it is for males, and may, in fact, be even less consistent. For example, one large epidemiological investigation concluded that similar demographic and social factors (such as single-parent families and low socioeconomic status) predict delinquency in males and females (Rantakallio, Myhrman, & Koiranen, 1995), while other investigators have concluded that the relationship between physical punishment and aggressive behavior does not appear to differ for males and females during childhood (Weiss, Dodge, Bates, & Petit, 1992; Dodge, Pettit, & Bates, 1994). These discrepancies in the literature indicate the need for further research that examines a wider array of family environment variables as well as manifestations of delinquent or anti-social behavior among adolescent girls. In particular, there is a need for theory-driven research, which tests hypothesized mediators of the relationship between specific indicators of “family dysfunction” and delinquent activity. RECENT RESEARCH ON GANG-INVOLVED AND INCARCERATED GIRLS Responding to the increasing numbers of girls behind bars, researchers have begun to characterize this population and the nature of their life experiences. Not unlike the research described above, research on gang-involved girls and girls incarcerated by the juvenile justice system have revealed some similarities and some differences from their male counterparts. For example, analyses of data from the Rochester Youth Development Study (Thornberry, 1998) revealed that neighborhood and school factors were more predictive of girls’ involvement in gangs, whereas boys’ gang involvement was more strongly associated with family factors and relationships with delinquent peers. That is, living in a disorganized and violent neighborhood was more strongly associated with gang involvement among girls than among boys, while higher lev-

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els of family violence were not associated with higher levels of gang involvement among the girls in this study. This finding suggests the possibility that correlates of gang involvement differ from correlates of general delinquency among adolescent girls. The limited amount of research that has been done with incarcerated adolescent females to date suggests that many of these girls have histories of trauma and victimization, as well as generally higher levels of associated psychological difficulties than incarcerated boys. For example, one third of the serious violent female offenders tracked by the Denver Youth Study (Huizinga & Jakob-Chien, 1998) displayed significant problems in the domains of victimization, academic performance, and mental health. Data collected from a sample of youth entering a juvenile assessment center indicated that females who come into contact with the juvenile justice system have higher rates of sexual abuse referrals and psychological difficulties (Dembo, Schmeidler, Sue, Borden, & Manning, 1995). Dembo and his colleagues also concluded that a troubled home life appeared to be a more significant factor in female delinquency. Within another sample of incarcerated youth, Evans 1996) found that females reported significantly more physical and sexual abuse, with more than 70% of the incarcerated girls reporting these experiences. Females also reported significantly more suicide attempts, with gang-involved females reporting the highest rates. Structured clinical interviews conducted with a sample of 96 incarcerated adolescent females revealed that over 65% had experienced PTSD during their lifetimes, while nearly 50% currently met diagnostic criteria for the disorder. In sum, the few investigations of incarcerated adolescent females conducted to date suggest that this group has unique assessment and intervention needs (Miller, Trapani, Fejes-Mendoza, & Eggleston, 1995). SUMMARY OF CORRELATES OF DELINQUENCY AMONG GIRLS Clearly, in this emerging body of research, all of the questions about gender differences and correlates of delinquent activity have not yet been answered. Some risk factors seem important to consider for both boys and girls (e.g., socioeconomic status or single-parent families). There are particularly discrepant findings in the literature, however, regarding the relative impact of family conflict, physical punishment, and community and school variables on delinquency among males and females. Discrepancies in these areas may be the result of how these vari-

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ables are measured, as well as the context in which they are considered (i.e., which sets of variables are examined simultaneously). Recent research with girls entering the juvenile justice system strongly suggests that delinquency among females is associated with psychological difficulties–notably suicidality and PTSD. What are the implications of this body of research for understanding girls’ trajectories of involvement in delinquent activity? These findings taken together might suggest that a disturbed family environment is not sufficient to predict delinquency among girls, but that girls’ development of psychological difficulties might trigger their involvement in the juvenile justice system. The later onset of delinquent activity among girls, if this interpretation is correct, may be the result of the onset of psychological symptomatology in midto late-adolescence. THE PRESENT STUDY The present study focuses on the unique trauma histories and mental health needs of incarcerated girls. More specifically, this study draws upon data obtained from 100 incarcerated adolescent girls, highlighting areas of similarity to and difference from incarcerated boys, including: overall levels of traumatic violence exposure, exposure to unique forms of traumatic violence, psychological symptomatology and risk behaviors associated with violence exposure, and correlates and trajectories of involvement in serious delinquent activity. Because of the discrepant findings in the literature highlighted above, this study was intended to be rather exploratory in nature. It was hypothesized that (a) incarcerated girls are likely to differ from incarcerated boys in terms of their exposure to multiple forms of violence, with girls reporting greater levels of exposure, (b) girls are likely to report higher levels of psychological symptomatology and risk behaviors, and (c) girls who are involved in more serious delinquent activity will have initiated this behavior later than their male counterparts, and will report more disturbed family environments. The latter hypothesis represents an exploration of adolescent girls’ trajectories of involvement in delinquent activity–that is, when do they begin their involvement and what might be some of the triggering or exacerbating conditions? By expanding consideration of forms of violence exposure to include dating violence and sexual assault experiences and by examining the prevalence of PTSD and other psychological difficulties among incarcerated females, this study adds to previous understandings of the corre-

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lates of serious, violent, delinquent behavior. In addition, this study provides a more qualitative description of the trauma histories and on-going adversities faced by incarcerated girls. A case example is presented to illustrate our hypotheses about the trajectories of adolescent girls’ involvement in serious delinquent behavior, as well as the prominent role of early trauma histories and repeated victimization in these trajectories. METHOD The procedures and sample for this study are also described in Wood et al. in this volume. Briefly, individual interviews were conducted with 200 adolescents, randomly selected from the population rosters of five probation camps and two juvenile halls to fill each cell of a 2 ⫻ 2 ⫻ 2 (Gender ⫻ Ethnicity ⫻ Offense) design. The sample was comprised, therefore, of equal numbers of males and females, Latinos and African Americans, and violent and non-violent offenders. The Female Subsample The female sample (n = 100) was randomly selected from the population rosters of one Los Angeles County probation camp and two juvenile halls. The recruitment of female participants was extended to the juvenile halls because the population at the camp (at that time, 90 females, on average) was considered too small to support the demands of the study. In comparison with the incarcerated adolescent male population, a larger proportion of Asian and Caucasian females were incarcerated in Los Angeles County; as a result, the ethnic composition of the female sample (46% African-American and 54% Latina) was less representative of the female population as a whole. Master’s-level psychology graduate students collected the data in an individual interview format. One of the interviewers was fluent in Spanish and conducted approximately five interviews with bilingual females predominantly in Spanish. Measures Table 1 presents information on the primary measures employed in this study, from three domains: violence exposure, psychological distress, and family dysfunction. Additional detail is available in Wood et

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TABLE 1. Measures Employed with Incarcerated and High-School Samples Incarcerated Sample

High-School Sample

(Interview)

(Questionnaire)

Community violence

Survey of Children's Exposure to Community Violence (SCECV; Richters & Saltzman, 1990) 46 true/false items assessing lifetime exposure to 18 types of community violence, including: 16 direct (“It happened to me”), 17 witnessed (“I saw this happen to someone else”), and 13 vicarious (“I know someone to whom this happened”) items

Survey of Children's Exposure to Community Violence (SCECV; Richters & Saltzman, 1990)

Physical punishment

Assessing Environments-III Physical Punishment subscale (AEIII; Berger, Knutson, Mehm, & Perkins, 1988) 12 true/false items ranging from “My parents used to spank me” to “I was severely beaten by my parents”

Not assessed

Sexual abuse

Sexual Abuse Exposure Questionnaire (SAEQ; Rowan, Foy, Rodriguez, & Ryan, 1994) 15 true/false items ranging from “Has anyone ‘flashed’ you” to “Has anyone ever talked you into or made you have sexual intercourse,” and two SCECV items

Two true/false items embedded in SCECV “Sexually assaulted, molested, or raped–this happened to me” and “I have seen this happen to someone else”

Los Angeles Symptom Checklist-RevisedAdolescent version (LASC-Revised-Adolescent; Foy et al., 1997) 17-item PTSD scale, comprised of 3 symptom cluster subscales: reexperiencing symptoms, arousal symptoms, and avoidance symptoms

Los Angeles Symptom Checklist-RevisedAdolescent version (LASC-RevisedAdolescent; Foy et al., 1997)

Violence Exposure

Posttraumatic Stress

al. (this volume) on the following measures of violence exposure and psychological distress: Assessing Environments-III (AEIII; Berger, Knutson, Mehm, & Perkins, 1988), the Sexual Abuse Exposure Questionnaire (SAEQ; Rowan, Foy, Rodriguez, & Ryan, 1994), the Survey of Children’s Exposure to Community Violence (SCECV; Richters & Saltzman, 1990), and the Los Angeles Symptom Checklist (LASC; Foy, Wood, King, King, & Resnick, 1997). If the measure was administered to the male subsample, this is indicated in Table 1 as well. Two measures of serious delinquent activity were administered to both the female and male subsamples: a 13-item Gang Affiliation index, as well

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as a 25-item Gun Possession scale. Further details regarding the development and psychometrics of these two instruments may be found in Wood et al. (this volume). RESULTS Overview First, the female subsample will be described in terms of victimization and violence exposure, as well as psychological distress. Where comparison data is available for incarcerated adolescent males, areas of difference and similarity will be highlighted. In addition, trajectories of involvement in serious delinquent activity (as indicated by gang affiliation and firearm possession) will be explored within the two sub-samples. That is, comparisons will be made between incarcerated males and females who are gang-involved in terms of their age of onset for this behavior, as well as family environmental correlates (including family dysfunction, family risk, and physical discipline). Similar comparisons will be made between males and females who report regularly carrying and using guns. Levels of Exposure to Traumatic Violence The means and standard deviations for each of the measures of violence exposure are presented in Table 2. Where comparison data was available for males, the statistical significance of the difference between the means for females and males is presented. Females reported significantly higher levels of physical punishment and sexual abuse exposure. Males, on the other hand, reported significantly higher levels of all three forms of community violence exposure: direct, witnessed, and vicarious or verbally mediated. In the present sample, 51 of the youth (approximately 25%) reported sustaining an injury as a result of physical punishment; a significantly higher proportion of females than males sustained such an injury (34% versus 16%; (χ2 (1, 200) = 8.64, p < .01). More than half of the youth (67% of males and 56% of females) also reported witnessing the homicide of a close other; the association between sex and witnessing a homicide was not significant.

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TABLE 2. Results of Hierarchical Regression Analyses Predicting PTSD Symptoms from Violence Exposure Variables

Male Subsample (N = 100)

Female Subsample (N = 100)

Predictor Entered at Each Step

Beta

R2 Change

Beta

R2 Change

1. Physical Punishment

.21*

.05

.38***

.14

2. Sexual Abuse

.01

.00

.33**

.09

3. Community Violence

.47***

.21

.32***

.10

2

Overall R for Model

* p < .05

** p < .01

.26***

.33***

*** p < .001

With regard to other types of violence exposure measured only within the female subsample, high rates of exposure to dating and sexual violence were reported. For example, 36% of the incarcerated female adolescents reported being kicked or hit with a fist by their boyfriends, 24% reported being beaten up at least once by their boyfriends, and 21% reported that their boyfriends have threatened them with a knife or gun. Twelve percent reported that their boyfriends have forced them to have sex on at least one occasion, and 22% reported they have been forced to have sexual intercourse by someone within the past few years. Reporting on their experiences before age 14, 18% of the incarcerated females had been forced by an adult to have sexual intercourse, and 31% had been touched in an unwanted, sexual way by an adult. These young women also reported high rates of community violence exposure. For example, 58% report that someone has held a gun to their head, 10% described having been tortured or physically mutilated (e.g., burned), and 31% indicated that they have been hit with an object such as a bat, club, or tire iron. Fifty-six percent have witnessed the homicide of a close friend or relative, while 16% were present when a close friend or relative committed suicide or accidentally killed him or herself.

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Levels of Psychological Distress Posttraumatic Stress. Mean scores and standard deviations for males and females on the LASC-R, as well as PTSD sub-scale scores, are presented in Table 3. Females reported significantly higher levels of overall psychological distress, as well as higher scores on all three PTSD TABLE 3. Results of Hierarchical Regression Analyses Predicting Serious Delinquent Activity from Violence Exposure Variables

Outcome Variable

Male Subsample

Female Subsample

(N = 100)

(N = 100)

Beta

R2

Beta

Change

R2 Change

Gang Affiliation 1. Physical Punishment

.01

.00

.17

.03

2. Sexual Abuse

.02

.00

.02

.00

3. Community Violence

.43***

.18

.47***

.21

Overall R2 for Gang Affiliation

.18***

.24***

Gun Possession 1. Physical Punishment

.13

.02

.32**

.10

2. Sexual Abuse

.12

.01

.00

.00

3. Community Violence

.38***

.13

.46***

.20

Overall R2 for Gun Possession

.17***

.30***

Current Offense 1. Physical Punishment 2. Sexual Abuse 3. Community Violence Overall R2 for Current Offense

* p < .05

** p < .01

*** p < .001

.00

.00

.09

⫺.02

.00

.09

.01

.15

.02

.14

.02

.02

.01

.03

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subscales–reexperiencing, arousal, and avoidance–compared to incarcerated males. In addition, using an approach to categorical scoring of the LASC-R PTSD scale described in King, King, Leskin, and Foy (1995), 52% of females could be classified as PTSD positive, in contrast to 28% of males (χ2 (1, 200) = 12.00, p < .001). Depressive Symptoms. Similarly, females reported significantly higher levels of depressive symptoms on the Center for Epidemiological Studies Depression scale (CES-D), as shown in Table 3. Risky Drug-Related Behavior. Males and females did not differ significantly on the drug risk variable. Within the male and female subsamples, 39% reported taking more than one drug at the same time, while 68% of males and 56% of females reported using drugs when alone. Similar proportions of males and females reported getting drunk while alone (40% and 35% respectively), while 6% of females and no males reported having used a needle to inject a drug. Family Environment Correlates and Age of Onset of Delinquent Activity In order to explore the differences between males and females in terms of trajectories of involvement in serious delinquent activity, two groups were examined: youth describing themselves as currently in a gang (85% of males and 76% of females) and youth who reported that they owned and carried a gun prior to their arrest (87% of males and 52% of females). As indicated in Table 4, male and female gang members did not differ significantly in terms of percent entering a gang before high school; females tended to report more years of gang involvement, however. In order to examine differences between males and females in terms of family correlates of gang involvement, a Multivariate Analysis of Variance (MANOVA) was performed using the three Family Dysfunction measures presented in Table 1, as well as the Physical Punishment scale. The multivariate F-test indicated that male and female gang members differed significantly on this set of four measures (F4,127 = 3.66, p < .01). Univariate F-tests (see Table 4) revealed that females reported significantly higher levels of family risk and physical punishment, compared to males. With regard to adolescents who reported owning and carrying guns, males and females did not differ significantly in terms of the proportion obtaining their first gun prior to high school. MANOVA revealed, however, that these males and females differed significantly from one another on the set of

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Family Dysfunction and Physical Punishment variables (F4,119 = 7.84, p < .001). As shown in Table 4, females involved with guns described higher levels of family risk, lower perceived social support from their families, and higher levels of physical punishment in comparison with their male counterparts. Male gun owners, however, reported higher levels of family conflict. Case Example The following case example represents a composite of a number of stories told by the adolescent girls interviewed for this study. It is intended to convey some of the common themes echoed throughout the lives of the girls in camp and juvenile hall and to illustrate a typical trajectory of involvement in serious delinquent activity. Marta is a 16-year-old Latina, arrested for possession of a firearm. This was not her first arrest and is her second time in Camp Scott. Marta ran away from home at the age of 13, afraid that she might try to kill her step-father who brutally abused her mother, physically and sexually. On one occasion, Marta witnessed her step-father throw her mother down a flight of steps. After leaving home, Marta turned to local gang members for shelter and protection. When interviewed about her exposure to community violence, Marta described being both the victim and perpetrator of numerous assaults, culminating in a recent incident in which she had been jumped and stabbed by rival gang members. Marta also described witnessing several sexual assaults, perpetrated by her homeboys [members of her gang], often against girls they believed were “snitches.” Marta’s most upsetting experience was when a homeboy was shot by rival gang members and died in her arms; she is committed to seeking revenge for this loss as soon as she is released from camp. During the interview, Marta endorsed many grief symptoms, and she received a high score on the LASC-R PTSD scale, reporting that intrusive memories of her friend’s murder are particularly troubling for her. Marta explained that she regularly carries a gun for protection, because she is identified with a gang, and so that she will be prepared to retaliate for her friend’s murder if any opportunity were to arise. Many of the young women interviewed for this study described troubled and frequently violent home lives; life on the streets with their

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TABLE 4. Comparisons Between Males and Females Involved with Gangs and Guns Female Subsample (N = 100)

Male Subsample (N = 100)

Signficant Difference?

Percent gang involved

76%

85%

no

Percent in gang before high-school

86%

88%

no

Mean number of years in gang

5.13

3.87

t = 2.14*

Family risk

2.58

1.83

F = 11.47***

Family conflict

4.15

4.94

no

Family support

13.33

13.91

no

Physical punishment

3.88

2.99

F = 4.81*

Percent owning and carrying gun

52%

87%

χ2 = 26.66***

Percent with gun before high-school

69%

70%

no F = 23.59***

Self-identified as gang involved

Family Dysfunction

Self-identified as gun carriers

Family Dysfunction Family risk

3.00

1.92

Family conflict

3.78

4.90

F = 5.56*

11.90

13.96

F = 7.44**

4.62

3.06

F = 14.23***

Family support Physical punishment * p < .05

** p < .01

*** p < .001

homeboys provided respect and a sense of belonging that they had not obtained at home or in school. Sustaining minor physical assaults or witnessing attacks on others were familiar and almost expected as part of everyday life. Cumulatively, however, these incidents contributed to a sense of vulnerability and a need to carry a firearm for protection. DISCUSSION Overview The incarcerated females interviewed for the present study described high levels of multiple forms of victimization, within their families of origin, in their relationships with boyfriends, and on the streets. In comparison with incarcerated male adolescents, they reported significantly

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higher levels of physical punishment and sexual abuse, as well as significantly higher levels of psychological distress, including PTSD and depressive symptomatology. Like the adolescent males in our study, females reported high levels of exposure to serious incidents of community violence, including witnessing the homicide of close others, and they engaged in a number of risky drug-related behaviors. Although few differences were observed between males and females in terms of age of onset of gang- and gun-related activity, a number of significant differences emerged between the sexes with regard to family correlates of serious delinquent activity. More specifically, the incarcerated females we interviewed reported exposure to high levels of traumatic violence in their homes and communities. For example, one out of every four females in our sample reported being beaten up by a boyfriend, being threatened with a weapon by a boyfriend, having been forced to have sexual intercourse within the past few years, or having been hit with an object such as a bat or tire iron. In comparison with incarcerated boys, girls reported more physical punishment at home, including two times the rate of physical injury sustained as a result of childhood abuse. Females also reported a significantly higher level of unwanted sexual contact in comparison with boys, with 18% reporting they were forced by an adult to have sexual intercourse before age 14. Boys, however, reported more direct community violence exposure, including being beaten up or stabbed. Nonetheless, the females in our sample reported disturbingly high rates of exposure to a number of forms of community violence, such as having a gun held to their heads (58%) and witnessing the homicide of a close other (56%). The incarcerated girls as a group reported dramatically high rates of PTSD symptomatology. Their mean scores on all three PTSD subscales of the LASC-R were significantly higher than among males. In addition, significantly more females than males could be classified as PTSD positive. Females also reported significantly higher levels of depressive symptomatology. Males and females did not differ significantly from one another in terms of drug-related risk behaviors, however, with over half of the entire sample reporting that they have used drugs while alone. Finally, mixed support was obtained for our hypothesis that males and females would differ in their trajectories of involvement in serious delinquent activity. In keeping with previous research that found that female delinquents tend to come from more disturbed families, the fe-

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male gang members in our study reported a greater number of family risk factors, as well as higher levels of physical punishment in childhood. Similarly, female gun owners reported a greater number of family risk factors, lower levels of perceived social support from their families, and higher levels of physical punishment compared to gun-owning males. Generally speaking, females involved with gangs and guns tended to report higher levels of family dysfunction compared to their incarcerated male counterparts. Contrary to our expectation that females would exhibit a later age of onset of serious delinquent activity, the females and males in our sample were equally likely to have initiated their involvement with guns and gangs prior to their high-school years. Females, in fact, reported more years of gang involvement, on average, than males. Implications for Further Research The results of the present study suggest that, although both male and female incarcerated adolescents are exposed to high levels of violence and display clinically significant levels of psychological distress, such experiences and difficulties are significantly more extreme for girls. Evidence also suggests that family risk, physical punishment, and low family support are more strongly associated with girls’ involvement in serious delinquent activity. The striking differences between incarcerated male and female adolescents in terms of violence exposure and psychological distress suggest that the males and females ought to be considered separately in further research with incarcerated youth. In particular, differences in family correlates of involvement in gang- and gun-related behavior indicate a need for further research on the different trajectories of male and female involvement in serious delinquent activity. Although some differences (e.g., rates of sexual abuse exposure) may be inflated by boys’ tendency to underreport such experiences, the consistent picture that emerges of delinquent girls’ histories of serious and repeated victimization suggests that multiple forms of violence exposure must be considered in future research. The results of the present study clearly underscore the prominent role of early trauma history and repeat victimization in the backgrounds of adolescent females involved in serious delinquent behavior. Although the mechanism for the association between family dysfunction and serious delinquent activity among females cannot be determined on the ba-

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sis of the present findings, family dysfunction appears to serve as a critical pathway to violent and criminal behavior among females, more so than among males. REFERENCES Astin, M., Ogland-Hand, S., Coleman, E., & Foy, D. (1995). Posttraumatic stress disorder and childhood abuse in battered women: Comparisons with maritally distressed women. Journal of Consulting and Clinical Psychology, 63 (2), 308-312. Berger, A., Knutson, J., Mehm, J., & Perkins, K. (1988). The self-report of punitive childhood experiences of young adults and adolescents. Child Abuse and Neglect, 12, 251-262. Budnick, K., & Shields-Fletcher, E. (1998). What about girls? Office of Juvenile Justice and Delinquency Prevention Fact Sheet #84. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Compas, B., Hinden, B., & Gerhardt, C. (1995). Adolescent development: Pathways and processes of risk and resilience. Annual Review of Psychology, 46, 265-293. Crick, N., & Dodge, K. (1994). A review and reformulation of social information-processing mechanisms in children’s social adjustment. Psychological Bulletin, 115 (1), 74-101. Dembo, R., Schmeidler, J., Sue, C., Borden, P., & Manning, D. (1995). Gender differences in service needs among youths entering a Juvenile Assessment Center: A replication study. Journal of Correctional Health Care, 2 (2), 191-216. Evans, W., Albers, E., Macari, D., & Mason, A. (1996). Suicide ideation, attempts and abuse among incarcerated gang and non-gang delinquents. Child and Adolescent Social Work Journal, 13 (2), 115-126. Foy, D., Wood, J., King, D., King, L., & Resnick, H. (1997). Los Angeles Symptom Checklist psychometric evidence with an adolescent sample. Assessment, 4 (4), 377-384. Gallagher, C. (1999). Juvenile offenders in residential placement, 1997. Office of Juvenile Justice and Delinquency Prevention Fact Sheet #96. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Henggeler, S., Edwards, J., & Borduin, C. (1987). The family relations of female juvenile delinquents. Journal of Abnormal Child Psychology, 15 (2), 199-209. Huizinga, D., & Jakob-Chien, C. (1998). The contemporaneous co-occurence of serious and violence juvenile offending and other problem behaviors. In R. Loeber, & D. Farrington (Eds.), Serious and violent juvenile offenders: Risk factors and successful interventions (pp. 47-67). Thousand Oaks, CA: Sage. Jaycox, L., & Repetti, R. (1993). Conflict in families and the psychological adjustment of preadolescent children. Journal of Family Psychology, 7 (3), 344-355. King, L., King, D., Leskin, G., & Foy, D. (1995). The Los Angeles Symptom Checklist: A self-report measure of posttraumatic stress disorder. Assessment, 2, 1-17.

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Lewis, D., Yeager, C., Cobham-Portorreal, C., Klein, N., Showalter, C., & Anthony, A. (1991). A follow-up of female delinquents: Maternal contributions to the perpetuation of deviance. Journal of the American Academy of Child and Adolescent Psychiatry, 30 (2), 197-201. Miller, D., Trapani, C., Fejes-Mendoza, K., & Eggleston, C. (1995). Adolescent female offenders: Unique considerations. Adolescence, 30 (118), 429-435. Moos, R., & Moos, B. (1981). The Family Environment Scale manual. Palo Alto, CA: Consulting Psychologists Press. Procidano, M., & Heller, K. (1983). Measures of perceived social support from friends and from family: Three validation studies. American Journal of Community Psychology, 11 (1), 1-24. Rantakallio, P., Myhrman, A., & Koiranen, M. (1995). Juvenile offenders with special reference to sex differences. Social Psychiatry and Psychiatric Epidemiology, 30, 113-120. Richters, J., & Saltzman, W. (1990). Survey of Children’s Exposure to Community Violence. Washington, DC: National Institute of Mental Health. Rowan, A., Foy, D., Rodriguez, N., & Ryan, S. (1994). Posttraumatic stress disorder in adults sexually abused as children. International Journal of Child Abuse and Neglect, 18, 51-61. Rutter, M. (1981). Stress, coping, and development: Some issues and some questions. Journal of Child Psychology and Psychiatry, 22, 323-356. Snyder, H. (1998). Juvenile arrests 1997. Juvenile Justice Bulletin. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Stattin, H., & Magnusson, D. (1989). The role of early aggressive behavior in the frequency, seriousness, and types of later crime. Journal of Consulting and Clinical Psychology, 57, 710-718. Straus, M. (1979). Measuring intrafamilial conflict and violence: The Conflict Tactics Scales. Journal of Marriage and the Family, 41, 75-88. Thornberry, T. (1998). Membership in youth gangs and involvement in serious and violent offending. In R. Loeber & D. Farrington (Eds.), Serious and violent juvenile offenders: Risk factors and successful interventions (pp. 147-166). Thousand Oaks, CA: Sage. Tolan, P., & Gorman-Smith, D. (1998). Development of serious and violent offending careers. In R. Loeber & D. Farrington (Eds.), Serious and violent juvenile offenders: Risk factors and successful interventions (pp. 68-85). Thousand Oaks, CA: Sage. Weiss, B., Dodge, K., Bates, J., & Pettit, G. (1992). Some consequences of early harsh discipline: Child aggression and a maladaptive social information processing style. Child Development, 63, 1321-1335. Zahn-Waxler, C. (1993). Warriors and worriers: Gender and psychopathology. Development and Psychopathology, 5, 79-89. Zoccolillo, M. (1993). Gender and the development of conduct disorder. Development and Psychopathology, 5, 65-78.

An Examination of the Relationships Between Violence Exposure, Posttraumatic Stress Symptomatology, and Delinquent Activity: An “Ecopathological” Model of Delinquent Behavior Among Incarcerated Adolescents Jenifer Wood David W. Foy Christopher Layne Robert Pynoos C. Boyd James

SUMMARY. The prevalence of violence exposure and PTSD symptomatology among a sample of incarcerated adolescents is compared with Address correspondence to: Jenifer Wood, PhD, National Center for Child Traumatic Stress, University of California, Los Angeles, 11150 West Olympic Boulevard, Suite 770, Los Angeles, CA 90064 (E-mail: [email protected]). This research was supported by a grant from the California Wellness Foundation Violence Prevention Initiative and by Charles R. Drew University of Medicine and Science. Support for the high school survey was provided by a University Research Council grant from Pepperdine University to the second author. [Haworth co-indexing entry note]: “An Examination of the Relationships Between Violence Exposure, Posttraumatic Stress Symptomatology, and Delinquent Activity: An ‘Ecopathological’ Model of Delinquent Behavior Among Incarcerated Adolescents.” Wood, Jenifer et al. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 127-147; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 127-147. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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that among a matched sample of high school students. Adolescents who have come to the attention of the juvenile justice system have been exposed to significantly higher levels of sexual and community violence, and report significantly higher levels of PTSD symptomatology. Within the incarcerated group, adolescents who report higher levels of delinquent activity (in the form of gun possession and gang involvement) also report higher levels of some forms of violence exposure. Incarcerated youth with more serious delinquent histories displayed higher levels of PTSD symptomatology, as well. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Adolescence, community violence, delinquency, firearms, juvenile justice, trauma

THE PROBLEM OF INCARCERATED YOUTH The number of adolescents involved in the juvenile justice system in the United States is very high and continues to grow. In a single year, police made 2.7 million arrests of persons under age 18, according to the FBI’s Uniform Crime Reports (UCR; Snyder, 1998), and, on a single day, an estimated 100,000 youth are being held in public detention facilities (Gallagher, 1999). Over 25 years, changes in the number of juvenile arrests have been unrelated to changes in the size of the juvenile population (Snyder, 1998). Although the violent crime rate among adolescents is dropping (a 4% drop in 1997 was the third such annual decline), the FBI UCR Violent Crime Index remains 49% above its 1988 level (Snyder, 1998). Incarcerated Youth as Victims of and Witnesses to Violence Frequently, adolescents are not only perpetrators of violence, but victims themselves. Generally speaking, juveniles between the ages of 12 and 17 are three times more likely than adults to be victims of violent crime (Sickmund, Snyder, & Poe-Yamagata, 1997). Incarcerated youth, in particular, have often been exposed to extraordinarily high levels of traumatic violence, both within their homes and on the streets of their communities. Gang-involved juveniles, for example, are twice

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as likely as arrestees overall to have been shot at (8 in 10, in comparison with 4 in 10; Sickmund, Snyder, & Poe-Yamagata, 1997). Data from the Denver Youth Study (Huizinga & Jakob-Chien, 1998) indicate that 42% of serious violent juvenile offenders have been victims of violent crimes, while 32% have been victims of non-violent crimes. The Prevalence of Mental Health Problems In addition to (and sometimes associated with) the high incidence of victimization, several recent studies have revealed high rates of mental health problems among incarcerated adolescents. It has been estimated that up to 60% of youth involved in the juvenile justice system suffer from diagnosable mental disorders, up to 20% meet criteria for “serious emotional disturbance” as a result of a mental disorder and functional impairment, and 50% have substance abuse problems (National Mental Health Association, 1999). Elevated levels of psychological problems have been observed among all categories of juvenile delinquents (from non-violent to serious, violent offenders) in comparison with their non-delinquent peers (Huizinga & Jakob-Chien, 1998). Each year, an estimated 150,000 detained youth meet diagnostic criteria for a mental disorder, 225,000 meet diagnostic criteria for alcohol abuse or dependence, and 95,000 for substance abuse or dependence (Coccozza, 1992). An analysis of the mental health needs of youth in the Virginia juvenile justice system (Justice Services Virginia Policy Design Team, 1994) revealed that 8-10% of the youth in their system have serious mental health problems requiring immediate attention; of these youth, only 14% were receiving mental health services. Researchers estimated that an additional 39% of the youth in that system had “moderate” mental health difficulties that would require referral to mental health services and continuing case management. A majority of incarcerated youth may have two or more comorbid psychiatric conditions, and the rate of comorbidity may be even higher among incarcerated adolescent females (Ulzen & Hamilton, 1998). Although less frequently addressed explicitly in the literature, incarcerated adolescents also describe significant posttraumatic stress symptomatology. Burton, Foy, Bwanausi, Johnson, and Moore (1994) found that 24% of youth detained in probation camps met diagnostic criteria for posttraumatic stress disorder (PTSD); violence exposure and family dysfunction were significantly related to PTSD symptoms in this sample. Steiner, Garcia, and Matthews (1997) reported an even higher PTSD positive of 32% among a sample of adolescents incarcerated by

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the California Youth Authority. Among this sample, 50% reported that their most traumatic experience was witnessing the murder of a close friend or family member; 27% reported that they had experienced traumatic intrafamilial violence. Few other studies have addressed the prevalence of PTSD symptomatology among detained youth, and this diagnosis is frequently omitted from mental health screening instruments and psychological or psychiatric evaluations for youth detained in the juvenile justice system. THE RELATIONSHIP BETWEEN VIOLENCE EXPOSURE AND DELINQUENT ACTIVITY A number of studies have examined whether exposure to violence and victimization is related to adolescents’ self-reported delinquent activity and/or officially recorded involvement with the juvenile justice system. For example, in their review of the long-term consequences of childhood physical abuse, Malinkosky-Rummell and Hansen (1993) found that physically abused children are more likely to exhibit delinquent behavior in adolescence. Adolescents abused in childhood have a higher incidence of acting-out behavior, running away, legal involvement, and promiscuity (Cavaiola & Schiff, 1988). Similar associations have been found between harsh physical punishment and delinquent behavior in adolescence as well (Loeber & Stouthamer-Loeber, 1987; Sampson & Laub, 1994). Data from the Rochester Youth Development Study (Thornberry, 1994) indicates that a history of maltreatment (based on Child Protective Services records) increased self-reports of violent behavior (e.g., assaults, armed robbery) by 24% and was significantly associated with officially recorded delinquency. Similarly, witnessing domestic violence or the maltreatment of a sibling was associated with self-reports of violent behavior among the adolescents in this study. A relationship between the severity of physical punishment or abuse and the degree of later delinquent and violent behavior has been documented as well. For example, Lewis, Mallouh, and Webb (1989) report the rate of childhood abuse among violent incarcerated delinquents to be 75%, compared with 33% for less violent juvenile offenders. Widom’s (1989) review of the literature, however, suggests that the research to date on the relationship between abuse and violence has been inconclusive; she emphasizes that the majority of abused children become neither delinquent nor violent offenders. Nevertheless, among a delinquent population, a history of abuse may be predictive of more serious violent behavior.

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THE PRESENT STUDIES The present studies were designed to examine the relationships between violence exposure, posttraumatic stress symptomatology, and delinquent activity among urban adolescents. Consistent with the literature reviewed above, it was hypothesized that adolescents who display higher levels of delinquent activity will retrospectively report higher levels of violence exposure–both within their families and in their communities–as well as higher levels of associated posttraumatic stress symptomatology. This central hypothesis was examined through two studies, presented here. Study 1 involved a comparison between youth with significant levels of juvenile justice system involvement (adolescents incarcerated within juvenile detention centers and county probation “camps”) and a community sample of high school students who reported little to no involvement in delinquent activity. Study 2 examined differences within the sample of incarcerated youth and, in particular, the relationship between more serious engagement in delinquent activity (e.g., gun carrying, gang activity) and higher levels of self-reported victimization and violence exposure. More specifically, the following hypotheses were tested across the two studies: 1. Incarcerated adolescents will report significantly higher levels of exposure to family and community violence than a matched sample of high-school students residing in similar communities. (Study 1) 2. Incarcerated adolescents will report significantly higher levels of PTSD symptomatology in comparison with the matched high school sample. (Study 1) 3. Within the incarcerated group, higher levels of PTSD symptomatology will be associated with higher levels of exposure to multiple forms of violence. (Study 2) 4. Within the incarcerated group, exposure to family and community violence will be significantly and positively associated with serious, violent, delinquent behavior, as indicated by an arrest for a violent offense, gang involvement, and possession and use of firearms. (Study 2) Taken together, these two studies examine the relationship between violence exposure and delinquent activity among a wide range of urban adolescents: from high-school students reporting little contact with delinquent peers, to youth who have committed non-violent offenses and

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report minimal gang involvement, to youth with more serious involvement with crime, firearms, and gangs. These studies also contribute to the literature by examining the unique contributions of various forms of familial and extra-familial violence exposure to delinquent behavior in adolescence. Here, community violence is added to the list of potential traumatic stressors that is examined as an element of the violence exposure-delinquent activity relationship. METHOD In order to conduct Studies 1 and 2, data was obtained on a number of constructs of interest from two samples: 200 incarcerated youth and a matched sample of 200 high-school students residing in similar inner-city communities. Incarcerated Sample Individual interviews were conducted with 200 adolescents, randomly selected from the population rosters of five probation camps and two juvenile halls to fill each cell of a 2 ⫻ 2 ⫻ 2 (Gender ⫻ Ethnicity ⫻ Offense) design. The sample was comprised, therefore, of equal numbers of males and females, Latinos and African Americans, and youth incarcerated for violent and non-violent offenses. The decision was made to sample only Latino and African American youth because these groups constituted a majority of the adolescents incarcerated in Los Angeles County at the time of the study. Criteria for discriminating violent from non-violent offenses were developed prior to selecting the sample; according to these criteria, violent offenses included, for example, attempted murder, armed robbery, and assault and battery. Examples of non-violent offenses included possession of illegal drugs, automobile theft, and burglary. The average age of incarcerated participants was 16 years. Master’s-level psychology graduate students collected the data in an interview format. Participants were excused from school or chores during the morning or afternoon that the interview took place, and a member of the staff introduced them to the interviewer. Each participant was interviewed individually, in a private area at the probation camp or juvenile hall. Each adolescent who had been randomly selected to take part in the study was informed of the nature and purpose of the interview and asked if he or she would like to participate. Prospective participants were assured that (a) the interviewers were not affiliated in any way with the police or probation departments, (b) permission had been

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obtained from the court to interview participants under the condition that the information was to be shared only with research project staff, and (c) their participation (or non-participation) would not become part of their record or affect their sentence in any way. Participants were also told that they could skip any questions that they did not feel comfortable answering. None of the males who were randomly selected for the study refused to participate; approximately 10% of the females refused, typically stating that they did not want to miss another activity scheduled at that time. Each interview took from 1 hour and 45 minutes to over 3 hours to administer. High School Sample The high school sample–matched to the incarcerated youth on age, gender, and ethnicity–was drawn from a larger sample of over 1000 adolescents surveyed as part of a study focusing on the epidemiology of community violence. With the consent of their parents, 1093 participants voluntarily completed a brief and anonymous questionnaire asking about their experiences with community violence as well as their psychological symptomatology. The mean age of participants was 16 years old, and the sample consisted of approximately equal numbers of males and females. The majority of participants were students at four public high schools that were selected as a representative cross-section of their large, urban school district. Because none of the students in the high school sample endorsed a questionnaire item assessing involvement with delinquent peers (“I am in a gang”), it is assumed that this group as a whole had little or no juvenile justice system involvement. These students completed the questionnaire during their lunch periods and received a free McDonald’s lunch for their participation. The high school comparison sample was obtained by randomly selecting a student who matched each incarcerated participant on gender, ethnicity (African American or Latino), and age. In the few cases in which a match could not be obtained on all three demographic variables, a student was selected who matched the incarcerated participant on gender and ethnicity, and differed in age by only one year or less. Measures: Study 1 The brief questionnaire (on experiences with community violence and psychological symptomatology) completed by the high school

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comparison sample contained a subset of the measures that were administered to the incarcerated sample using an interview format. Table 1 presents basic information on measures common to the two samples, as well as those unique to the incarcerated group. The following measures were equivalent across the two samples, although they were administered in different formats (self-report versus interview). Community Violence Exposure. Both samples were administered the screening portion of the Survey of Children’s Exposure to Community Violence (SCECV; Richters & Saltzman, 1990). The SCECV is a 46-item, true-false instrument designed to screen for lifetime exposure to approximately 20 forms of violence or violence-related activities taking place in the community. Exposure to each form of violence is assessed across three channels: (a) direct exposure (e.g., “I have been shot or shot at”), (b) witnessing the victimization of another person (e.g., “I have seen someone being raped or sexually assaulted”), and (c) verbally-mediated exposure (e.g., “I heard about someone committing suicide”). Items are scored 1 if there is a lifetime history of exposure to the event, and 0 if there is not. In the present study, the SCECV was both summed across all items to create the total violence exposure score, and was also summed across the three exposure channels to create the direct, witnessing, and verbally-mediated exposure subscales. Sexual Abuse. Both the incarcerated and high school samples answered two questions embedded within the SCECV (see above) addressing exposure to sexual abuse and assault: “I have been sexually assaulted, molested, or raped,” and “I have seen someone sexually assaulted, molested, or raped.” Posttraumatic Stress Symptoms. Both samples completed the Los Angeles Symptom Checklist (LASC; Foy et al., 1997), which is a 43-item self-report inventory assessing current levels of PTSD and collateral symptoms. Embedded within this inventory is a 17-item PTSD subscale, which assesses re-experiencing, avoidance/numbing, and hyperarousal symptoms consistent with DSM-IV criteria. Each item contains a brief problem description (e.g., “trouble trusting other people”), and is rated on a 5-point scale ranging from 0 (not a problem) to 4 (an extreme problem). The LASC is well suited to the assessment of individuals with histories of extensive violence exposure because its items are not referenced to a specific traumatic event. The LASC was used in the present study as both a continuous measure of PTSD symptomatology as well as a dichotomous designation of “PTSD positive” versus “PTSD negative.”

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TABLE 1. Measures Employed with Female and Male Subsamples Measures Administered to Female Subsample

Violence Exposure Community Violence

Physical Punishment

Sexual Abuse Exposure

Physical Dating Violence

Admin to Male Sample?

Survey of Children’s Exposure to Community Violence (SCECV; Richters & Saltzman, 1990) 46 true/false items assessing direct, witnessed, vicarious exposure to 18 types of community violence

yes

Assessing Environments-III Physical Punishment subscale (AEIII; Berger, Knutson, Mehm, & Perkins, 1988) 12 true/false items Sexual Abuse Exposure Questionnaire (SAEQ; Rowan, Foy, Rodriguez, & Ryan, 1994) 15 true/false items, exposure assessed “before age 14” and “14 and after” Conflict Tactics Scale (CTS; Straus, 1979) Form N-expanded version (Astin et al., 1995) physical conflict items 17 items rated on a 0-3 scale (0 = never happened, 3 = more than 10 times)

yes

Psychological Distress General Distress Los Angeles Symptom Checklist-Revised-Adolescent version (LASC-Revised-Adolescent; Foy et al., 1997) 43 items rated on 5-point scale (0 = not a problem, 4 = an extreme problem) Post-Traumatic LASC 17-item PTSD scale, comprised of 3 symptom cluster Stress subscales: reexperiencing symptoms, arousal symptoms, and avoidance symptoms Depressive Symptoms Center for Epidemiological Studies Depression scale (CES-D) 20 items rated on a 4-point scale describing symptoms during past week (0 = not at all, 4 = a lot) Drug-Related Risk 10 true/false items pertaining to risky drug-related behaviors Behavior Examples include: “Have you ever gotten drunk while alone?”, “Have you ever taken two drugs at the same time?” Family Dysfunction Family Risk 6 true/false items assessing family risk factors, adapted from Rutter (1981) Items assess parental conflict, divorce or separation, out-of-home placement, death of a parent or sibling, overcrowded living conditions, and parental emotional problems Family Conflict 9-item subscale from the Family Environment Scale (Moos & Moos; 1981) Examples of true / false items include: “We fight a lot in our family” and “Family members often criticize one another.” Family Support 20-item Perceived Social Support-Family (Procidano & Heller, 1983) Items rated as “yes” (1), “no” (0), or “don't know” (0), and examples include: “My family gives me the moral support I need” and “Members of my family are good at helping me solve problems.”

before / after 14 not asked separately no

yes

yes

yes

yes

yes

yes

yes

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Measures: Study 2 Violence Exposure. As shown in Table 1, within the incarcerated sample, physical punishment and sexual abuse exposure were measured using psychometrically validated instruments, the 12-item Physical Punishment subscale of Assessing Environments-III (AEIII; Berger, Knutson, Mehm, & Perkins, 1988) and the 15-item Sexual Abuse Exposure Questionnaire (SAEQ; Rowan, Foy, Rodriguez, & Ryan, 1994). These instruments enabled a more detailed examination of violence exposure within this study, in contrast to Study 1, described above. Delinquent Activity. Three measures of delinquent activity were obtained from the incarcerated sample. One indicator of a pattern of more serious, violent offending that was coded from each adolescent’s official record was the nature of the offense for which he or she was presently incarcerated.1 An attempt was made to refine the initial classification of the current offense as either “violent” or “non-violent” by enlisting a team of eight expert raters (familiar with the juvenile justice system and the project as a whole, although not with the specific hypotheses of this study) to rank the 14 recorded offenses in order of seriousness, with a ranking of 1 representing “least serious” and 14 representing “most serious.” Average rankings were then used to create a new variable for which each adolescent obtained a score from 1 to 14 based upon the seriousness of his or her current offense. For example, vandalism and trespassing were given a score of 1, whereas homicide was given a score of 14. Second, a measure of gang affiliation was adapted specifically for this study. This instrument was developed for a previous study of community violence exposure among high school students (Layne, 1996) and was subsequently refined using a focus group of self-identified gang members familiar to the principal investigator from his ethnographic work on gangs in Los Angeles. Each of 13 true/false items assesses a specific gang-related behavior, such as “Do you have a gang nickname?”, “Do you wear colors?”, or “As far as you know, are you on a police list as a known gang member?” Layne’s (1996) preliminary psychometric evaluation of the instrument suggests high internal consistency and support for construct validity. In the present sample, Cronbach’s alpha for the 13-item scale was .83. Also embedded within the interview protocol was a set of 25 items assessing ownership and use of firearms and other weapons. The majority of the items comprising this scale were rated “true” or “false.” Examples of true/false items include: “Did you carry a gun in order to ‘get

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someone’?”, “Did you pack your gun at school?”, and “Did you usually carry a knife?” Three additional items employed different response scales. Intention to carry a gun in the future was rated on a 4-point scale (0 = never owned a gun and never will and 3 = owned or carried a gun and probably will carry one again). Age at which the respondent first decided to obtain a gun was rated on a 3-point scale (1 = high school and 3 = elementary school). An item regarding total number of guns owned was open-ended (responses ranged from 0 to 11). For this reason, the 25 items were standardized before being summed to construct the Gun Possession scale. This scale had high internal consistency within the present sample (Cronbach’s alpha = .90). RESULTS Study 1 In terms of exposure to sexual violence as measured by single items embedded within the SCECV (Richters & Saltzman, 1990), the incarcerated sample reported significantly higher levels of direct exposure; 16% reported having been sexually assaulted, molested, or raped, in contrast to 6% of the high-school sample (χ2 (1, 398) = 10.22, p < .001). Similarly, 18.5% of the incarcerated sample reported witnessing someone else being sexually assaulted, molested, or raped, in contrast to 7% of the high-school sample (χ(2 (1, 397) = 11.77, p < .001) (see Figure 1). Nearly three times as many females in the incarcerated sample reported having been sexually assaulted or molested, in comparison with their high school counterparts (29% among incarcerated females, versus 11% among female high school students). As measured by the SCECV (Richters & Saltzman, 1990), the incarcerated group reported significantly more overall community violence exposure, as well as significantly more direct, witnessed, and verbally mediated community violence exposure, respectively. For example, incarcerated youth reported direct exposure to an average of 6.8 types of community violence, in contrast to an average of 3.1 types endorsed by the high-school sample. With regard to individual items on the SCECV (Richters & Saltzman, 1990), many significant differences emerged between the two groups (see Figure 1). For example, 92% of incarcerated youth reported knowing someone who had been killed, in contrast to 58% of the high school comparison sample (χ2 (1, 400) = 63.06,

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FIGURE 1. Self-Reported Violence Exposure in the Two Samples as Measured by the SCECV (Richters & Saltzman, 1990) Incarcerated Youth (N = 200) 3 29

Raped or molested

17

Witnessed rape

16% 18.5%

20

Know someone who was killed

94

Saw a dead body

83

Shot, or shot at with gun

86

90

58

67

Saw someone being killed

26

39

Stabbed 17

Saw someone committ suicide 0

16 20

72%

71

64%

56

56.5%

41

55

Know someone who committed suicide

77%

71

57

Beaten or jumped

92%

48% Male Female

32.5%

16.5% 40

60

80 100 120 140 160 180 Number of Participants

200

High-School Students (N = 200) Raped or molested 111 6% Witnessed rape 4 10 7% 52

63

Know someone who was killed 26

Saw a dead body (not at wake or funeral)

20

35

Shot, or shot at with gun

57.5%

23%

11 23%

20 9 14.5%

Beaten or jumped

Saw someone being killed 10 9 9.5% 26

28

Stabbed 12 5

8.5%

Know someone who committed suicide

27% Male Female

Saw someone committ suicide 6 2 4% 0

20

40

60

80 100 120 140 160 180 200 Number of Participants

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p < .001). Moreover, 57% of the incarcerated youth reported actually seeing someone (often a close friend or family member) being killed; only 10% of inner city high school students reported having had this experience (χ2 (1, 399) = 117.45, p < .001). Among the incarcerated sample, 72% reported being shot or shot at, whereas only 23% of high school students endorsed this item (χ2 (1, 400) = 96.28, p < .001). The incarcerated and high school samples obtained significantly different mean scores on the Los Angeles Symptom Checklist-Revised (LASC-R; Foy et al., 1997) PTSD scale, with incarcerated youth endorsing higher levels of symptomatology (M = 24.5, SD = 13.0) in contrast to their high school counterparts (M = 17.4, SD = 12.6; t = 5.52, p < .001). The means for the incarcerated group were significantly higher than those for the comparison high school sample on all three symptom cluster subscales (reexperiencing, arousal, and avoidance symptoms). Using an approach to categorical scoring of PTSD diagnosis from the LASC described in King, King, Leskin, and Foy (1995),2 a significantly greater percentage of incarcerated adolescents (40%) could be classified as PTSD positive, in contrast to 23% of the high school sample (χ2 (1, 400) = 13.39, p < .001) (see Figure 2). Within both samples, females obtained higher mean PTSD scale scores than males. Among the high school females, the mean PTSD scale score was significantly higher than among high-school males (female M = 19.26, SD = 12.6, versus male M = 15.54, SD = 12.5; t = 2.09, FIGURE 2. Percentage of Each Sample Classified as PTSD Positive

Percentage of Participants

60 Males Females

50 40 52

30

30

20 28 10

16

0 Incarcerated Youth Total = 40

High School Students Total = 23

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p < .05), with 30% of the female students classified as PTSD positive, and only 16% of males classified as PTSD positive. Among incarcerated females, the mean PTSD scale score was significantly higher than among high-school males (female M = 28.3, SD = 13.6, versus male M = 20.7, SD = 11.2; t = 4.34, p < .001), with 52% of the incarcerated female sample classified as PTSD positive, versus 28% of incarcerated males. Study 2 The relationship between exposure to violence and posttraumatic stress symptomatology (Hypothesis #3) was examined in the incarcerated sample, using standardized measures of physical punishment (AEIII; Berger, Knutson, Mehm, & Perkins, 1988), sexual abuse exposure (SAEQ; Rowan, Foy, Rodriguez, & Ryan, 1994), and community violence (SCECV; Richters & Saltzman, 1990). In order to determine which forms of violence exposure accounted for unique increments in the prediction of PTSD, hierarchical regression analyses were conducted. In the regression model, the three exposure variables were entered in the following hierarchical sequence: physical punishment, sexual abuse, and community violence. This sequence was employed in order to examine the extent to which exposure to community violence contributes to posttraumatic stress symptomatology beyond the contributions of the two more commonly studied traumatic stressors, childhood physical punishment and sexual abuse exposure. Because of significant gender differences in exposure and PTSD, males and females were examined separately. Identical multiple regression analyses were performed on the two subsamples of males (N = 100) and females (N = 100). The results of these analyses are presented in Table 2. As shown in Table 2, the overall model was significant for males (R2 = .26, p < .001) and for females (R2 = .33, p < .001). For males, community violence was the strongest predictor of PTSD symptomatology, accounting for 21% of the variance in the outcome variable. Physical punishment also emerged as a significant predictor of PTSD symptoms among incarcerated boys, although it only accounted for 5% of the variance. Among females, in contrast, all three types of violence exposure–physical punishment, sexual abuse, and community violence exposure–were significant predictors of PTSD symptomatology. Similar hierarchical regression analyses were employed to examine the relationship between violence exposure (physical punishment, sexual abuse, and community violence) and more serious delinquent activ-

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TABLE 2. Mean Scores on Violence Exposure Variables Female Subsample

Male Subsample

Significant

(N = 100)

(N = 100)

difference?

m (SD)

m (SD)

t statistic

Physical Punishment

3.85 (2.79)

3.02 (1.96)

2.43*

Sexual Abuse Exposure

3.65 (3.08)

1.38 (1.90)

6.06***

NAa

Dating Violence (physical)

6.73 (9.54)

Direct Community Violence

3.36 (2.02)

4.13 (1.64)

⫺2.96**

Witnessed CV

9.83 (3.96)

12.15 (3.09)

⫺3.33***

Vicarious CV

9.32 (3.76)

10.93 (3.04)

⫺4.61***

a

Measure not administered to male subsample. ** p < .01 *** p < .001 * p < .05

ity within the incarcerated group (Hypothesis #4). Separate models were tested for each of the three indicators of serious delinquent activity: current offense, gang affiliation, and gun possession and use. As in the previous analyses, males and females were examined separately. The results of these analyses are presented in Table 3. As shown in Table 3, the overall model was not significant for nature of current offense among males or females. For both males and females, the regression model for gang affiliation was significant (R2 = .18, p < .001 for males and R2 = .24, p < .001 for females), with community violence exposure emerging as the only significant predictor in both models. For gun possession, the overall model was significant for males (R2 = .17, p < .01), with community violence exposure again emerging as the only significant predictor. Among females, however, the overall model was significant (R2 = .30, p < .001), with both physical punishment and community violence exposure emerging as significant predictors of gun possession and use. Among the incarcerated female sample, self-reports of physical punishment in childhood accounted for 10% of the variance in gun possession and use as an adolescent; community violence exposure accounted for an additional 20%. DISCUSSION Summary of Results Study 1 revealed significant differences between incarcerated youth and the high-school comparison sample. The prevalence of violence ex-

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TABLE 3. Mean Scores on Psychological Distress Variables Female Subsample Male Subsample (N = 100) (N = 100)

Significant difference?

m (SD)

m (SD)

t statistic

Overall distress (LASC-R total)

57.16 (27.67)

43.53 (22.76)

3.80***

PTSD total

28.33 (13.59)

20.68 (11.20)

4.34***

5.32 (2.98)

4.03 (2.93)

3.09**

9.03 (5.56)

4.36***

PTSD - Reexperiencing PTSD - Hyperarousal PTSD - Avoidance Depressive symptoms Drug-related risk behavior * p < .05

** p < .01

13.02

(7.27)

9.99

(5.50)

7.62 (4.63)

3.30***

32.60 (11.87)

23.58 (9.53)

5.93***

3.10 (2.38)

no

3.31

(2.65)

*** p < .001

posure and PTSD symptomatology among incarcerated adolescents is striking in comparison with high school students from similar inner-city communities. The clearest difference that emerged is that adolescents who have come to the attention of the juvenile justice system have been exposed to significantly higher levels of sexual violence and incidents of violence in their communities, such as physical assault and witnessing a homicide. Associated with these high levels of violence exposure are levels of PTSD that are significantly higher than among their high school counterparts. The results of Study 2 were more ambiguous. Within the incarcerated group, youth with more violence exposure reported higher levels of PTSD symptomatology. Differences in levels of delinquent activity, however, were not consistently associated with higher levels of violence exposure. Study 1: The Comparison Between Incarcerated and High School Youth Hypothesis #1 was supported, as significantly higher rates of traumatic violence exposure and victimization were observed among the incarcerated sample than among the matched high school group. The incarcerated group reported higher rates of direct and witnessed exposure to sexual abuse and assault, as well as to numerous and frequently life-threatening forms of community violence exposure. For example, more than half of the incarcerated sample (57%) witnessed the murder

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of a friend or relative, and 17% actually witnessed a suicide. A majority of these youth have been assaulted and shot or shot at in their communities. Hypothesis #2 was supported as well, in that significantly higher rates of PTSD were reported by the incarcerated group. Due to the cross-sectional nature of this study, however, the possibility that PTSD symptoms were the result of adolescents’ experiences within the juvenile justice system cannot be ruled out. Two characteristics of Study 1 should be noted, which limit the conclusions that can be drawn on the basis of these data. First, because different methods of data collection were employed with the two samples (written self-report versus interview), differences in adolescents’ responses might be due, at least in part, to the methods used. Second, while there was some evidence to support our assumption that the high-school comparison sample was significantly less involved with delinquent peers and activities, the data obtained from this group were insufficient to conclude that none of the high school sample had histories of involvement with the juvenile justice system. Despite the significant differences observed between incarcerated youth and the high school comparison sample, we were surprised to find such high levels of violence exposure and psychological distress within our comparison group. The high school student volunteers reported rates of PTSD well above those generally observed in community samples (American Psychiatric Association, 1994). Over 30% of the high school females could be classified as PTSD positive. Over half of the high school females reported that they knew someone who was killed, and over one-third of the high school males reported that they had been shot or shot at. Although they are significantly lower than the rates reported by the incarcerated youth, these statistics are disturbing. They suggest that many young people in our inner-city communities are suffering the consequences of victimization and violence exposure; the youth in these communities who come to the attention of the juvenile justice system may represent only the most extreme cases–the tip of the iceberg. Study 2: An Examination of Within-Group Differences Among Incarcerated Youth Some support was obtained for the hypothesis that, among incarcerated youth, those who reported higher levels of delinquent activity also report higher levels of violence exposure in their homes and communities. Among the incarcerated females, exposure to physical punishment

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was significantly associated with reports of gun possession and use. That is, among a group already involved with the juvenile justice system, female adolescents who reported higher levels of physical punishment were more likely to report carrying and using guns. For some of these young women, carrying a gun may be an adaptation to a pervasive sense of threat and vulnerability with its origins in their early years. This is consistent with literature that suggests that abused children begin to perceive the world as a dangerous place, which demands constant vigilance (Garbarino, 1993). A significant relationship was also observed, for both sexes, between exposure to community violence and self-reported gang- and gun-related behavior. It is less clear how to interpret this finding, however, as the relationship between community violence exposure and serious delinquent activity is likely to be bi-directional. Also, due to the cross-sectional nature of the present study, we cannot draw conclusions regarding the etiological role of community violence exposure in the development of gang involvement and gun-related behavior among incarcerated youth. Clearly, these youth engage in behaviors (e.g., associating with delinquent peers, using alcohol and marijuana regularly) that place them at particularly high risk for exposure to traumatic violence; adolescent involvement with gangs and guns will almost certainly increase their risk of exposure to incidents of violence in the community. It is also possible, however, that exposure to sometimes life-threatening violent incidents and witnessing the homicide of close others can result in damaging social, emotional, and cognitive consequences, including PTSD. The negative impact of chronic violence exposure may place some youth firmly on a trajectory of serious delinquent activity that is difficult to reverse. CONCLUSIONS AND IMPLICATIONS In sum, youth who have been adjudicated delinquent report higher levels of exposure to violence and direct victimization, and those youth who are more serious offenders in terms of gang and gun involvement report greater exposure to at least some forms of violence than their less seriously delinquent counterparts within the juvenile justice system. Unfortunately, the present study was not able to test a theoretically derived model, positing a specific mechanism that accounts for the relationship between violence exposure and violent behavior. Longitudinal

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research investigating potential mechanisms or mediating variables in this relationship is needed. Given the strong association between violence exposure and PTSD symptoms, we expect that physical, psychological, and behavioral responses to trauma may be among the mediators of the violence exposure-violent behavior relationship. In addition, the results of the present study suggest that a more sophisticated analysis of the causes and meaning of gun-related behavior among urban adolescents is needed. In particular, gun ownership and use among urban adolescent females appears directly related to their experiences of physical punishment in childhood. Prevention and intervention efforts around gang- and gun-related behavior should be informed by more complex understandings of the connections between these behaviors and violence exposure/victimization. Attempts to reduce the prevalence and use of firearms among adolescents, for example, should expand consideration of potentially etiological factors beyond availability of firearms, media images, and penalties, to include violence exposure and beliefs about one’s personal safety. Finally, the results of the present study also suggest the need for a reexamination of the literature on trajectories of involvement in delinquent behavior (see Browning & Loeber, 1999) to incorporate variables such as histories of victimization and levels of psychological distress. Although not directly tested in the present study, our results suggest that these variables may play a role, either in triggering the onset of delinquent activity or in maintaining a pattern of delinquent behavior over time, which deserves further exploration. NOTES 1. Additional information regarding each adolescent’s arrest and adjudication history could not be obtained for the present study. Highest charge for most recent offense was the only data available from official records for these analyses. 2. Following this procedure, Houskamp and Foy (1991) found that LASC-based diagnoses correspond well to Structured Clinical Interview for DSM-IIIR (SCID-R; Spitzer & Williams, 1985) diagnoses, with a sensitivity rate of 70% and a specificity rate of 80% among a sample of battered women. Although the LASC-R has been normed on adolescents (see Foy, Wood, King, King, & Resnick, 1997), validation of the procedure for categorical scoring of the adolescent version of the LASC has not yet been completed.

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REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Berger, A., Knutson, J., Mehm, J., & Perkins, K. (1988). The self-report of punitive childhood experiences of young adults and adolescents. Child Abuse and Neglect, 12, 251-262. Browning, K., & Loeber, R. (1999). Highlights of findings from the Pittsburgh Youth Study. Office of Juvenile Justice and Delinquency Prevention Fact Sheet #95. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Burton, D., Foy, D., Bwanausi, C., Johnson, J., & Moore, L. (1994). The relationship between traumatic exposure, family dysfunction, and posttraumatic stress symptoms among male juvenile offenders. Journal of Traumatic Stress, 7, 83-93. Cavaiola, A., & Schiff, M. (1988). Behavioral sequelae of physical and/or sexual abuse in adolescents. Child Abuse and Neglect, 12, 181-188. Cocozza, J. (1992). Responding to the mental health needs of youth in the juvenile justice system. Seattle, WA: National Coalition for the Mentally Ill in the Criminal Justice System. Foy, D., Wood, J., King, D., King, L., & Resnick, H. (1997). Los Angeles Symptom Checklist: Psychometric evidence with an adolescent sample. Assessment, 4, 377-384. Gallagher, C. (1999). Juvenile offenders in residential placement, 1997. Office of Juvenile Justice and Delinquency Prevention Fact Sheet #96. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Garbarino, J. (1993). Children’s response to community violence: What do we know? Infant Mental Health Journal, 14 (2), 103-115. Houskamp, B., & Foy, D. (1991). The assessment of posttraumatic stress disorder in battered women. Journal of Interpersonal Violence, 6, 368-376. Huizinga, D., & Jakob-Chien, C. (1998). The contemporaneous co-occurence of serious and violent juvenile offending and other problem behaviors. In R. Loeber & D. Farrington (Eds.), Serious and violent juvenile offenders: Risk factors and successful interventions (pp. 47-67). Thousand Oaks, CA: Sage. Justice Services Virginia Policy Design Team (1994). Mental health needs of youth in Virginia’s juvenile detention centers. Richmond, VA: Justice Services. King, L., King, D., Leskin, G., & Foy, D. (1995). The Los Angeles Symptom Checklist: A self-report measure of posttraumatic stress disorder. Assessment, 2, 1-17. Layne, C. (1996). Effects of community violence on minority high school students. Unpublished doctoral dissertation, University of California, Los Angeles. Lewis, D., Mallouh, C., & Webb, V. (1989). Child abuse, delinquency, and violent criminality. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 707-721). Cambridge: Cambridge University Press. Loeber, R., & Stouthamer-Loeber, M. (1987). Prediction. In H. Quay (Ed.), Handbook of Juvenile Delinquency (pp. 325-382). New York: John Wiley & Sons. Malinkosky-Rummell, R., & Hansen, D. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114, 68-79. National Mental Health Association. (1999). Children with emotional disorders in the juvenile justice system: Position statement. Alexandria, VA: National Mental Health Association.

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Richters, J., & Saltzman, W. (1990). Survey of Children’s Exposure to Community Violence. Washington, DC: National Institute of Mental Health. Rowan, A., Foy, D., Rodriguez, N., & Ryan, S. (1994). Posttraumatic stress disorder in adults sexually abused as children. International Journal of Child Abuse and Neglect, 18, 51-61. Sampson, R., & Laub, J. (1994). Urban poverty and the family context of delinquency: A new look at structure and process in a classic study. Child Development, 65, 523-540. Sickmund, M., Snyder, H., & Poe-Yamagata, E. (1997). Juvenile offenders and victims: 1997 update on violence. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Snyder, H. (1998). Juvenile arrests 1997. Juvenile Justice Bulletin. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Spitzer, R., & Williams, J. (1985). Instructional manual for the Structured Clinical Interview for DSM-III-R (SCID). New York: New York State Psychiatric Institute, Biometrics Research Department. Thornberry, T. (1994). Violent families and youth violence. Office of Juvenile Justice and Delinquency Prevention Fact Sheet #21. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Ulzen, T., & Hamilton, H. (1998). The nature and characteristics of psychiatric comorbidity in incarcerated adolescents. Canadian Journal of Psychiatry, 43 (1), 57-63. Widom, C. (1989). Does violence beget violence? A critical examination of the literature. Psychological Bulletin, 106, 3-28.

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Neurobiological Disturbances in Youth with Childhood Trauma and in Youth with Conduct Disorder Deborah S. Lipschitz Charles A. Morgan III Steven M. Southwick

SUMMARY. Traumatized children often present with symptoms of behavioral dyscontrol (aggression, impulsivity, and hyperactivity). There is some symptom overlap between childhood PTSD and the disruptive behavioral spectrum disorders (ADHD, ODD, CD). To date, there are two separate and emerging bodies of literature that describe underlying neurobiological abnormalities in traumatized youth and in youth with conduct disorder/juvenile delinquency. In this article we first review and contrast some of the neurobiological mechanisms associated with disordered arousal (these include basal cortisol and cortisol reactivity to stress, psychophysiological parameters, and catecholamine studies) in each of these two groups. Next, we attempt to integrate some of these

Address correspondence to: Deborah Lipschitz, MBChB, Psychiatry Service (116a), Connecticut VAMC, 950 Campbell Avenue, West Haven, CT 06510 (E-mail: [email protected]). [Haworth co-indexing entry note]: “Neurobiological Disturbances in Youth with Childhood Trauma and in Youth with Conduct Disorder.” Lipschitz, Deborah S., Charles A. Morgan III, and Steven M. Southwick. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 149-174; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 149-174. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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neurobiological findings and make recommendations for future studies. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Disordered arousal, trauma, PTSD, conduct disorder

INTRODUCTION Other articles in this book have focused on the epidemiological, phenomenological, developmental, and treatment implications of the overlap between juvenile delinquency and trauma. In this article, we focus on findings from studies that characterize neurobiological functioning related to dysregulation of arousal systems in individuals suffering from traumatic stress or from one of the DSM-IV (APA, 1994) disruptive behavior disorders (defined here as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). We will confine our review to studies of traumatized and/or aggressive youngsters that have focused on traditional measures of arousal, which include: 1. Cortisol levels at baseline, and in response to stress: a reflection of Hypothalamic Pituitary Adrenal (HPA) axis function. 2. Psychophysiological indices of arousal (such as heart rate, blood pressure, and skin conductance) at baseline, and in response to stressful stimuli. 3. Measures of central and peripheral catecholamine activity (epinephrine, norepinephrine, dopamine, and their metabolites). Studies of the HPA axis, catecholamines, and psychophysiology clearly are not the only biological approaches to the study of traumatized or conduct-disordered populations. Indeed, there is evidence that the Hypothalamic Pituitary Gonadal (HPG) axis (as measured by testosterone) also is affected by stress and involved in aggression. There is a relatively large literature linking aggression to high levels of testosterone in animals (see Archer, 1988) in adult males with chronic aggressive behavior (Ehrenkranz, Bliss & Sheard, 1974), and in perpetrators of violent crimes (Dabbs, Frady, Carr, & Besch, 1987;

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Virkkunen, Rawlings, Tokola, & Russel, 1994). However, high levels of testosterone are not correlated necessarily with aggressive behavior in children and adolescents with conduct disorder (Constantino et al., 1993; Susman et al., 1987). There also is a large body of literature that links serotonergic activity to aggression, particularly impulsive aggression. Serotonin is a modulatory neurotransmitter with general inhibitory effects known to affect the mediation of fear and anxiety, mood, and appetite. In the brain, its receptors are located primarily in the frontal cortex and in the limbic system. Low cerebrospinal (CSF) levels of the serotonin metabolite 5-hydroxyindoleacetic (5-HIAA) predict suicidal behavior in depressed adults (Traskman, Asberg, Bertilsson, & Sjostrand, 1981), and aggressive behavior and repeat offenses in adult criminals (Virkkunen, De Jong, Bartko, Goodwin, & Linnoila, 1989). Low levels of 5-HIAA also have been linked to aggression in children (Lahey et al., 1998). A study by Unis and colleagues (1997) reported that adolescents with childhood-onset conduct disorder had higher whole-blood serotonin than those with an adolescent onset. Serotonin levels were positively correlated with violence ratings. Unfortunately, almost no research has examined serotonergic function in traumatized children and adolescents; therefore, we cannot compare findings related to serotonergic function in traumatized and aggressive youth. Clinical presentations of physically and sexually abused children and adolescents are extremely diverse. Traumatized children can present with aggressive, irritable, and hyperactive behavior; bouts of anxiety, clinginess, and new fears; and periods of withdrawn, sad, and tearful behavior. They also may display sleep disturbances, appetite changes, regressed play, and/or delayed developmental milestones. (For a comprehensive review of the complex developmental changes that can occur following childhood sexual and physical abuse, see reviews by Putnam and Trickett (1993) and Cicchetti and Toth (1995).) For some traumatized youngsters, symptoms and changes in social and academic functioning may be transient; however, for a substantial number of children these symptoms will persist with the result that various mental health providers and/or courts become involved. Such children might be assigned a wide array of DSM-IV (APA, 1994) based psychiatric diagnoses, including adjustment disorders, major depression, separation anxiety disorder, enuresis, psychotic disorders, attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder and, of course, posttraumatic stress disorder (PTSD). In the setting of juvenile detention centers and correctional facilities, a primary diagnosis of conduct disorder with or without ADHD,

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rather than a diagnosis of PTSD, is more often assigned to the traumatized adolescent who has perpetrated an act of violence (Greenwald, this issue). Indeed, we know that child abuse, in general, is associated with conduct disorder (Finkelhor & Berliner, 1995) and that physical abuse, in particular, can be an important factor in the later development of conduct problems (Dodge, Bates, & Petitt, 1990; Flisher et al., 1997). Phenomenologically, there is some symptom overlap between PTSD and what the DSM-IV (APA, 1994) terms the “disruptive behavior disorders,” which include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). For example: 1. Bouts of irritability, aggression, and rage–examples of cluster-D or hyperarousal symptoms of PTSD–might manifest as “temper tantrums” or “constant arguing with adults,” both of which are behavioral features of ODD. Irritability, aggression, and rage might also manifest as “bullying and threatening” or “recurrent physical fights,” which are behavioral features of conduct disorder. 2. Poor attention span and concentration are both cluster-D or hyperarousal symptoms of PTSD as well as part of the diagnostic criteria for ADHD. 3. A sense of numbness and foreshortened future are two symptoms from PTSD’s cluster-C (i.e., avoidance symptoms). Numbness might lead to impaired empathy and a willingness to violate others. A sense of foreshortened future might lead to a preference for instant gratification; impulsive and high risk behaviors; and a lack of concern for the consequences of behavior. These attitudes might manifest as a “persistent disregard of rules or rights of others,” which is a diagnostic criterion for conduct disorder. In order to further explore neurobiological mechanisms that might explain some of the overlap in clinical phenomena mentioned above, we have organized this review as follows: We will provide a brief overview of the ways in which traumatic stress and/or adversity may affect brain development (both brain structure and function). Next, we will review some of the neurobiological findings in youth that are associated with childhood trauma and/or PTSD. In the third section, we will describe some of the neurobiological findings associated with childhood and adolescent-onset aggression, focusing mainly on youngsters with conduct disorder and/or juvenile delinquents and contrasting these findings to the neurobiological abnormalities in victims of childhood trauma. Finally, we will attempt to integrate some of this information and make recommendations for future studies.

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EARLY CHILDHOOD TRAUMA AND THE DEVELOPING BRAIN The brain is a relatively plastic organ and its final structure and function are determined by a complex interplay of genetic and environmental factors. There are progressive maturational changes in brain structure from infancy to the third decade of life. Histologically, as the brain develops, neurons undergo myelination, differentiation, migration, sprouting, and pruning. It has been proposed that periods of structural brain growth and cortical reorganization correspond with the developmental changes in physical growth, cognition, behavior, emotional maturity, and psychological function that we, as clinicians, observe in children. Increases in the myelination of neurons occur predominantly between the ages of six months to three years, and decreases in the proportion of cerebral grey matter to white matter occur after age four (Jernigan & Sowell, 1997). Thus, a developmental period (six months to four years) might represent a time of increased stress-related vulnerability for children. Indeed, animal studies with baby rodents (Ladd, Owens, & Nemeroff, 1996; Meaney, Aitken, van Berkel, Bhatnager, & Sapolsky, 1988) and baby primates (Coplan, Rosenblum, & Gorman, 1995; Suomi, Eisele, & Grady, 1975) have shown that the type, timing, and predictability of stress can influence the development of neuroendocrine systems and brain structures long after the stressor is removed, and that the effect of certain types of stress can still be measured in adult rodents and primates. For example, in response to foot shock, adult rats that were separated from their mothers for six hours a day on postnatal days 2-20 (a critical period), reacted with increased basal and stress related ACTH responses compared to adult rats that were not separated from their mothers in infancy (Ladd et al., 1996). From a structural standpoint, there are many cortical and subcortical structures that might be preferentially affected by early maltreatment. Examples of such structures include the hippocampus, amygdala, prefrontal cortex, and corpus callosum. These brain structures are now being studied by investigators using various neuroimaging techniques such as magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT). Almost all of the work has been conducted in traumatized adult subjects, but there are a few investigators who are now using these neuroimaging techniques in traumatized children.

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Teicher and colleagues (1997) postulated that early abuse, prior to age six, could affect both the pattern and degree of cortical development. The authors used a measure of electroencephalography (EEG) that they term “EEG coherence” to compare EEG patterns in 15 children, aged 6 to 15 years, with histories of severe sexual and physical abuse to 15 matched controls. Abused children had greater left hemispheric coherence than controls, but comparable right-sided hemispheric coherence to controls. The corpus callosum is the large, myelinated tract that connects the right and left cortical hemispheres. Myelination of the corpus callosum peaks between the ages of six months and three years, but it continues well into the third decade (Jernigan & Sowell, 1997). Teicher and colleagues postulated that early abuse might delay maturation of the corpus callosum, thereby affecting the lateralization of EEG coherence. Consistent with their hypothesis, and using magnetic resonance imaging (MRI) records, the authors calculated the volume of different regions of the corpus callosum of 51 psychiatrically hospitalized children (mean age of 10 years). Both physical abuse and neglect, but not sexual abuse, were associated with volumetric reductions in certain regions of the corpus callosum. These findings were more pronounced in boys than girls. In a second study, De Bellis, Keshavan et al. (1999) also reported significantly smaller volumes of the midsagittal, posterior, and middle regions of the corpus callosum in 44 maltreated children and adolescents with PTSD, compared to 61 matched healthy controls. Once again, the corpus callosum volume reduction findings applied only to boys. In a third study, Giedd et al. (1994) also reported volume reduction of the corpus callosum in boys with ADHD, but in a different region of the corpus callosum than in the boys with PTSD. These MRI findings, although preliminary, might help to explain the reported comorbidity of PTSD and ADHD in maltreated children (Famularo, Fenton, Kinscherff, & Augustyn, 1996). Recent work by Perry (1999) shows that young children who are severely abused and neglected in the first few years of life show neurodevelopmental changes in a variety of brain structures. Fifty-three percent of 30 abused and neglected children (aged 3 months to 17 years) had MRI scans with evidence of cortical atrophy or enlarged ventricles that were out of proportion to their developmental milestones and nutritional status. Similarly, De Bellis, Keshavan et al. (1999) reported that 44 maltreated children and adolescents with PTSD (aged 6 to 17 years) had significantly smaller intracranial and cerebral volumes than 61 matched controls. Brain volume correlated positively with the age of

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onset of abuse and negatively with the duration of abuse. This implies that smaller brains were associated with earlier onset and longer duration of trauma. However, more definitive evidence from further studies comparing cortical structure and ventricular volume between abused youngsters with and without PTSD, controlling for the effects of physical abuse, as well as age- and sex-matched comparison groups, are very much needed. NEUROBIOLOGICAL FINDINGS IN MALTREATED CHILDREN AND IN CHILDREN WITH PTSD Studies of Basal Cortisol and Cortisol Responses to Stress The Hypothalamic Pituitary Adrenal (HPA) axis is one of the major neuroendocrine systems that physiologically mediates the mammalian stress response (Munck, Guyre, & Holbrook, 1984). Psychological stress results in release of corticotrophin releasing factor (CRF) from the hypothalamus. CRF, in turn, initiates the release of adrenocorticotropic hormone (ACTH) from the anterior pituitary and cortisol from the adrenal cortex into the bloodstream. Cortisol is a glucocorticoid (steroid) hormone that is secreted by the adrenal glands in response to stress. Among its multiple functions, cortisol stimulates the liver’s production of glucose, suppresses inflammation, dampens the body’s immune response, and ostensibly influences mood and emotion (Gunnar, 1992). Physiological responses to psychological stress can be measured by the adrenal gland’s production of cortisol at baseline and 20-30 minutes following exposure to a stressor. Once secreted into the bloodstream, cortisol is primarily bound to a protein called corticosteroid binding globulin (CBG). When circulating levels of cortisol exceed the binding capacity of the plasma proteins, unbound or free cortisol is excreted into the saliva and urine. Standard radioimmunoassay kits are now available to reliably measure free or unbound cortisol in the saliva and urine. Single samples of salivary cortisol reflect HPA-axis function at one point in time (phasic activity), whereas 24-hour collections of urinary cortisol reflect HPA axis function over time (tonic and phasic activity). There is considerable evidence for HPA-axis dysregulation in adults with PTSD (for a full review, see Yehuda, 1997). Findings in adult patients with PTSD have included: (a) decreased basal 24-hour urinary

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cortisol in most (Mason, Giller, Kosten, Ostroff, & Podd, 1986; Yehuda, Kahana et al., 1995), but not all (Pitman & Orr, 1990), studies; (b) decreased 24-hour plasma cortisol levels, with increased circadian signal-to-noise ratio (Yehuda, Teicher, Trestman, Levengood, & Siever, 1996); (c) increased numbers of lymphocyte-glucocorticoid receptors (Yehuda, Boisoneau, Lowy, & Giller, 1995; Yehuda, Boisoneau, Mason, & Giller, 1993); (d) supersensitivity to the suppressant effects of a low dose of dexamethasone (Yehuda, Southwick et al., 1993); (e) a blunted ACTH response to ovine CRF (Yehuda, 1997); and (f) increased cerebrospinal fluid (CSF) levels of CRF and somatastatin (Bremner et al., 1997). When these findings are considered together, it appears that adult individuals with PTSD may exhibit an enhanced reactivity of their HPA axis. In one study of urinary cortisol in traumatized children, De Bellis, Chrousos, and colleagues (1994) reported no significant difference in 24-hour urinary cortisol levels between 13 girls (aged 7-15 years) with histories of childhood sexual abuse compared to age- and sex-matched control girls. However, in a more recent study of 18 prepubertal maltreated boys and girls, De Bellis, Baum, and colleagues (1999) found that maltreated youngsters (aged 8-13 years) secreted higher amounts of urinary free cortisol (UFC) than both children with DSM-III-R (APA, 1987) overanxious disorder and healthy control children. Clearly, further investigations of baseline cortisol levels in traumatized children are needed, but both the age of the child at the time of assessment and the age of the child at the time of the abuse could affect the HPA axis regulation of cortisol levels. In addition to studying baseline cortisol, several investigators have measured cortisol reactivity to both physical and psychological stressors in traumatized children. Over a one-month period, Hart, Gunnar, and Cicchetti (1995) measured daily morning salivary cortisol levels in maltreated preschoolers, and compared their mean cortisol levels and daily fluctuations in cortisol values to a comparison group of preschoolers who had not been maltreated, but who were from low and comparable SES families. For each morning of the study, teachers rated the children’s social behaviors and interactions (social competence) at the time of salivary cortisol collection. Cortisol reactivity was positively correlated with social competence scores and negatively correlated with shy and inhibited behavior. Maltreated preschoolers displayed blunted fluctuations in their daily cortisol levels, and this diminished responsivity was correlated with impaired social competence, as noted by their teachers.

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In an ongoing prospective study of the psychobiological effects of prepubertal sexual abuse, Putnam and Trickett (1997) assessed morning and afternoon plasma cortisol levels in sexually abused girls (aged 7-15 years) compared to age-, gender-, and ethnically-matched healthy girls. The researchers found an alteration in the diurnal rhythm, with sexually abused girls having comparatively higher morning levels and lower afternoon levels of cortisol than control girls. These investigators also assessed the cortisol response to the insertion of an intravenous catheter over a 40-minute time period. Sexually abused girls produced cortisol at a faster rate, and at 40 minutes post infusion, their cortisol levels were still far above their baseline levels, whereas the cortisol values of the control girls had returned to their baseline levels. Once again, these findings suggest that there may be an alteration in the cortisol regulation among victims of maltreatment with periods of both heightened and prolonged, as well as blunted responses of the HPA axis to relatively minor external stressful events, such as a venepuncture or having to interact with peers in a classroom. Psychophysiological Studies in Maltreated Youth The sympathetic (autonomic) nervous system (SNS) is one of the primary systems mobilized in the body’s fight-or-flight response. This complex central and peripheral neural circuit enables the body to respond to potentially dangerous situations by increasing blood flow to the heart and muscles, dilating pupils, and increasing available glucose stores for fuel. The body becomes alert, ready for action, and equipped to deal with a threat. In PTSD, there appears to be a heightened responsiveness of the SNS (for a review, see Southwick et al., 1999). Over the past 40 years, numerous psychophysiological studies have reported increased sympathetic nervous system reactivity in subjects with PTSD (for a review, see Prins, Kaloupeck, & Keane, 1995). These studies generally have found no difference in resting blood pressure or heart rate between subjects with PTSD, trauma survivors without PTSD, and healthy controls. However, significantly greater increases of systolic blood pressure and heart rate have been reported in subjects with PTSD when exposed to specific trauma-related cues. Perry (1994) hypothesized that persistent fear and alarm reactions (as might occur in a child who has been maltreated in early childhood) physiologically leads to a “dysregulated” brain stem. This condition manifests with signs and symptoms that include impaired cardiovascular regulation, extreme affective lability, and poor impulse control. Cer-

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tain brain areas, those most concerned with fear and alarm reactions (e.g., the central catecholamine/ noradrenergic system) might become “hypertrophied” at the expense of other brain structures that govern other functions. Using cardiovascular lability as a physiological correlate of brainstem catecholaminergic dysregulation, Perry studied 34 children (mean age of 10 years) who met criteria for PTSD, secondary to chronic childhood abuse. Eighty-five percent of the subjects had a resting tachycardia greater than 94 beats per minute. (The average 10-year-old has a resting heart rate of 84 beats per minute.) Following an orthostatic challenge, where the child lay supine for 9 minutes and then stood up and remained standing for a further ten minutes, two patterns of heart rate changes emerged. The first pattern consisted of a higher-than-control basal heart rate, a dramatic overshoot of heart rate upon standing, and a slow return to baseline rate over the ten minutes. The second pattern consisted of a normal increase in heart rate with a sluggish return to the baseline rate. Recently, Perry (1999), using continuous heart rate monitoring and a different challenge paradigm (namely, undergoing an interview of their abuse experiences), found that certain children, predominantly girls and those with many dissociative symptoms, show a decrease in their heart rate during a structured interview of the abuse event compared to a period of free play. However, children with prominent hyperarousal symptoms show an increased heart rate during a structured interview about their abuse, compared to their free play period. These findings suggest that certain traumatized children respond to maltreatment by emotionally “shutting down” and physiologically “under-reacting,” whereas other children are emotionally hyperaroused and physiologically “over-reactive.” In a separate study, and using a different challenge paradigm, Carrey, Butter, Persinger, and Bialik (1995) studied the physiological responses of 18 abused children (7-13 years of age) to different stimuli (slides of emotional content or slides with cognitive demands) and compared them to a group of control children. Abused children had smaller changes in their pulse rate (suggestive of reduced physiological responsivity) and lower electrodermal responses in all stimulus conditions compared to the control children. In summary, there appears to be a dysregulation of psychophysiological responsiveness, such as heart rate regulation and electrodermal responses, in traumatized youngsters. Some children show increased responsiveness, whereas others display inhibited responsiveness. Further studies are needed to determine if these differences in autonomic nervous system functioning are due to constitutional differences, gender

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and age differences, differences in the type and timing of the trauma, amount of subjective hyperarousal symptoms, comorbid diagnoses, and/or types of coping styles. Hormonal Measures of Noradrenergic Activity: Catecholamine Production in Maltreated Youth The locus coeruleus (LC) is the brain’s major noradrenergic nucleus. It is a group of cell bodies located in the central gray region of the caudal pons (midbrain). Its efferent fibers innervate multiple structures, including the brainstem, neocortex, hypothalamus, cerebellum, spinal cord, amygdala, and hippocampus. Many of these structures are critically involved in vigilance, attention, the regulation of the cardiovascular system, and the body’s response to fear and pain (Aston-Jones, Foote, & Bloom, 1984). Cell bodies in the LC synthesize and release norepinephrine (NE), one of three catecholamines that function as neurotransmitters in mammalian systems. The other two catecholamines are epinephrine (EPI) and dopamine (DA). Breakdown products of NE and EPI include normetanephrine (NMN), metanephrine (MN), vanillylmandelic acid (VNA), and 3-methoxy-4-hydoxyphenyglycol (MHPG). The main breakdown product of dopamine is homovanillic acid (HVA). All breakdown products are secreted by the kidney and can be measured in the urine. Compared to other psychiatric patients (Kosten, Mason, Giller, Ostroff, & Harkness, 1987) and healthy controls (Yehuda et al., 1998), combat veterans with PTSD have been reported to increase 24-hour urine epinephrine and norpinephrine excretion. Two studies of 24-hour urine catecholamine excretion in children reported differences between traumatized children and healthy controls (De Bellis, Baum et al., 1999; De Bellis, Lefter et al., 1994). In one study of sexually abused girls (aged 8-15 years) elevated levels of metanephrine, vanillylmandelic acid, homovanillic acid, and total catecholamines were excreted by girls with histories of sexual abuse, compared to healthy controls. After controlling for height, the strongest developmental covariate, homovanillic acid, remained significantly elevated in the sexually abused girls, while there were trends toward greater excretion of VNA, MN, and total catecholamines (De Bellis, Lefter et al., 1994). In the second study, prepubertal boys and girls with PTSD (aged 8-13 years) were compared to children with DSM-III-R (APA, 1987) overanxious disorder and to healthy controls (De Bellis, Baum et al., 1999). Children with PTSD excreted significantly greater amounts of epinephrine than the other two

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groups. There were no significant differences between groups in urinary norepinephrine or dopamine excretion. Urinary catecholamine studies need to be replicated in other groups of traumatized children, taking into account age and gender of child, type of trauma, age of onset and duration of trauma, and current psychiatric status of the child. NEUROBIOLOGICAL FINDINGS IN CONDUCT DISORDER Disruptive behavior disorders (DBDs) are a heterogeneous group of psychiatric disorders that encompass the DSM-IV (APA, 1994) based diagnoses of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). They are characterized by age-inappropriate hyperactivity, aggression, and impulsivity; there is substantial overlap between these three disorders; and “pure” forms are very rare in clinical settings (Biederman, Newcorn, & Sprich, 1991). General population estimates of the prevalence of conduct disorder vary from 1-16%, depending on the operational criteria, method of evaluation, and characteristics of the sample being studied (Steiner & Wilson, 1999). One of the cardinal features of conduct disorder is aggression; however, there is a great deal of phenotypic heterogeneity in the amount and type of aggression displayed by conduct disordered youth, and only about one-third of children with conduct disorder will grow up to have an antisocial personality disorder (ASP) and/or a criminal outcome (Rutter, 1989). Investigators in the DSM-IV field trials adopted a developmental approach and used the age of onset of conduct disorder symptoms to further categorize conduct disorder (childhood onset versus adolescent onset) (Lahey et al., 1998). This classification has proven to have ecological validity as investigators have begun to map out different family environments, developmental trajectories, and comorbidity profiles of the childhood and adolescent subtypes (Steiner & Wilson, 1999). Studies of Basal Cortisol and Cortisol Responses to Stress in Aggressive Youth In adult males with antisocial personality disorder, several investigators have noted an inverse relationship between their magnitude of behavioral deviation, or degree of antisocial behavior, and their baseline cortisol levels (King, Jones, Scheuer, Curtis, & Zarcone, 1990; Virkkunen, 1985). In one study of adult male offenders, those with ha-

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bitually violent behavior had significantly lower 24-hour urinary cortisol levels than offenders who were not habitually violent and normal controls (Virkkunen, 1985). However, other studies have reported no relationship between cortisol and antisocial personality disorder (Moss, Yao, & Panzuk, 1990) or aggression (Buydens-Branchey & Branchey, 1992). In children, the findings of basal cortisol secretion and dimensions of aggression are equally inconsistent (see Table 1). Some investigators report a relationship between low cortisol and dimensions of externalizing psychopathology in healthy children, such as hostility toward teachers (Tennes & Kreye, 1985), aggression toward peers (Tennes, Kreye, Avitable, & Wells, 1986), and the number of a child’s conduct-disorder symptoms (Vanyukov et al., 1993). Other investigators have reported no such relationship in children with disruptive behavioral disorders (Kruesi, Schmidt, Donnelly, Hibbs, & Hamburger, 1989; Schultz, Halperin, Newcorn, Sharma, & Gabriel, 1997). A recent study by van Goozen and colleagues (1998) on boys with oppositional defiant disorder (ODD) reported lower basal cortisol, but similar cortisol responses to a provocation task in boys with ODD, compared with normal controls. This variability in the relationship of low cortisol and aggression led McBurnett and Pfifner (in press) to hypothesize that low cortisol levels are associated only with the most severe and aggressive subtype of conduct disorder (possibly the childhood-onset type). In contrast to the high degree of variability in the relationship between cortisol and aggression, the relationship between basal cortisol and cortisol responses to psychological stressors is much more robust for anxious children or children displaying internalizing psychopathology. Kagan, Reznick, and Snidman (1987) were the first investigators to describe a biological correlate of a temperamental construct that they termed “behavioral inhibition.” Children who became anxious, avoidant, and fretful upon exposure to a novel situation demonstrated an increase in cortisol levels–termed heightened cortisol responsiveness–compared to youngsters who were not classified as “behaviorally inhibited.” Children with behavioral inhibition during their preschool years were later shown to be at a higher risk for childhood anxiety disorders (Biederman et al., 1990). Anxiety disorders and disruptive behavior disorders were later conceptualized as lying on opposite ends of the spectrum in their cortisol responses to stress. McBurnett et al. (1991) reported that boys with conduct disorder and an anxiety disorder had higher levels of basal cortisol than boys with conduct disorder alone (see Table 1). Susman and Ponitrakis (1997) studied

162 sons of fathers with active substance salivary abuse or psychiatric disorders cortisol

clinic referred sample of boys with salivary CD and anxiety vs. boys with CD only cortisol aggressive boys with ADHD vs. non-aggressive boys with ADHD

10-12/boys

7-16/boys

8-13/boys

7-11/boys

8-15/girls

8-15/boys and girls

Vanyukov et al. (1993)

Kruesi et al. (1989)

McBurnett et al. (1991)

Schulz, Halperin, Newcorn, Sharma, & Gabriel (1997)

De Bellis, Chrousos et al. (1994)

De Bellis, Baum et al. (1999)

no significant difference in cortisol between the two groups children with PTSD had significantly higher basal cortisol than the other two groups

24-hour urinary cortisol

no significant difference in cortisol between the two groups

boys with CD and anxiety disorders had higher levels of basal cortisol than boys with CD only

no significant differences in UFC output between the two groups

basal cortisol negatively correlated with number of conduct symptoms in children and number of antisocial symptoms in their fathers

basal cortisol negatively correlated with aggression towards peers

24-hour urinary cortisol

plasma cortisol

24-hour urinary cortisol

2-hour UFC

basal cortisol negatively correlated with hostility towards teacher

Findings

Note. UFC = urinary free cortisol; ADHD = attention-deficit hyperactivity disorder; CD = conduct disorder; PTSD = post traumatic stress disorder.

children with PTSD vs. children with overanxious disorder vs. normal controls

girls with childhood sexual abuse vs. matched controls

ADHD/CD subjects vs. matched controls

normal second-graders

Tennes, Kreye, Avitable, 7/boys and girls & Wells (1986)

2-hour UFC

normal second-graders

7/boys and girls

Measure

Tennes & Kreye (1985)

Sample

Age/Gender

Study/Year

TABLE 1. Studies of Basal Cortisol in Children with Conduct Problems and in Children with Maltreatment

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cortisol reactivity to the stressor of a first-time examination in adolescents who were assessed for conduct disorder. In response to the novel situation, she found three groups of cortisol reactors: (a) a group with increased reactivity, in which cortisol levels increased at each timepoint; (b) a group with decreased reactivity, in which cortisol levels decreased; and (c) a group with minimal reactivity, in which cortisol levels remained unchanged. One year following the hormonal assessments, adolescents with high cortisol reactivity displayed more behavioral problems and depressive symptoms than the other two groups. In all of the above mentioned cortisol studies, investigators did not obtain histories of childhood trauma, nor did they ascertain the presence of PTSD in their samples. These factors could account for some of the variability in their results. Psychophysiological Studies in Aggressive Youth The best replicated psychophysiological correlate of antisocial and aggressive behavior has been low resting heart rate. Psychophysiological under-arousal can be viewed as reflective of a chronically under-aroused autonomic nervous system. A meta-analysis of 25 independent samples by Raine, Venables, and Williams (1995) showed a medium effect size in 22 samples for low resting heart rate in childhood and later aggressive or antisocial behavior. This relationship seems particularly convincing in prospective studies (Farrington, 1987; Wadsworth, 1976). In a sample of over one thousand British male children, Wadsworth (1976) reported a significant relationship between low resting heart rate at age 11 and criminal convictions between the ages of 8 and 21 years. In the Cambridge Study of Delinquent Development, Farrington (1987) reported a significant relationship between low resting heart rate at age 18 and violent, criminal offenses at age 25. The implications of such findings are that youngsters with chronically under-aroused autonomic nervous systems might be more biologically prone to thrill-seeking behaviors and less likely to respond to the negative feedback effects of punishment. Thus, they do not learn to modulate their aggressive impulses. Skin-conductance and skin-conductance response to orientating stimuli are examples of other psychophysiological measures that have been widely studied in relation to antisocial or aggressive behavior (for a review, see Raine, 1993). In a nine-year prospective study of crime, Raine, Venables, and Williams (1990) reported that deficits in skinconductance orientating responses measured at age 15 in healthy school-

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boys were predictive of criminal activity at age 24. In a separate study of delinquent boys, subjects at age 29 who no longer engaged in criminal activity were found to have had greater orientating responsiveness at age 15 (suggestive of higher autonomic activity) than youngsters who later became adult criminals (Raine et al., 1995). Skin-conductance and heart rate were found to be significantly higher in non-criminal men who had criminal fathers than in criminal men with criminal fathers, and in non-criminal men with non-criminal fathers (Brennan et al., 1997). One possible explanation for this latter finding is that higher levels of autonomic responsiveness in people at risk for delinquent behavior may serve as a biological protective factor against criminal outcomes (Brennan et al., 1997). Alternatively, there might indeed be two biological subtypes of conduct disorder. Youngsters with the childhood-onset form of this disorder display greater psychophysiological under-arousal (low resting heart rate, low blood pressure, and low skin-conductance), whereas youngsters with the adolescent-onset form of this disorder have more autonomic reactivity (Raine et al., 1995). Early and severe childhood trauma that alters a number of stresssensitive neurobiological systems might be one possible factor that may help explain the observation that some youngsters with conduct-related problems have psychophysiological under-arousal, while other youngsters are over-aroused. Hormonal Measures of Noradrenergic Activity: Catecholamine Production in Aggressive Youth Measurement of catecholamine excretion has not been a focus of neurobiological studies in youth with conduct disorder. One study of children and adolescents with disruptive behavior disorders found no significant difference in cerebrospinal fluid levels of MHPG (a metabolite of norepinephrine) or HVA (a metabolite of dopamine) in youngsters with a DBD compared to youngsters with obsessive-compulsive disorder (Kruesi et al., 1990). In contrast, the noradrenergic system has been one of the more important neurotransmitter systems studied in the pathophysiology of ADHD (for a review see Pliska, McCracken, & Maas, 1996 and Zametkin & Liotta, 1998). Urinary catecholamine studies of ADHD that have focused primarily on norepinephrine and MHPG (a metabolite of norepinephrine) have yielded inconsistent results (Hanna, Ornitz, & Hariharan, 1996). Two groups of investigators reported lower levels of 24-hour baseline MHPG levels in hyperactive boys compared to normal

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controls (Shekim, Javaid, Davis, & Bylund, 1983; Yu-cun & Yu-feng, 1984); however Rapoport and colleagues (1978) and Khan and Dekirmenjian (1981) found no significant differences in MHPG between these two groups. In contrast, urinary epinephrine levels have been reported to be consistently significantly lower in youngsters with ADHD than in controls (Klinteberg & Magnussen, 1989; Pliszka, Maas, Javors, Rogeness, & Baker, 1994). To the best of our knowledge, investigators studying urinary catecholamine excretion in children with ADHD have not necessarily controlled for trauma histories or PTSD; however, boys aged 6 to 12 years with comorbid anxiety and ADHD secrete significantly higher amounts of urinary epinephrine during a stressful task than boys with ADHD alone or than normal controls (Pliszka et al., 1994). CONCLUSIONS AND FUTURE DIRECTIONS There are very few studies of disturbances in arousal-regulating mechanisms in traumatized children. Based on the few studies published thus far, traumatized children can have a variety of disturbances in their HPA axis and psychophysiological functioning. Compared to healthy children, they might show an altered diurnal pattern in their cortisol production and an altered responsiveness of cortisol production to relatively minor external stresses (i.e., their threshold for responding to stimuli appears low and their ability to turn off cortisol production following exposure to stimuli is likely to be impaired). Psychophysiologically, there appear to be at least two groups or subtypes of traumatized youngsters: those with high autonomic responsiveness and those with reduced autonomic responsiveness. These biological subtypes might correspond to two different clinical responses that we often see in traumatized children, both of which have survival value. In one clinical response, the child is hypervigilant, on guard, fearful, and anxious (heightened autonomic nervous system and HPA axis responsiveness). In the other clinical response, the child withdraws, dissociates, and becomes numb and depressed (diminished autonomic nervous system and HPA axis responsiveness). Reasons for these different biological subtypes could include hereditary factors and childhood temperament (for example, a “behaviorally inhibited” temperament), age and gender of the child, type and timing of the traumatic events, current symptoms of posttraumatic stress (particularly hyperarousal symptoms), amount and type of aggressive behavior exhibited by the child,

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types of coping styles, as well as current psychosocial stressors or adversity. Some studies suggest that gender, in particular, might account for the variation in both clinical and physiological responses. (See the study by Perry (1999) comparing the heart rate responses of traumatized girls and boys to a structured interview of their abuse experiences.) Studies of the neurobiological underpinnings of chronic aggressive and violent behavior in youngsters have been conducted for a longer period of time than studies of neurobiological abnormalities associated with trauma and uncontrollable stress in children. As in the case of traumatized youngsters, there appear to be at least two biological subtypes of conduct disorder. The first subtype is a group that shows autonomic under-arousal at baseline and in response to provocation tasks. This subtype may also have low basal urinary cortisol. Clinically, Steiner and Wilson (1999) speculated that these youngsters might be classified as having DSM-IV (APA, 1994) childhood-onset conduct disorder. They may have a greater genetic predisposition for conduct disorder and they may be more likely to become adults with antisocial personality disorder. The second subtype of conduct-disordered youngsters shows a heightened physiological responsiveness and highly reactive cortisol responses to stress. Clinically, these youngsters have been described as having conduct disorder with co-occurring internalizing symptoms such as depression and anxiety. Alternatively, they might be classified as having DSM-IV adolescent-onset conduct disorder. Another unexplored explanation, and one that should be factored into future studies of aggressive youth, is that they might have had extensive histories of maltreatment and that posttraumatic stress responses could account for the highly reactive biological subtype of conduct disorder. One might be tempted to pose the question: Do traumatized youth and youth with disruptive behavioral disturbances share a similar pattern of dysregulation in the reactivity of their stress-related hormonal and psychophysiological systems? Currently, there is insufficient empirical evidence to provide an answer to this question. Many methodological differences in the studies reviewed in this article complicate the comparison. These include demographic factors, such as a variety of age, gender, and pubertal stages of youngsters in different studies, as well as measurement differences. In terms of demographic factors, the majority of studies have been comprised of relatively small numbers of subjects, of both genders, who often show a wide range in age. Because age, gender, and developmental level may have significant bearing on neuroendocrine, neuroanatomical, and physiological functions, future

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studies should be designed to include adequate sample sizes with ageand gender-matched comparison subjects. Increased attention to these design issues may clarify observed differences between clinical groups of subjects. In terms of measurement differences, we note that some investigators measure cortisol and catecholamines in 24-hour urinary samples, whereas other investigators measure cortisol and catecholamines in a two-hour or six-hour urinary sample, and often, during a stressful task. These approaches provide different values and information and, therefore, do not really allow for a true comparison across studies. Finally, investigators studying adult criminals and/or aggressive youngsters typically have not assessed histories of trauma or symptoms of PTSD in their subjects. Likewise, investigators of traumatized children typically have not assessed for the disruptive behavior spectrum disorders or for levels of aggression or violence in their subjects. Our strong recommendation for future studies is that investigators who study neurobiological abnormalities in aggressive youth take into account histories of trauma and assess for posttraumatic stress symptoms in their subjects. They could do this by using newly developed, reliable, and standardized trauma and posttraumatic stress disorder instruments. Examples of these types of measures include the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) (Newman et al., in press), a clinician rated PTSD interview for children, and the K-SADS-PL (Kaufman et al., 1997), a semi-structured interview for all Axis I psychiatric disorders that has a reliable PTSD section. Other factors, such as gender, ethnicity, and pubertal stage of the child, as well as trauma variables, such as type, timing, and consequences of the trauma need to be factored into equations that compare physiological responses of aggressive children and healthy controls. Investigators should also attempt to standardize when and how they measure various neurobiological indices (e.g., baseline heart-rate, continuous heart-rate monitoring, two-hour collections of urinary cortisol, 24-hour collections of specific urinary catecholamine metabolites). It is important to emphasize that laboratory test settings are not neutral and can be stressful. Establishing a good baseline level of neuroendocrine functioning and physiology is extremely important. Newer technologies such as salivary assessment of hormone levels and the use of portable continuous heart rate monitors (polar monitors) may provide investigators with valuable information about true baseline activity levels. The assessment of the effects of a stressor on psychophysiological functioning is complex. At present, we do not recommend that studies test responses to both neutral and emotionally .

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stimulating material during the same test setting. Studies in traumatized adults show that once the subject becomes aroused in the test session, they may stay aroused for considerable periods of time, and this may alter subsequent assessment of responses to other stimuli (Grillon & Morgan, 1999). Thus, a standardized neuroendocrine and psychophysiological methodological approach would allow for a comparison of children across study sites, and would greatly advance this field of research. Another under-explored and possibly related area is the role of heredity and temperament, and their relationship to the clinical and neurobiological manifestations of trauma-related sequelae. Behaviorally inhibited children, with their heightened startle responses and cortisol responsivity to minor external stresses are at risk for anxiety disorders in childhood (Biederman et al., 1990). It remains to be explored whether they are also at risk to develop posttraumatic stress disorder following exposure to chronic maltreatment and/or neglect. Clarification of the above mentioned biological domains may significantly increase our understanding of the pathophysiology of aggression and violence, as well as posttraumatic stress responses, and as a result, may lead to improved diagnosis and treatment for youngsters with disruptive behaviors, as well as youngsters with trauma-related symptomatology. REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Archer, J. (1988). The behavioural biology of aggression. Cambridge, England: Cambridge University Press. Aston-Jones, G., Foote, S. L., & Bloom, F. E. (1984). Anatomy and physiology of locus coeruleus neurons: Functional implications. In M. G. Ziegler & C. R. Lake (Eds.), Norephinephrine: Clinical aspects (pp. 92-116). Baltimore, MD: Williams & Wilkins. Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 150, 1792-1798. Biederman, J., Rosenbaum, J. F., Hirshfield, D. R., Faraone, S. V., Bolduc, E. A., Gersten, M., Kagan, J., Snidman, N., & Reznick, J. S. (1990). Psychiatric correlates of behavioral inhibition in young children with and without psychiatric disorders. Archives of General Psychiatry, 47, 21-26. Bremner, J. D., Licinio, J., Darnell, A., Krystal, J. H., Owens, M. J., Southwick, S. M., Nemeroff, C. B., & Charney, D. S. (1997). Elevated CSF corticotropin releasing

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SECTION TWO: INTERVENTIONS

Preliminary Development of Trauma-Focused Treatment Groups for Incarcerated Juvenile Offenders Robert A. McMackin Mary Beth Leisen Leslie Sattler Karen Krinsley David S. Riggs

SUMMARY. Most male juvenile offenders have been exposed to trauma. Many juvenile offenders have experienced both acute and chronic trauma. Trauma exposure among offenders is closely linked to their criminal behavior, yet few protocols have been developed to treat posttraumatic sequelae in a delinquent population. This article describes initial efforts to develop group therapy services for incarcerated male juAddress correspondence to: Robert A. McMackin, EdD, 22 Cedar Point Road, Norwell, MA 02061 (E-mail: [email protected]). [Haworth co-indexing entry note]: “Preliminary Development of Trauma-Focused Treatment Groups for Incarcerated Juvenile Offenders.” McMackin, Robert A. et al. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 175-199; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 175-199. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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venile offenders who have histories of significant trauma exposure and current symptoms of PTSD. Four separate pilot groups were conducted in two Massachusetts Department of Youth Service secure residential facilities. The treatment included trauma psychoeducation (including the relationship between trauma and offending), therapeutic trauma exposure through discussion and expressive arts, and coping skill development. The treatment development and initial implementation as well as directions for future research are discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. PTSD, delinquency, offending behavior, aggression, expressive therapy

An understanding of the relationship between trauma and delinquency has evolved over the past 60 years, with the emphasis moving from the impact of trauma on intrapsychic development to its effect on personality, beliefs, and behavior. Aichhorn (1935) first noted that trauma contributed to delinquents’ failure to successfully negotiate early developmental stages (Erikson, 1950; Menninger, 1966) and led to severe deficits in ego and superego development (Loewald, 1962; Novey, 1955). In the 1960s and 1970s, empirical research documented the relationship between life experiences and subsequent behavior. Minuchin and Guerny (1967) stated that “a multitude of children in the institutions and slums of our big cities share with each other a style of thinking, coping, communicating and behaving, aspects of which can be directly traced to the structure and processes of the family system of which they are a part” (p. 193). More recently, Garbarino, Dubrow, Kostelny, and Pardo (1992) compared the impact of living in a violent urban environment to growing up in a war zone. Exposure to such acute and chronic danger “imposes a requirement for developmental adjustment–accommodations that are likely to include persistent PTSD” (Garbarino, Kostelny, & Dubrow, 1991, p. 377). Many juveniles grow up in familial and community “war zones,” which shape their personality structure, cognitive beliefs, and behavior. In this article, we present our initial attempts to integrate the treatment of trauma-associated emotional, psychological, and behavioral sequelae into two residential juvenile offender treatment programs. We

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present rationale for the treatment approach, initial group interventions, and then report on the feedback and modifications to the treatment model. Finally, we make recommendations for further development of this intervention. TRAUMA AND DELINQUENCY Over the past ten years, studies have documented high rates of trauma exposure among juvenile offenders, with many youths experiencing numerous traumatic events. These events include (a) experiencing childhood physical and/or sexual abuse; (b) experiencing serious life threats and/or injuries; (c) witnessing severe injury and/or death of another, and (d) being involved in gang violence (Burton, Foy, Bwanausi, Johnson, & Moore, 1994; Cauffman, Feldman, Waterman, & Steiner, 1998; McMackin, Morrissey, Newman, Erwin, & Daly, 1998; Smith & Thornberry, 1995; Steiner, Garcia, & Matthews, 1997; Weeks & Widom, 1998; Widom, 1995). The typical juvenile offender, in the brief span of his or her life, has been exposed to numerous potentially traumatic events. Such exposure may lead to the development of posttraumatic stress disorder (PTSD), an often chronic and debilitating psychological disorder characterized by intrusive memories of the trauma, increased avoidance and interpersonal difficulties, and increased physiological arousal (American Psychiatric Association, 1994). Development of PTSD is predicted by (a) presence of previous psychological problems (i.e., depression, anxiety, and substance abuse) and life stress (Breslau, Davis, Andreski, & Peterson, 1991; Burgess, Hartman, & McCormack, 1987; Kiser, Heston, Millsap & Pruitt, 1991); (b) prior trauma history (Pelcovitz, Kaplan, Goldenberg, Mandel, Lehane, & Guarrera, 1994); (c) severity of the trauma (e.g., March, 1993); and (d) perceived life threat during and after the traumatic event (e.g., Kilpatrick & Resnick, 1993; Kilpatrick, Saunders, Amick-McMullan, Best, Veronen, & Resnick, 1989; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Studies indicate that 25%-30% of individuals exposed to traumatic events subsequently develop PTSD (Carlson, 1997). Protective factors that mitigate against the development of PTSD are a well-developed sense of self (van der Kolk, 1987) and strong family/community support (Galante & Foa, 1986; McFarland, 1987). The severity and number of trauma exposures identified in a delinquent population, combined with their psychological and developmental vulnerabilities, and their lack of protective factors, place delinquent youth at

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high risk for developing PTSD. In the few studies of PTSD in juvenile offender populations, rates of a current PTSD diagnosis range from 24% to 51% among males juvenile offenders (Berton & Stabb, 1996; Burton et al., 1994; McMackin et al., 1998; Nadel, Spellman, Alvarez-Canino, Lausell-Bryant, & Landsberg, 1996) and 49% among female juvenile offenders (Cauffman et al., 1998). The Justice Department recognizes the association of a history of trauma with subsequent violent behavior. In Combating Violence and Delinquency: The National Juvenile Justice Action Plan (Coordinating Council on Juvenile Justice and Delinquency Prevention, 1996), Objective 5 is to “Break the cycle of violence by addressing youth victimization, abuse and neglect” (p. 9). Novaco and Chemtob (1998) describe this cycle of violence in relation to trauma and PTSD: Anger regulation is affected by traumatic experience, which resets activation and inhibition patterns in accordance with perceived threat, and by the shift into “survival mode” functioning. Patients with PTSD readily shift into “survival mode,” and, as a part of the peremptoriness of that shift, there is a substantial loss of self-monitoring . . . . High-intensity anger combined with diminished inhibitory control is alarming and worrisome. (p. 171) For youths, this relationship between arousal and anger may have long-lasting developmental effects on styles of interaction, with the propensity for violence becoming a lifelong behavior trait (Cicchetti & Toth, 1995; Davis & Boster, 1992; Patterson, DeBaryshe, & Ramsey, 1989). Cicchetti and Toth (1995) found that rather than habituating to further aggression, abused and neglected children appear to be sensitized to it. Specifically, traumatized children become more aroused and angered by witnessing conflict and report greater distress and fear (Cummings, Hennessey, Rabideau, & Cicchetti, 1994; Hennessey, Rabideau, Cicchetti, & Cummings, 1994). Hypervigilance and arousal may lead to the development of aggressive patterns, particularly if home conflict is chronic (Lewis, 1992). To break the lifelong and potentially intergenerational cycle of violence, interventions to counter the effects of trauma exposure among juvenile offenders is necessary. JUVENILE OFFENDER TREATMENT The treatment of delinquency has become more focal and structured over the past twenty years. Current juvenile justice interventions are

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outcome-driven and fit within the Justice Department’s concept of “Restorative Justice” where “the offender leaves the criminal justice system more capable than when s/he entered” (Carey, 1997). A primary focus in juvenile offender treatment is to reduce the offender’s “risk factors” for future delinquent behavior, while enhancing “protective factors” that will help the offender make a successful community adjustment (Office of Juvenile Justice and Delinquency Prevention, 1997). Risk factors often associated with delinquent behavior include school problems, substance abuse, young age at first offense, intellectual factors, family dysfunction, parental substance abuse, family criminal involvement, poverty, and organic problems (Zigler, Taussig, & Black, 1992). Outcome studies that compared the efficacy of different juvenile offender treatment approaches found that cognitive-behavioral approaches were more effective at reducing recidivism than were nondirective or psychodynamic approaches (Andrews & Bonta, 1994; Gendreau & Ross, 1981; Goldstein, 1988). The recognized effectiveness of cognitive-behavioral treatment with offenders has given rise to numerous intervention programs designed specifically for delinquent youth (Carey, 1997; Dryfoos, 1991; Tate, Reppucci, & Mulvey, 1995). Currently, protocols are available for juvenile offender treatment programs aimed at social skill development (Bazemore & Terry, 1997), aggression management (Goldstein, 1988), substance abuse (Gorski, 1993), and sexual offending (Laws, 1989). Most of the current cognitive-behavioral interventions emphasize that delinquents must learn about and take responsibility for their behavior as well as develop alternatives to maladaptive behavior and beliefs (Bazemore & Terry, 1997; Carey, 1997). Mastery, competency, and related improvements in selfesteem, along with family and community involvement, are stressed (Dryfoos, 1991; Goldstein, 1988). Due to the high prevalence of language deficits among juvenile offenders (Andrew, 1974; Stattin & Klackenberg-Larsson, 1993; Walsh, 1992), non-verbal techniques such as role-playing and expressive arts are integrated into many intervention programs. Juvenile justice professionals are sensitive to not providing excuses to offenders for their behavior. George and Marlatt (1989) described this concern with respect to sex offender treatment: [In the] acknowledgment of oneself as addict and admission of powerlessness, the sexual-addiction approach places the locus of responsibility for the offense pattern and for treatment outside the offender. Such an externalization of blame and treatment respon-

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sibility can backfire with offenders who are already reluctant to take any responsibility for their misdeeds and choose to view this so-called addiction as a convenient excuse before and after a reoffense. (p. 12) The concept that an individual is accountable for his or her actions is central to offender treatment. The desire to avoid providing offenders with an excuse or rationalization for criminal behavior may have delayed recognition of the need to treat trauma exposure in this population. Many delinquency interventions use a “Relapse Prevention” or “Offense Cycle” treatment approach to help offenders learn about and gain control over their criminal acting-out. Most relapse prevention (RP) models of treatment utilize a behavior cycle. The behavior cycle is a sequence of emotions, cognitions, and behaviors that if unchecked can create a self-reinforcing, and at times, addictive, pattern of offending behavior. For sex offenders, the cycle may be referred to as the offender’s “Deviant” or “Offender Cycle” (Longo-Freeman & Bay, 1988), whereas the cycle may be referred to as the youth’s “Angry Behavior Cycle” in treatment of aggression (Goldstein, 1988). Gray and Pithers (1993) describe the sex-offense cycle as “a direct sequence of offense precursors.” They outline the sequence as: “Unpleasant Affect -> Deviant Fantasy -> Passive Planning -> Cognitive Distortion -> Disinhibition -> Deviant Act” (p. 297). The idea of a trigger or an offense precursor is central to all RP models of treatment. The offense trigger can initiate or move an offender into his or her cycle. All interventions strive to have the offender “intervene in or break into his offense pattern at its very first sign” (Knopp, 1984), recognizing that the deeper an offender goes into the thoughts, fantasies, and behaviors of a cycle, the more difficult it is to break. That trauma-associated affects may become offense triggers makes theoretical sense considering the high rate of trauma exposure among sex-offenders, yet only one empirical study has been done to link trauma-associated affects and PTSD to offense triggers. McMackin, Leisen, Cusack, LaFratta, and Litwin (2001) interviewed treating clinicians to examine the link between trauma-associated sequelae and offender triggers among juvenile sex-offenders. In a sample of 40 juvenile sex-offenders treated with an RP model for at least six months, McMackin et al. found that offense triggers were related to an intense trauma-associated feeling of fear in 37.5% of the sample, horror in 20%, and helplessness in 55% of the sample.

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TRAUMA TREATMENT Most treatment protocols for PTSD and trauma exposure were developed for adults and children rather than for adolescents. Effective approaches to treating trauma-related psychological difficulties have traditionally been divided into two broad categories: skills training and therapeutic exposure. Skills training approaches include a number of interventions aimed at improving an individual’s ability to cope with and manage emotional reactions (e.g., anxiety) related to their traumatic memories (e.g., Foa, Rothbaum, Riggs, & Murdock, 1991; Kilpatrick, Veronen, & Resick, 1979). However, as conceptualizations of post-traumatic reactions expanded to incorporate a wider variety of emotional reactions, such as anger, sadness, and guilt, cognitive and behavioral techniques to cope with these feelings were incorporated into treatment approaches (Kimble, Riggs, & Keane, 1998). Typically, skills training programs include relaxation techniques, role-playing, self-talk, and cognitive restructuring. Focused interventions aimed at specific issues such as communication and assertiveness difficulties, social skills problems, and violence may also be included (Kimble et al., 1998). In general, such skills-based programs have proven successful in reducing trauma-related distress among adults (Foa et al., 1991; Kilpatrick, Veronen, & Resick, 1979). The other effective approach to treating post-trauma reactions is the use of direct therapeutic exposure (e.g., desensitization, flooding, prolonged exposure), which has proved effective with adult rape survivors (Foa et al., 1991) and combat veterans (Boudewyns, Hyer, Woods, Harrison, & McCraine, 1990; Keane, Fairbank, Caddell, & Zimering, 1989). More recently, exposure-based treatments for PTSD have been found effective with children and adolescents (March, Amaya-Jackson, Murry, & Schulte, 1998; Saigh, 1992). Therapeutic exposure requires the client to directly confront traumatic cues and memories within a supportive individual or group therapy environment. Typically, clients are asked to relate the events of their trauma to the group (or individual therapist) verbally or in writing. In conjunction with these exercises, the client is encouraged to generate a mental image of the events that includes as much sensory information as possible. To optimize the effectiveness of exposure-based interventions, it is suggested that clients reexperience the intense emotions associated with the memories, as well as relating the actual events of the trauma (Foa & Kozak, 1986). Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro,

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1995) is another validated treatment for PTSD (Chemtob, Tolin, van der Kolk, & Pitman, 1999), which is of less interest to us because it cannot be adapted to a group format. Although the underlying mechanisms of EMDR have yet to be fully understood (e.g., Chemtob et al., 1999), it is a hybrid method that includes many of the components common to effective cognitive-behavioral approaches (Hyer & Brandsma, 1997; Sweet, 1995). Four common themes occur across the various adult and child trauma treatment approaches (Gil, 1991; Greenwald, 2000; Lubin & Johnson, 1997; Pynos & Eth, 1986; Saigh, 1992): 1. Creating a safe treatment environment; 2. Providing education about trauma and its effects; 3. Desensitizing clients to traumatic material through discussion, habituation, or exposure to the traumatic stimuli; and 4. Developing and/or strengthening coping skills to manage traumaassociated sequelae. Many PTSD treatment protocols can be adapted for use in individual or group therapy. Treatment programs vary in their degree of emphasis on skills training and/or exposure. All treatment protocols require, first, establishing a safe treatment environment. Generally adolescent participants receive educational material regarding trauma and its impact in the early stage of treatment, while trust is being established. The educational material provides a common language and understanding of trauma that can then be integrated throughout the treatment. Most trauma treatment programs for children tailor the educational material to the child’s level of cognitive development and may include the use of non-verbally based techniques to access traumatic material (Gil, 1991). The four themes outlined above are not sequential steps in trauma treatment. For example, the development, maintenance, and deepening of a safe, trusting treatment environment may be emphasized initially but would remain a theme throughout the course of treatment. FIRST INTERVENTION TRIAL Overview. Within Massachusetts Department of Youth Service (DYS) residential programs there has been an increased awareness of the extensive trauma exposure and PTSD symptomatology among juvenile offenders. This awareness has led to collaboration between the first au-

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thor and staff at the National Center for Posttraumatic Stress Disorder (NC-PTSD) at the Boston VA Medical Center. The trauma treatment groups described below were a pilot project that grew out of earlier research on the relationship between trauma exposure and delinquency conducted by the first author and NC-PTSD staff (McMackin et al., 1998; Erwin, Newman, McMackin, Morrissey, & Kaloupek, 2000). We will report on the early development of trauma-focused group therapy services within two residential programs for delinquent youth. Cognitive-behavioral and milieu group therapy are the primary treatment modalities used within the Massachusetts DYS system at each of their juvenile justice facilities. The juvenile justice literature has stressed the effectiveness of cognitive-behavioral group treatment over individual therapy with respect to the acquisition of skills that would allow an offender to succeed in the community and not recidivate (Bazemore & Terry, 1997; Carey, 1997). A group intervention was selected to address trauma associated sequelae in juvenile offenders in order to be consistent with existing services at each site and to draw on established PTSD group treatment protocols (i.e., skills building and therapeutic exposure). The first set of groups was patterned partly on outpatient psychoeducational groups offered at the Boston VA PTSD Outpatient Clinic and NC-PTSD (Monroe & Bitman, 1997). These were 10-12-session, cognitive-behavioral groups for male PTSD combat veterans that included psychoeducation and limited controlled exposure. An NC-PTSD psychologist provided ongoing consultation to the juvenile offender group leaders. The group leaders drew on their collective experience in the treatment of juvenile offenders, the VA group format, and trauma and juvenile justice treatment literature to develop the initial program. Because this was a new intervention strategy, the primary objectives of the first groups were to become familiar with and modify group procedures. The overall treatment goal was to give the participants a better understanding of how trauma affects their lives and to help members develop socially acceptable coping skills to manage the effects of trauma. The treatment protocol was based on cognitive-behavioral principles, and utilized psychoeducation, controlled exposure, skills development, and expressive arts. Group members were given psychoeducation about the nature of trauma and PTSD. Expressive arts and controlled exposure were used to access and discuss traumatic material. Members also learned skills to manage their arousal and emotions. All group members had previously participated in cognitive- and behaviorally-based treatment groups for aggressive behavior, substance abuse, or other offense related behaviors while in the facility.

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Intervention Sites. Groups were conducted in two Massachusetts DYS residential centers, the Connelly Treatment Unit (CTU) and the Pilgrim Center (PC). CTU is a 16-bed, secure facility serving juvenile offenders from the metro Boston area. CTU represents the most secure type of facility in Massachusetts. Youths range in age from 13 to 21 years, and are committed for property and person crimes, excluding rape, indecent assault and battery, and murder. The treatment program at CTU is a mix of individual therapy and group therapy, as well as family therapy whenever possible. The average length of stay is six months, and youths return to their homes or to a residential placement after leaving CTU. PC is a residential, 24-bed facility located in a suburb of Boston. PC is considered a medium staff-secure facility, meaning there is no fence or wall around the perimeter and doors are unlocked to allow free movement within the program. Many residents placed at PC have been stepped-down after a stay in a higher security facility. Youth range in age from 13 to 18 years, and are committed for property and person crimes, including rape, and indecent assault and battery. The treatment program is a mix of individual and group therapy, family therapy, sex offender treatment, and other offense-specific treatment. PC is an “open” program, meaning all offenders and staff are aware of the offense of each resident, although they are not necessarily aware of the details of the offense. The average length of stay is 15 months for sex offenders and nine months for other offenders. Youths return to their homes or to independent living situations after completing the PC program. The primary treatment orientation at both CTU and PC is cognitive-behavioral group treatment. Juvenile offenders in treatment at both CTU and PC are expected to examine beliefs that underpin their criminal behaviors and place them at risk for future criminal acts. They have opportunities to learn and practice new behaviors, such as how to manage disagreements without resorting to violence, both within treatment and in the program milieu. The trauma treatment groups were provided as part of each youth’s CTU or PC treatment plan. Participant Assessment and Selection. All residents at both facilities were screened for trauma exposure and PTSD symptoms. Screening instruments included an adapted Richters’ (1990) Exposure to Community Violence (CETV) scale and the Child PTSD Checklist (Amaya-Jackson, McCarthy, Newman, & Cherney, 1995). On the CETV, youths were asked to endorse the frequency of exposure to community violence (e.g., witnessing a shooting or life threat). On the Child PTSD Checklist, youths were asked to write three things they

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found “very scary or frightening,” and then to answer questions about PTSD symptoms related to the identified events. PTSD diagnoses were determined via symptom endorsement on the Child PTSD Checklist. The CETV and PTSD checklist responses of each youth were reviewed with the youth’s individual therapist, and referral to the group was discussed. Youths who endorsed at least one reexperiencing item and at least one other symptom of PTSD were interviewed for possible participation. Traumatic events and posttraumatic symptoms were reviewed, and youths were told that the group was for residents who had been exposed to a significant traumatic event and who were still affected by the trauma. Although they were told that the group was voluntary, group members understood that their participation would earn them points toward facility privileges. Youths were told that they would learn about the effects of trauma and would be expected to explore and discuss their traumatic experience. They were told that it would be their decision as to how much detail they provided about their experiences. Five individuals were selected for the first PC group and six for the first CTU group. All group members met full current PTSD diagnostic criteria as measured by the Child PTSD checklist. The initial groups were eight weeks long. The CTU group was co-led by a social worker and an art therapist. The PC group was co-led by a social worker and a psychologist (third and first authors). A childcare staff attended the CTU group but not the PC group. The CTU childcare staff person was a participant observer and monitored security. At both PC and CTU it is a unit practice for childcare staff to actively participate in the treatment program, including attending and leading some groups. The group leaders met biweekly with the consulting psychologist from the Boston VA Medical Center and with each group member’s individual therapist. Goals. The initial goal (Phase 1) was to create a safe, trusting group environment, while also educating the members about trauma exposure and possible symptoms. The trauma education gave group members a frame of reference through which they could understand their own experience and share it with others. The goal of Phase 2 was for members to participate in a self-paced controlled exposure experience to begin processing their traumatic experience. This was done through an expressive arts project that represented the member’s personal trauma experience, and the projects were shared with the group. Special attention was focused on trauma-related feelings of fear and helplessness, as these were strongly endorsed on the screening measures. The goal of

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Phase 3 was for each participant to learn a coping skill to manage trauma-related stress. Muscle relaxation, breathing techniques, and use of music were selected since these are easily learned and have been proven effective to manage anger (Novaco & Chemtob, 1998). It was expected Phase 1 would be two weeks, Phase 2, four weeks, and Phase 3, two weeks. Procedures. Each group session was 75 minutes in length and followed the same format. The session began with a “check-in” to help group members focus on the group tasks and acknowledge issues or conflicts within the group or residence. The check-in assisted in establishing a safe treatment environment where all members acknowledged the shared purpose of the group. As part of the check-in the group leaders presented the topics, goals, and activities for the session. Each session included either an expressive arts project or a discussion of an earlier project. The group concluded with a “check-out,” during which each group member reviewed his experience in the session and acknowledged any conflicts or issues that arose. Group leaders met regularly with members’ individual therapists and also contacted them with additional concerns when necessary. Phase 1. In the first sessions of Phase 1, group members described their understanding of trauma and collectively developed a definition of trauma. They also made collages of traumatic events taken from the newspaper and magazines and then discussed their collages. They provided members with explanations to clarify misconceptions they held regarding trauma and PTSD. Members were shown video clips from movies and then discussed the role of trauma in the movie from the perspective of individual characters. Group members also made drawings and small sculptures to depict feelings of helplessness and extreme fear. Finally, members drew faces expressing different feelings. They then listened to various types of music to find themes of trauma, which they then associated with the faces. The faces were subsequently used as props by all group members for the remainder of the group to explain feelings associated with traumatic experiences. During Phase 1, many youth spontaneously spoke of their traumatic experiences. Members were discouraged from detailed discussion of their personal experiences, since it was not known if group cohesion and safety were adequately established. Treatment issues were discussed with the primary therapist as needed. Phase 2. During Phase 2, members worked on two expressive arts projects. In the PC group, members constructed “self-boxes,” which

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were cardboard boxes with a lid. Group members were told that the exterior of the boxes represented themselves, including their traumatic experience. The interior represented how the trauma affected them internally. In the CTU group, members constructed free-form sculptures that represented their trauma-associated feelings. Participants worked on their projects individually or in small groups over two sessions. While the residents were working on projects, group leaders worked individually with members discussing what the projects represented and sharing ideas. Participants shared their projects with the group over two sessions. Phase 3. The first two phases of the groups took longer than expected because the discussion of the youths’ art projects and personal trauma experiences required more time than initially anticipated. Only one relaxation training session of a controlled breathing technique was conducted. Discussion of First Group Intervention. All youths were interviewed for feedback after the final session. A number of group members said during the first two group sessions that they felt “tricked” into the group. They stated that, although they took the self-report measures along with all other PC and CTU residents, they believed they were unfairly chosen to participate in the group. Youths were reminded during the first two group sessions that they were selected for participation based on their trauma histories and current trauma-related problems. All youths accepted this explanation by the third group session. All group members lived together in the therapeutic milieu and participated in other treatment groups together. Their initial concerns about being “tricked” into the group were viewed by the leaders as related to the development of group trust and an initial resistance that is often present at the beginning of any group in a juvenile justice setting. It is our interpretation that explanations provided by the leaders and the participants’ familiarity with each other helped group members get past their initial resistance to establish group trust. At PC the initial resistance was somewhat complicated by having the group scheduled in what had previously been free time. During post-group interviews, the majority of participants said that the most helpful part of the group was “when everyone sat down and talked about certain events which happened in their lives that still hurt them.” Similarly, the most frequently stated benefit of the group was members’ ability to talk about their traumatic experiences. Several times, a youth’s trauma experience was directly expressed or acted out symbolically in the group. In one PC session, when individuals dis-

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cussed their pictures of helplessness, three boys put tape over their mouths, eyes, and ears. In a criminal justice setting, there is a temptation to sanction such behavior with some form of discipline, such as not awarding group participation points. In this case, however, such behavior was discussed as a strategy to cope with the stress of listening to another’s experience of helplessness, or having to discuss one’s own, rather than as a disciplinary problem. Group members reported that this discussion helped them to understand how their traumatic experiences could be expressed in their daily life. In the CTU group, the childcare staff was able to introduce material regarding a participant’s behavior in the milieu, particularly social isolation and aggressive posturing that was then discussed as possibly related to prior trauma exposure. Participants stated that the educational material assisted them in developing a common understanding regarding trauma, its impact and relationship to their criminal behavior. All PC group members participated in a relapse prevention model of treatment for either sex offending or substance abuse treatment. These youth applied their understanding of trauma to their offense cycle in relation to substance abuse and violence by recognizing that while in the community they used substance abuse and violence as means to deal with unpleasant affects associated with earlier trauma. Many members of the CTU group, although not in RP therapy, understood the connection between their violent behavior, substance abuse, and trauma history. Ongoing communication between group leaders and individual therapists appeared to facilitate exploration of trauma issues in and outside of the group context. Both groups included individuals who had experienced multiple traumas, including sexual victimization and other violent trauma. During the controlled exposure phase, many youths spoke of life threatening situations, severe physical abuse, and violent losses, but no one openly acknowledged sexual victimization. Even in their symbolic representations of their traumatic experiences, group members appeared reluctant to express themes of sexual victimization; their art projects primarily focused on family and community physical violence. Youths spoke directly about violent situations they had experienced, such as shootings, but only indirectly referred to sexual victimization experiences with phrases such as “bad things that happened to me.” The group leaders allowed members to proceed at their own pace with respect to describing their traumatic experiences. All group members said they understood the purpose of the expressive arts projects, although they indicated that they should have had a range of projects from which to select. Most group members and all

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group leaders saw eight weeks as too short a time period. At the exit interview, all but one member acknowledged the major impact that trauma had had on their lives, yet no participants thought they had PTSD. Due to time constraints, particularly the amount of time it took participants to discuss their large art projects, the Phase 3 goal of learning a coping skill was not achieved for any participants. Part of the last session was devoted to a controlled breathing exercise but participants did not get to practice this technique in other sessions. SECOND INTERVENTION TRIAL Overview. Based on the feedback from members and leaders of the first group, the format of the second groups was modified. The number of sessions was extended to 10 weeks at CTU and 12 weeks at PC. The PC group remained co-led by the same two therapists and in the CTU group the social worker was replaced by the PC psychologist group leader. A childcare staff member was added to the PC group since having had such a staff member in the CTU group provided feedback from the milieu on daily behavior, particularly withdrawal or aggression that may be associated with trauma exposure. As with the first groups, screening instruments were administered during youths’ facility intakes. The groups were held at a pre-established group time to minimize resistance. A group pre-test was added to measure understanding of and beliefs about trauma and PTSD. Group members were given several options for the controlled exposure project to allow for more individual expression of their trauma experience. The group phases and goals remained the same and will be discussed in more detail below. A relapse prevention component was added to the PC group because all PC group members participated in RP therapy, and all group members from the first intervention trial, particularly the sex offenders, identified the connection between trauma exposure and offending behavior. The group leaders believed that, due to PC group members’ familiarity with RP language and therapy, a relapse prevention-based trauma cycle would help them apply the educational material to their personal experience. An RP trauma cycle was developed for the PC group. Stages of the trauma cycle included: Trauma -> Reaction -> Action -> Symptoms -> Coping -> Feeling Okay. The first stage is the traumatic event or a re-experiencing of that event. The Reaction stage is the individual’s immediate response to the traumatic event, while the Action stage is what the person does after the event. The next stage involves Symptoms asso-

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ciated with the trauma. Coping, the final stage, represents how an individual attempts to decrease internal distress and arousal to feel Okay again. Procedures. Thirteen youths participated in the second group cycle, six at PC and seven at CTU. All youths had significant trauma exposure with at least one re-experiencing symptom, and one or more additional symptoms of PTSD. Eleven youth met full criteria for a diagnosis of PTSD based on the Child PTSD checklist (Amaya-Jackson et al., 1995). Pre-test results showed that members had a poor understanding of trauma and its effects, and did not believe trauma treatment would be beneficial. The majority felt they received some support from their families, and recognized that others had similar experiences. Unexpected negative factors affected the second cycle of groups. At CTU, major staff changes resulted in having only one on-site therapist available for the group leaders to speak with regarding group members. At PC, one group leader missed four group sessions due to a family member’s illness. Space constraints resulted in the CTU group being held in a room less than half the size of the room used for the PC group. Phase 1. Several components were added to Phase 1. First, a “trust fall” exercise, where members allow themselves to relax and fall back into the arms of another group member, was used in the first session of the PC group. The “trust fall” was to facilitate the development of trust and safety so group members could have more ownership of the group rather then feeling “tricked” into it. Second, relaxation techniques were introduced in the first PC group session and practiced in each subsequent session to allow time for skill acquisition. Both diaphragmatic breathing and deepening relaxation procedures were used to help members achieve a relaxed state. Finally, at PC, the trauma cycle was presented to help integrate the trauma treatment into each member’s overall treatment plan. Phase 2. The PC group members were presented with a range of art supplies from which to create the large expressive arts project. Projects included collages, “self-boxes,” writing rap songs, and drawings. The confined space of the office used at CTU did not allow for each group member to complete a large expressive arts project. A number of smaller, alternative expressive arts projects were utilized. These projects included drawings that were representative of members’ traumatic experiences, making small multimedia sculptures, and listening to and discussing music. Phase 3. In Phase 3, situations from movie segments were discussed to understand adaptive and maladaptive trauma coping skills. In addi-

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tion, participants examined how they used self-destructive means, particularly substance abuse and violence, to manage the emotions trauma evoked in them. In the PC group, the cycle of trauma was discussed with emphasis on how it related to coping skills and each member’s offender cycle. As noted, relaxation procedures were introduced in the first PC session and practiced in each subsequent session. The final session of both groups was used for a review of the group. Discussion of Second Group Intervention. The second series of groups provided a striking contrast to the first series, with the PC group proceeding as planned, and the CTU group progressing in a more haphazard manner due to staffing and space constraints. Prior to the beginning of the second CTU group, the unit’s clinical director, who co-led the first group, and a second clinician left the program. The unit was left with minimal clinical support, forcing childcare staff to assist with clinical services. The staffing situation did not allow for ongoing communication with each member’s therapist since many members did not have an individual therapist, and the trauma treatment was never integrated into each youth’s overall treatment plan. Group leaders were consultants who did not have official staff status on the unit. As such, they had less authority in redirecting disruptive behavior through the loss of daily program points. Additionally, the reduction of clinical staff contributed to a general decline in the therapeutic milieu. The second CTU group was held in a small office, less than half the size of the classroom where the second PC group was held. CTU group members were not able to work alone or in small groups on projects as was possible in the PC group. With seven group members, two leaders and one childcare staff, the CTU group members were frequently in each other’s way. The safe milieu, considered essential for treatment of trauma, was not adequately established. In contrast, the large open space available for the PC groups enhanced development of the safe, trusting milieu by providing areas for the group to work as a whole or in smaller subgroups. Even with these constraints, all of the CTU group members participated and explored their trauma histories directly and symbolically. Group members were loud and disruptive at times, but were never disrespectful to members who spoke of their personal trauma experiences. While there can be a tendency for juvenile offenders to tell “war stories,” where past exploits are told in a glamorous or provocative way, the stories told in the group were shared within an atmosphere of support and seriousness. Members examined their maladaptive coping strategies and discussed alternative behaviors. They did not receive relaxation training due to the size of the room.

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In the PC group, trust was rapidly established. Holding the group at an established group time and providing a clear explanation that the youth was selected for the group due to his prior trauma experience helped avoid members saying they were “tricked” into the group. Additionally, the “trust fall”exercise appeared to help facilitate trust. All group members understood the relapse prevention model, and familiarity with RP terminology appeared to help them discuss trauma and its relationship to their offense cycle in group and individual therapy. The integration of the relaxation protocol across sessions worked well. All group members developed some mastery of the relaxation techniques, and two reported they used it successfully to assist them with sleep disorders that predated the group. All group participants had individual therapists who were consulted weekly. The feedback from group participants in the CTU group was mixed, while it was uniformly positive from PC group members. All group members viewed the sharing of traumatic life experiences and listening to others as the most important component. Two members of the CTU group and all members of the PC group expressed a desire for the groups to continue. Many members of the CTU group saw some of the expressive arts projects as “dumb.” Overall, CTU group members took a more passive approach to the group than members of the PC group; for example, CTU members wanted to watch a video rather than work on an art project. Clinician feedback was only available for the PC group. Each member’s individual therapist indicated that the group and each youth’s trauma history were discussed in individual therapy. Clinicians felt participants had improved their understanding of how trauma-associated feelings related to their offending. The relationship of trauma-associated affects of fear and helplessness to subsequent violence and substance abuse was addressed in group members’ individual work and other treatment groups to help lower a youth’s “risk” for future offending. RESULTS Members of both the first and second group cycles reported an increased understanding of the ways trauma had impacted on them. Most members acknowledged how they used violence and substance abuse as ways to manage trauma-associated stress at different times in their lives. Participants’ individual therapists reported trauma themes emerged more often in individual treatment than prior to the group. Participants familiar

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with Relapse Prevention therapy reported the trauma cycle helped them see the connection between trauma exposure and aggressive behavior. Members of the second PC group that were able to practice relaxation procedures for 12 weeks reported improved coping skills including improved sleeping patterns and a better ability to manage anger. A composite case example will help illustrate how the trauma treatment group was integrated into and impacted on the overall treatment plan for a youth. Case Example: Lonny Lonny was a 17-year-old boy who was placed at PC after spending one year in a secure treatment setting. Lonny’s parents separated when he was five years old. Both parents were alcoholics, neglectful, and showed minimal interest in Lonny’s education. Lonny had experienced school problems, mainly peer aggression, starting in the first grade. Lonny stated he “loved” to fight, both to hit and be hit by others. By the third grade he was placed in a class for students with behavior problems. When he first entered DYS secure treatment, his academic performance was over three grades below age level in all subjects. Lonny’s mother and maternal grandmother raised him until age 10, when his mother died in a car accident. After his mother’s death, he was raised by his grandmother and had periodic contact with his father. At eight years of age, Lonny had been sexually molested and anally raped at least five times by his mother’s boyfriend. Lonny began to drink by age nine, smoked marijuana by age 10, and began taking sedating drugs regularly in his early teens. At age 15, Lonny was convicted of indecent assault and battery, reduced from rape charges. Lonny and two friends had gang-raped a 13-year-old girl at a party. Initially, Lonny insisted the rape was consensual. He participated in over two years of sex offender relapse prevention treatment at PC and in secure treatment. After eight months of treatment, he acknowledged his involvement in the rape. Within RP offender-based treatment, Lonny had discussed his offenses in detail, as well as his history of abuse. He had identified substance abuse and anger as offense precursors or triggers. At trauma group intake, Lonny identified the rapes and being shot at as significant traumatic events. He reported intrusive thoughts related to both events, as well as other associated symptoms of PTSD. During the trauma group, Lonny discussed the violence in his family and a serious threat to his life, but only indirectly referred to his history of sexual

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abuse. Lonny’s individual therapist reported that the sexual abuse was being discussed both in individual therapy and sex offender group. Lonny understood that there was an association between his trauma history and offending behavior, but he did not fully appreciate the depth of that connection until he participated in the trauma group. The ongoing communication between Lonny’s group therapist and his individual therapist facilitated a closer examination of the relationship between Lonny’s trauma history and his offending behavior. In trauma group Lonny recognized that his experience of trauma-related helplessness contributed to his anger response and substance abuse. He used relaxation procedures to better manage his anger. In RP sex-offender therapy Lonny addressed the direct link between trauma-associated feelings of helplessness with anger and his risk of sexually acting out. Lonny’s understanding of the close association of trauma-associated affects, particularly helplessness, to anger and substance abuse was seen among many participants in all groups. The ability for a youth to focus on this in treatment was best done at PC based on the reports of individual therapists. It is the belief of the group leaders that the common relapse prevention language shared by all PC group members helped the youth make the connection between trauma-associated affects and high-risk situations. CONCLUSIONS AND LIMITATIONS Trauma treatment for juvenile offenders is in its nascent stage. This paper describes trauma treatment groups based on education, self-paced controlled exposure and skill development, through the use of cognitive-behavioral and expressive arts techniques, that were provided to juvenile offenders in residential placement. The groups were an initial attempt to address trauma related issues in over 20 delinquent youth. Group participants indicated that sharing their trauma experiences both directly and symbolically were the most important parts of the groups. Participants came to recognize the association between their trauma experience and their criminal acting-out, particularly their use of violence and substance abuse as coping mechanisms for the management of trauma-associated feelings. The youth that were familiar with the Relapse Prevention therapy found this approach helpful in assisting them to make a clear connection between trauma-associated sequelae and criminal behavior triggers. The groups were heterogeneous both in terms of trauma history and degree of trauma exposure of members. Many juveniles experience

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multiple and diverse traumas including sexual abuse, physical abuse, crime victimization, and community violence. It is unknown if it would have been beneficial to have youths in more homogeneous groups with respect to their type of trauma exposure (i.e., separate groups for those with sexual and physical victimization histories) or extent of exposure (i.e., separate groups for those with a few incidents of trauma exposure and those with hundreds of exposures). All groups were conducted in highly controlled treatment environments where the members’ behavior was monitored and clinical support was available. Many of the behaviors participants identified as problematic and associated to trauma (i.e. aggression and substance abuse) were environmentally controlled. It remains unclear how beneficial the groups were, particularly in relation to the expression of those behaviors in a less controlled environment. A longer study with a control group and community follow-up would be beneficial. Additionally, valid and reliable pre and post treatment measures should be integrated into any future study. The first and third authors of the paper were treatment providers and the fourth author was an ongoing consultant to the treatment groups. The authors, due to their close association with the group, may have some reporting bias. It would be good to have independent evaluation of future treatment groups. We believe that self-paced, controlled exposure in a safe treatment environment is an important element that should be considered as part of the treatment plan for juvenile offenders with histories of trauma exposure. We intend to expand this pilot program through further feedback-based refinements and the inclusion of treatment evaluation measures. REFERENCES Aichhorn, A. (1935). Wayward youth. New York: Viking Press. Amaya-Jackson, L., McCarthy, G., Newman, E., & Cherney, C. (1995). Child PTSD Checklist. Unpublished instrument. Duke University, Department of Psychiatry, Durham, NC. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Andrew, J. M. (1974). Delinquency, the Wechsler P > V sign, and the I-level system. Journal of Clinical Psychology, 30, 331-335. Andrews, D. A., & Bonta, J. (1994). The psychology of criminal conduct. Cincinnati, OH: Anderson. Bazemore, G., & Terry, W. C. (1997). Developing delinquent youth: A reintegrative model for rehabilitation and a new role for the juvenile justice system. Child Welfare, 76, 665-717.

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Berton, M. W., & Stabb, S. D. (1996). Exposure to violence and post-traumatic stress disorder in urban adolescents. Adolescence, 31, 489-498. Boudewyns, P. A., Hyer, L., Woods, M. G., Harrison, W. R., & McCranie, E. (1990). PTSD among Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure. Journal of Traumatic Stress, 3, 359-368. Breslau, N., Davis, G. C., Andreski, P. & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216-222. Burgess, A. W., Hartman, C. R., & McCormack, A. (1987). Abused and abuser: Antecedents of socially deviant behavior. American Journal of Psychiatry, 144, 1431-1436. Burton, D., Foy, D., Bwanausi, C., Johnson, J., & Moore, L. (1994). The relationship between traumatic exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile offenders. Journal of Traumatic Stress, 7, 83-93. Carey, M. (1997). Cog Probation. American Probation and Parole Association Perspectives, Spring, 27-42. Carlson, E. B. (1997). Trauma assessments: A clinician’s guide. New York: Guilford Press. Cauffman, E., Feldman, S., Waterman, J., & Steiner, H. (1998). Posttraumatic stress disorder among female juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1209-1216. Chemtob, C. M., Tolin, D., van der Kolk, B., & Pitman, R. K. (1999, November). Treatment guidelines for EMDR. In E. Foa (Chair), ISTSS PTSD Treatment Guidelines. Symposium conducted at the annual meeting of the International Society for Traumatic Stress Studies. Cicchetti, D. & Toth, S. L. (1995). A developmental psychopathology perspective on child abuse and neglect. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 541-561. Coordinating Council on Juvenile Justice and Delinquency Prevention. (1996). Combating violence and delinquency: The national juvenile justice action plan. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Cummings, E. M., Hennessey, K., Rabideau, G., & Cicchetti, D. (1994). Responses of physically abused boys to interadult anger involving their mothers. Developmental Psychology, 6, 31-42. Davis, D. L., & Boster, L. H. (1992). Cognitive-behavioral-expressive interventions with aggressive and resistant youths. Child Welfare, 71, 557-573. Dryfoos, J. G. (1991). Adolescents at risk: A summation of work in the field–programs and policies. Journal of Adolescent Health, 12, 630-637. Erikson, E. (1950). Childhood and society. New York: W.W. Norton. Erwin, B. A., Newman, E., McMackin, R. A., Morrissey, C., Kaloupek, D. G. (2000). PTSD, malevolent environment, and criminality among criminally involved male adolescents. Criminal Justice and Behavior, 27 (2), 196-215. Foa, E. B. & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35. Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723.

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Galante, R., & Foa, E. (1986). An epidemiological study of the psychic trauma and treatment effectiveness for children after a natural disaster. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 79-87. Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, C. (1992). Children in danger. San Francisco: Jossey-Bass. Garbarino, J., Kostelny, K., & Dubrow, N. (1991). What children can tell us about living in danger. American Psychologist, 46, 376-383. Gendreau, P., & Ross, R. R. (1981). Correctional potency: Treatment and deterrence on trial. In R. Roeoch & R. R. Corrado (Eds.), Evaluation and criminal justice policy. Beverly Hills, CA: Sage. George, W. H., & Marlatt, G. A. (1989). Introduction. In R. Laws, (Ed.), Relapse prevention with sex offenders (pp. 1-31). New York: Guilford Press. Gil, E. (1991). The healing power of play: Working with abused children. New York: Guilford Press. Goldstein, A. P. (1988). New directions in aggression reduction. International Journal of Group Tensions, 18, 286-313. Goldstein, A. P. (1988). The prepare curriculum. Champaign, IL: Research Press. Gorski, T. (1993). Relapse prevention with chemically dependent criminal offenders. Independence, MO: Herald House/Independence Press. Gray, A. S., & Pithers, W. D. (1993). Relapse prevention with sexually aggressive adolescents and children: Expanding treatment and supervision. In H. E. Barbaree, W. L. Marshall, & S. M. Hudson (Eds.), The juvenile sex offender (pp. 289-318). New York: Guilford Press. Greenwald, R. (2000). A trauma-focused individual therapy protocol for adolescents with conduct disorder. International Journal of Offender Therapy and Comparative Criminology, 44, 146-163. Hennessey, K., Rabideau, G., Cicchetti, D., & Cummings, E. M. (1994). Responses of physically abused children to different forms of interadult anger. Child Development, 65, 815-828. Hyer, L. & Brandsma, J. M. (1997). EMDR minus eye movements equals good psychotherapy. Journal of Traumatic Stress, 10, 515-522. Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260. Kilpatrick, D. G. & Resnick, H. S. (1993). PTSD associated with exposure to criminal victimization in clinical and community populations. In J. R. T. Davidson & E. B. Foa (Eds.), Posttraumatic stress disorder: DSM-IV and beyond (pp. 113-143). Washington, DC: American Psychiatric Press. Kilpatrick, D. G., Saunders, B. E., Amick-McMullan, A., Best, C., Veronen, L. J., & Resnick, H. S. (1989). Victim and crime factors associated with the development of crime related post-traumatic stress disorder. Behavioral Therapy, 20, 199-214. Kilpatrick, D. G., Veronen, L. J., & Resick, P. A. (1979). The aftermath of rape: Recent empirical findings. American Journal of Orthopsychiatry, 49, 658-669. Kimble, M. O., Riggs, D. S., & Keane, T. M. (1998). Cognitive behavioural treatment for complicated cases of post-traumatic stress disorder. In N. Tarrier, A. Wells, & J.

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Haddock (Eds.), Treating complex cases: The cognitive behavioral therapy approach. Wiley series in clinical psychology (pp. 105-130). Chichester, England: John Wiley & Sons. Kiser, L. J., Heston, J., Millsap, P. A. & Pruitt, D. B. (1991). Physical and sexual abuse in childhood: Relationship to post-traumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 30 776-783 Knopp, F. H. (1984). Retraining adult sex offenders: Methods and models. Syracuse, NY: Safer Society Press. Laws, R. (1989). Relapse prevention with sex offenders. New York: Guilford Press. Lewis, D. O. (1992). From abuse to violence: Psychophysiological consequences of maltreatment. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 383-391. Loewald, H. (1962). Internalization, separation, mourning and the superego. Psychoanalytic Quarterly, 31, 483-504. Longo-Freeman, R., & Bays, L. (1988). Who am I and why am I in treatment? Brandon, VT: Safer Society Press. Lubin, H., & Johnson, D. R. (1997). Interactional psychoeducational group therapy for traumatized women. International Journal of Group Psychotherapy, 47, 271-290. March, J. S. (1993). What constitutes a stressor? The “Criterion A” issue. In J. R. T. Davidson & E. B. Foa (Eds.), Posttraumatic stress disorder: DSM-IV and beyond (pp. 37-54). Washington, DC: American Psychiatric Press. March, J. S., Amaya-Jackson, L., Murray, M. C., & Schulte, A. (1998). Cognitivebehavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single incident stressor. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 585-593. McFarland, A. C. (1987). Post-traumatic phenomena in a longitudinal study of children following a natural disaster. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 764-769. McMackin, R., Leisen, M. B., Cusack, J., LaFratta, J., & Litwin, P. (2001). The relationship of trauma exposure to sex offending behavior among male juvenile offenders. Manuscript in preparation. McMackin, R., Morrissey, C., Newman, E., Erwin, B., & Daly, M. (1998). Perpetrator and victim: Understanding and managing the traumatized young offender. Corrections Management Quarterly, 2, 35-44. Menninger, C. (1966). The crime of punishment. New York: Viking Press. Minuchin, S., & Guerny, B. G. (1967). Families of the slums. New York: Basic Books. Monroe, J., & Bitman, D. (1997). Understanding PTSD–group manual. Unpublished manuscript. Boston: Boston Veterans Administration Healthcare System. Nadel, J., Spellman, M., Alvarez-Canino, T., Lausell-Bryant, L., & Landsberg, G. (1996). The cycle of violence and victimization: A study of the school-based intervention of a multidisciplinary youth violent-prevention program. American Journal of Preventive Medicine, 12, 109-119. Novaco, R.W., & Chemtob, C.M. (1998). Anger and trauma conceptualization: Assessment and treatment. In V. M. Follette, J. I. Ruzek, & F. R. Abueg (Eds.), Cognitive behavioral treatments of trauma (pp. 162-190). New York: Guilford Press.

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Novey, S. (1955). The role of the superego and ego-ideal in character formation. International Journal of Psychoanalysis, 36, 254-259. Office of Juvenile Justice and Delinquency Prevention. (1997). Effective and promising strategies and programs: Balanced and restorative justice. Washington, DC: Author. Patterson, G. R., DeBaryshe, B. D., & Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44, 329-335. Pelcovitz, D., Kaplan, S., Goldenberg, B., Mandel, F., Lehane, J. & Guarrera, J. (1994). Post-traumatic stress disorder in physically abused adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 305-312. Pynoos, R. S. & Eth, S. (1986). Witness to violence: The child interview. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 306-319. Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E. & Best, C. L. (1993). Prevalence of civilian trauma and posttraumatic stress disorder on a representative sample of women. Journal of Consulting and Clinical Psychology, 61, 984-991. Richters, J. E. (1990). Screening survey of exposure to community violence: Self-report version. Unpublished manuscript. Rockville, MD: National Institute of Mental Health, Child and Adolescent Disorders Research Branch. Saigh, P. A. (1992). The behavioral treatment of child and adolescent posttraumatic stress disorder. Advances in Behavioral Therapy, 14, 247-275. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press. Smith, S., & Thornberry, T. P. (1995). The relationship between childhood maltreatment and adolescent involvement in delinquency. Criminology, 33, 451-481. Stattin, H., & Klackenberg-Larsson, I. (1993). Early language and intelligence development and their relationship to future criminal behavior. Journal of Abnormal Psychology, 102, 369-377. Steiner, H., Garcia, I. G., & Matthews, Z. (1997). Posttraumatic stress disorder in incarcerated juvenile delinquents. Journal of American Academy of Child and Adolescent Psychiatry, 36, 357-365. Sweet, A. (1995). A theoretical perspective on the clinical use of EMDR. The Behavior Therapist, 18, 5-6. Tate, D. C., Reppucci, D. N., & Mulvey, E. P. (1995). Violent juvenile delinquents: Treatment effectiveness and implications for future action. American Psychologist, 50, 777-781. van der Kolk, B. A. (1987). Psychological trauma. Washington, DC: American Psychiatric Press. Walsh. A. (1992). The P > V sign in corrections: Is it a useful diagnostic tool? Criminal Justice and Behavior, 19, 372-383. Weeks, R., & Widom, C. S. (1998). Self-reports of early childhood victimization among incarcerated adult male felons. Journal of Interpersonal Violence, 13, 346-361. Widom, C. S. (1995). Victims of childhood sexual abuse-late criminal consequences. Research in Brief: National Institute of Justice, 3, 1-8. Zigler, E., Taussig, C., & Black K. (1992). Early childhood intervention: A promising preventative for juvenile delinquency. American Psychologist, 47, 997-1006.

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Cognitive Processing Therapy for Incarcerated Adolescents with PTSD Julia Ahrens Lillian Rexford

SUMMARY. Despite increased recognition of trauma’s association with conduct disorders, trauma treatment for the conduct-disordered population has been neglected. This study evaluated the effect of short-term, cognitive processing therapy (CPT) treatment on self-reported symptoms of trauma, such as anxiety, depression, intrusion, avoidance, and numbing. After treatment, the CPT group showed significant declines in these symptoms, while the wait-list control group did not. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Adolescent treatment, cognitive-behavioral therapy, conduct disorder, juvenile delinquency, posttraumatic stress disorder, trauma therapy, treatment, violence

Address correspondence to: Julia Ahrens, PhD, 1125 West Spruce, Olathe, KS, 66061 (E-mail: [email protected]). The authors wish to thank the Topeka Juvenile Correctional Facility and Carrol Mills, PhD, for their aid and support of this project. [Haworth co-indexing entry note]: “Cognitive Processing Therapy for Incarcerated Adolescents with PTSD.” Ahrens, Julia, and Lillian Rexford. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 201-216; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 201-216. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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INTRODUCTION The prevalence of trauma and stress is endemic in our society, yet only recently has the treatment of trauma become a focus of research. Bell and Jenkins (1991), in a review of the literature, reported that the United States surpassed other industrialized nations in violent crimes, including homicides. Furthermore, among African-Americans ages 15-34, homicide is the leading cause of death (Parson, 1994). In a pioneering study, Terr (1983) found that almost 50% of her sample of children displayed trauma symptoms after events ranging from abuse to accidents. Additional examples of trauma in our lives are natural disasters, such as the California earthquakes and floods, and manmade disasters, such as the Oklahoma City bombing, atrocities in Bosnia, and school violence. Exposure to potentially traumatic events is the primary risk factor for developing post-traumatic stress disorder. The diagnosis of PTSD requires a history of one or more traumatic event(s) that triggered fear, helplessness, and horror. In children, these symptoms may include reenactment of the trauma, disorganized or agitated behavior, traumatic play, and frightening dreams (DSM-IV; American Psychiatric Association, 1994). PTSD was initially studied among veterans and the majority of research has been on adults. Studies of combat-related PTSD have consistently shown a significant level of PTSD symptomatology among veterans, using a variety of research methods (Fairbank, Hansen, & Fitterling, 1985; Sutker, Winstead, Goist, Malow, & Allain, 1986; Zeiss, Dickman, & Nichols, 1985). Among adults, both rape and sexual abuse have also been studied using a PTSD formulation (Kilpatrick, Veronen, & Best, 1985; Rychtarik, Silverman, VanLandingham, & Prue, 1984). Until recently, few studies of children and adolescents with PTSD have been conducted, and many have been anecdotal (e.g., Brassard, Tyler, & Kehle, 1983; Rosenfeld, 1976; Saigh, 1987a, 1987b, 1987c). Chemtob and Taylor (in press) found eighty published studies in English of treatment for children and adolescents exposed to trauma. Of these, only one was found to assess for PTSD using DSM-IV (APA, 1994) criteria and to randomly assign participants to treatment and control conditions. CHILDREN AND TRAUMA It is recognized that sexually and physically abused children often meet criteria for PTSD (Deblinger, McLeer, Atkins, Ralphe, & Foa,

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1989; Krener, 1985; McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988). In a study of 121 children referred to a pediatric abuse clinic (Livingston, Lawson, & Jones, 1993), PTSD was not predicted by the type of abuse (sexual vs. physical), but by the intensity and number of other stressors experienced. These findings are consonant with Terr’s (1983) findings described above. Other studies have identified characteristics that are correlated with PTSD. In a study of 90 abused children, the nature and severity of abuse, along with the children’s self-reported feelings of guilt, best predicted PTSD status (Wolfe, Sas, & Wekerle, 1994). Green (1978) found that abused children displayed interpersonal difficulties and a delay in the development of the self. She also pointed out that abused children had symptoms in common with children who were diagnosed with attention deficit disorder (ADD): hyperarousal, hypervigilance, and impulsivity. McLeer, Callaghan, Henry, and Wolfe (1994) found that among sexually abused children there was a significant correlation between PTSD, ADD, and antisocial personality disorder (conduct disorder for those under 18). Many recent surveys have pointed to increased exposure to violence among youth. Chemtob and Taylor (in press) cited prevalence rates of PTSD after exposure to community violence ranging from 27% (exposed to a fatal shooting) to 74% (one year after a sniper attack). Freeman, Mokros, and Poznanski (1993) found that youth who had experienced urban violence were more likely to display depression, low self-esteem, dysphoria, and anxiety. With the increase in violence in urban areas, the associated rise in psychological trauma and PTSD among urban youth merits attention. Trauma may play a role in the violence cycle; those who have a history of trauma due to urban violence, abuse and/or disasters are postulated to be more prone to perpetrate violence (Widom, 1989). Chemtob, Roitblat, Hamada, Carlson, and Twentyman (1988) proposed a self-perpetuating cycle of violence: The expectancy of threat leads to increased acting out and/or numbing. They suggested that the state of hyperalertness often engendered by experiencing trauma predisposes individuals to heightened sensitivity to threat, which is often misperceived in even innocuous stimuli. The resultant acting out, avoidance, or withdrawal can reinforce beliefs that the world is a dangerous place, which becomes a self-fulfilling prophecy of aggression, withdrawal, or vacillation between the two. There are many lines of research suggesting that trauma plays a key role in the development and persistence of antisocial behaviors (Green-

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wald, 2002). Many studies have noted the link between trauma and adolescent acting-out (Carrion & Steiner, 2000; Caufman, Feldman, Waterman & Steiner, 1998; Rivera & Widom, 1990; Steiner, Garcia & Matthews, 1997). Furthermore, incarcerated adolescents diagnosed with conduct disorder have symptom profiles similar to adolescents in residential treatment who meet criteria for PTSD (Shamsie, Hamilton, & Sykes, 1996). It is likely that children exposed to violence, who historically have had few resources and supports, are prone to developing acting-out behaviors and becoming involved in the correctional system. TREATMENT OF ADULT PTSD Because PTSD often manifests itself in emotional and behavioral dysregulation and is often associated with antisocial behavior, it produces costs ranging from human suffering to increased tax burdens on citizens. Thus, treatment issues are of particular concern. The treatment of PTSD falls into two broad categories: direct therapeutic exposure and coping skills training (Fairbank & Brown, 1987). Each of these treatment approaches makes certain assumptions about the nature of PTSD. Therapies that rely on direct therapeutic exposure often view PTSD as a learned response via a classical conditioning two-factor model (Mowrer, 1960). Thus, a previously neutral stimulus is paired with a stress-inducing stimulus (unconditioned stimulus [UCS]) and becomes a conditioned stimulus (CS). The conditioned stimuli become associated with negative emotional, physiological, and cognitive reactions, are then avoided, and this avoidance becomes a hallmark of PTSD. Treatment based on this model often uses relaxation training followed by flooding (repeated exposures to the traumatic stimuli) to extinguish the response. Early studies utilized this model effectively with Vietnam veterans (Black & Keane, 1982; Fairbank, Gross, & Keane 1983; Fairbank & Keane, 1982). This model has been criticized on several fronts. First, it does not allow for the possible effects of cognitive mediation of the trauma (Saigh, 1985). Second, it has been suggested that differing interventions are suited to specific traumatic events. For example, Courtois (1988) has suggested that, for survivors of sexual traumas, exposure therapy is contraindicated since it may recreate feelings of powerlessness and lack of control. Third, Kilpatrick and Best (1984) question the use of implo-

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sion or flooding techniques because the therapist may become the conditioned stimulus for anxiety. Additional difficulties associated with these techniques are the distress engendered in the participants and the related high dropout rate from treatment. Coping skills training is linked to an information-processing model of PTSD, which is based on Lang’s (1977) model. Lang proposed that information is stored in a fear network that includes stimuli, responses, and the meanings of these two elements. Beck and Emery (1985) elaborated on this theory by suggesting that fear reactions arise from appraisals of threat. Fear appraisal is based on the reactivation of a pre-existing (trauma-induced) cognitive schema, which disposes the person to attend to evidence that is consistent with the schema and discount evidence that is inconsistent. Therefore, even ambiguous stimuli can be interpreted to signal threat and fear responses. Support for this theory has been offered by Wong and Weiner (1981), who found that automatic searches and pervasive negative attributions were most frequent when an event was negative and unexpected, as in the case of PTSD. McCann, Sakheim, and Abrahamson (1988) proposed that five areas of attribution are affected by victimization: safety, trust, power, esteem, and intimacy. Foa and Kozak (1986) proposed that two conditions are necessary for the disempowering of fear structures in an information-processing model. First, the fear must be activated, and second, new information that is incompatible with the current fear structure must be provided. They suggest that activation of the memory can occur through any of the three network elements: (1) information about the stimuli, (2) responses to the stimuli, and (3) meanings of the stimuli. Resick and Schnicke (1992) tested Foa and Kozak’s (1986) theory of fear structure dismantling utilizing 19 sexual assault survivors, comparing participants’ PTSD symptomatology and level of depression with a control group. They found significant improvement in symptoms among the treated group. Resick and Schnicke developed a treatment called cognitive processing therapy (CPT), consisting of three components: (1) education about PTSD symptoms and information processing theory, (2) exposure, and (3) cognitive therapy. The first portion was didactic and included differentiation of feelings from thoughts and a discussion of information processing theory. The second component, exposure, utilized a less threatening technique than imagery: writing and reading an account of the trauma. The cognitive component consisted of training in the identification of thoughts and affect, challeng-

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ing maladaptive beliefs, and specific sessions for each of the five areas of beliefs: safety, trust, power, esteem and intimacy. TREATMENT OF CHILD/ADOLESCENT PTSD Though there have been attempts to test the efficacy of treatment for children and adolescents with PTSD, few rigorous studies have been conducted. However, Deblinger, Lippman, and Steer (1996) used a cognitive-behavioral approach to treat children (ages 7-13) displaying PTSD symptomatology. Using random assignment to groups and standardized measures, they tested the efficacy of 12-session treatment with 100 sexually abused children referred from community sources. The majority (71%) had a diagnosis of PTSD, and children were randomly assigned to child-only, parent-only, or parent-child treatment. The treatment conditions consisted of teaching coping skills, gradual exposure, and prevention/behavior management skills. These treatments were compared to a community control condition. Measures of anxiety, depression, general symptomatology, PTSD, and parenting practices were taken at two times during treatment. Significant decreases in depression and externalizing symptoms along with improved parenting skills were found in the child-only and parent-child conditions. In a similar study by March, Amaya-Jackson, Murray and Schulte (1998) 14 children (ages 10-16) were treated with cognitive-behavioral psychotherapy after a single incident stressor. Measures of PTSD, depression and anger were taken pre- and post-treatment. After 18 weeks of treatment, approximately 57% of the sample did not meet PTSD criteria; at six-month follow-up about 85% of the sample did not. Levels of depression, anxiety and anger also decreased after treatment. RATIONALE Recently, adolescents experiencing post-traumatic symptoms have garnered more attention (Carrion & Steiner, 2000; Cauffman et al., 1998; Costello et al., 1998). Because PTSD is so debilitating, including costs to the family, society and individual, treatments to address these costs are important. This is of particular concern in the juvenile delinquent population, where PTSD is rampant and may make a significant contribution to the delinquent behavior.

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This study attempted to assess the treatment efficacy of Cognitive Processing Therapy (Resick & Schnicke, 1992) for traumatized adolescent males meeting diagnostic criteria for PTSD. The present study compared CPT treatment with a group of wait-list control subjects. It was predicted that adolescents who received short-term (8 sessions) CPT treatment (exposure and cognitive restructuring) would show fewer symptoms of post-traumatic stress and depression than those who were on a waiting list (controls). SUBJECTS Participants were 38 adolescent males, ages 15-18 (mean = 16.4), incarcerated in a youth facility for adolescent offenders. The sample was ethnically diverse (African American = 10, Caucasian = 23, Hispanic = 2, Native American = 2, Other = 1). As part of admission procedures to the study, youths were assessed by staff psychologists via clinical interview and checklists to determine if they met DSM-IV (APA, 1994) criteria for PTSD. Those identified as meeting the criteria were randomly assigned to two conditions (wait-list n = 19 or CPT n = 19). Interview data indicated that about one-third of the youths had experienced multiple traumas (n = 11, 29%), and over half had documented trauma histories (n = 26 or 68%, as documented in their charts from collateral sources ranging from Social Rehabilitation Service investigations, child protective services reports, hospital reports, etc.). Half of the sample (n = 19) was incarcerated due to assault charges, while the remaining were charged with various crimes including burglary, theft, drug charges, etc. According to interview data, many had seen someone they knew die (often in gang violence; n = 12). Additionally, over half of participants (n = 20, 52%) stated that they had experienced a head injury that had led to a loss of consciousness, and over one-third stated that they had been diagnosed with ADD or ADHD in the past (n = 15, 40%). Many also admitted to histories of substance use and abuse including alcohol, marijuana, cocaine, heroin and other drugs. THERAPISTS AND GROUPS Therapy was conducted by a female doctoral candidate and a female psychologist employed at the facility who co-led the groups (the former had six years of treatment experience while the latter had nine years of

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experience including correctional settings). Treatment was provided according to protocol outlined in the CPT treatment manual (Resick & Schnicke, 1993). Measurements were taken immediately before and four weeks after treatment (at 0 and 12 weeks, respectively). The participants in the wait-list control group received CPT treatment after waitlist measures had been taken at weeks 0 and 12; however, measures collected from the control group after wait-list were not included in the analysis. INSTRUMENTS Levels of depression and PTSD symptomatology were assessed via self-report inventories twice: at week 0 and week 12. At the outset of treatment, it was postulated that those who met criteria for PTSD might be relatively older individuals incarcerated for more serious offenses and thus would have a higher likelihood of a traumatic history. Pilot data suggested that the age of participants would average 18 and older (these were individuals who had the most serious offenses and were incarcerated until age 21). Thus, adult forms of the instruments were selected. Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961). The BDI is a 21-item self-report measure that has been widely used in research on depression (Beck, Steer, & Garbin, 1988) and has been used effectively with PTSD populations (Foa, Rothbaum, Riggs, & Murdock, 1991; Resick & Schnicke, 1992). Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979). The IES is a 15-item scale that has two subscales: Intrusion and Avoidance. For the purposes of this study, scores on the subscales were combined. Arata, Saunders, and Kilpatrick (1991) found the IES to correctly classify 84% of respondents with PTSD. PTSD Symptom Scale Self-Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum,1993). This 17-item scale has three subscales measuring avoidance, intrusion, and arousal, which were combined for this study. Using a structured diagnostic interview as the criterion, Foa et al. (1993) found the PSS-SR to correctly identify the PTSD status of 86% of participants in one study. The authors point out that the self-report scale yields a slightly more conservative diagnosis of PTSD than does the interview version.

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PROCEDURE CPT was conducted using the procedure outlined by Resick and Schnicke (1993). CPT consisted of eight sixty-minute sessions. Participants learned about the symptoms of PTSD, did exercises distinguishing thoughts and feelings, examined thoughts that they had associated with the trauma, and wrote a narrative describing the trauma. At the first session, an information-processing model of PTSD was presented, and participants were asked to describe the model in their own words. At the second session, clients worked on A-B-Cs (Antecedents, Beliefs, and Consequences) in order to begin to separate thoughts and feelings, and they were given homework sheets to fill out throughout the week to practice the A-B-Cs. These two sessions comprised the education component. For the next two sessions, the participants were asked to share written or taped narratives of the trauma experience(s), including their own thoughts and feelings at the time. When they wrote the account, they were asked to be as detailed as possible about thoughts and feelings they were experiencing at the time of the trauma and afterwards. These sessions were the exposure portion of treatment. The homework assignments were utilized to identify maladaptive beliefs, troubling memories, and expectations related to the memories and help overcome them. Starting with the fifth session, CPT clients were taught to identify and challenge their own maladaptive beliefs. The clients were given a list of thoughts that cause problems (adapted from Beck & Emery, 1985) and each client identified ways in which he used maladaptive thinking. In addition, each participant was given a “challenging beliefs” worksheet, a more elaborate form of the A-B-C worksheet, which included challenging questions and exercises to examine faulty thinking patterns (also adapted from Beck & Emery, 1985). On the basis of work by McCann et al. (1988), five themes that are likely to have been affected by the trauma (safety, trust, power, esteem and intimacy) were introduced. At the sixth session, the first two (safety and trust) of five areas of belief were addressed. In week seven, the final three themes (power, esteem and intimacy) were discussed. These areas were addressed in modules sequentially by the participants, and homework assignments with worksheets were given. Participants were encouraged to examine their own beliefs and how each of the five areas of belief areas was affected by the trauma. Finally, suggestions for alternative self and other statements were generated.

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The final session was used to summarize the participants’ beliefs about the trauma, to discuss the client’s narrative, discuss goals for the future, and say goodbye. Throughout the therapy, it was emphasized that treatment would continue after the eighth session by the client practicing the skills he had learned. (For more information about conducting CPT, the reader is referred to Resick and Schnicke, [1993].) ANALYSES Repeated measures analyses were conducted on the CPT group to assess changes over time. Specifically, two by two multivariate analyses of variance (MANOVAs) were conducted: occasion (pretreatment, follow-up) by treatment (CPT, wait-list), with occasion as a repeated measure. The dependent variables were subscales of the PSS-SR, IES and the BDI. Then two by two ANOVAS were conducted to assess simple effects. RESULTS Results of the MANOVA indicated that there were significant changes over time in reported symptomatology (Wilk’s Lambda = .78, F (3, 31) = 2.83, p = .05). Power was estimated to be .62. There also was a significant group by time effect (Wilk’s Lambda = .67, F (1, 25) = 4.90, p = .007. Univariate homogeneity of variance tests for each of the scales were not significant. Follow-up univariate analyses were conducted separately for each dependent variable. To control for type one error, alpha was set at .02 for each ANOVA (.05/3). The ANOVA for the PSS-SR was found to be significant, F (1, 36) = 19.44, p = .0001.The ANOVA for the IES measure was significant, F (1, 36) = 20.49, p = .0001, as was the Beck Depression Inventory, F (1, 36) = 17.95, p = .002. Levels of depression were in the borderline clinical depression range before treatment in both groups. After CPT treatment, BDI scores were in the normal range, while those in the wait-list control condition remained at pre-test levels. IES scores were in the moderate range before treatment; scores for the CPT group fell to the mild range at post-test, while scores for the wait-list group remained in the moderate range. Treatment group scores on the PSS-SR fell by over 50%. Thus, it appeared that measures of

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trauma symptoms and depression decreased significantly over time (see Table 1). DISCUSSION The characteristics of this sample were consistent with expectations based on prior research. Many of these adolescents, incarcerated for a variety of offenses (including person and property crimes) had a history of trauma and met criteria for posttraumatic stress disorder. Of note, too, is that many in this sample had comorbid disorders, including previously diagnosed ADHD and a history of head trauma. Most also had experienced multiple traumas in spite of their relatively young age. Thus, there is a reasonable likelihood that this severely challenged population TABLE 1 Means and Standard Deviations for PSS-SR by Treatment Group Pre Test X

Follow Up SD

X

SD

CPT

16.89

10.49

7.82

10.00

CONTROL

19.36

10.12

20.38

10.46

Means and Standard Deviations for IES by Treatment Group Pre Test

Follow Up

X

SD

CPT

35.52

11.80

23.41

6.88

CONTROL

33.42

8.70

33.50

6.29

X

SD

Means and Standard Deviations for BDI by Treatment Group Pre Test

Follow Up

X

SD

CPT

15.26

12.10

6.88

7.14

CONTROL

18.52

9.97

17.94

8.22

X

SD

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may be representative of a significant subset of incarcerated juvenile delinquents. There are several methodological limitations that may affect the interpretation of the study’s findings. First, the treatment groups were rather small and findings may not be generalizable. Second, the prevalence of comorbid diagnoses along with PTSD among this population may have complicated the treatment process, making brief therapy modes less effective. Third, the outcome measures (self-report questionnaires) may not provide a sensitive enough measure of the effects of treatment among this population. This is further complicated by the utilization of adult measures, which may have reduced validity for the slightly younger-than-expected sample. Finally, the fact that the principal investigator provided treatment may have introduced experimental bias effects. Although cognitive and supportive approaches have been used successfully with adults suffering from PTSD (e.g., veterans, rape victims, abuse victims) these approaches have been rarely used with incarcerated adolescents. Similarly, although cognitive-behavioral approaches have been successful with incarcerated adolescents (e.g., Goldstein, Glick, Irwin, McCartney, & Rubama, 1989), treatment has focused on impulse and anger control and problem-solving skills. The virtual absence of research on the effect of treatment of PTSD with incarcerated adolescents provides little context in which to interpret the results. In this study, a cognitive processing model that was structured and contained cognitive and narrative components lessened self-reported levels of depression and trauma related symptoms (intrusion, avoidance, and hypervigilance) as measured four weeks post CPT treatment. Additionally, participants spontaneously reported that they were helped by the groups in expressing their feelings more effectively in their day-to-day lives. Several also volunteered to participate in further treatment, even though groups coincided with a weekly swimming/basketball recreation time. This range of positive responses to the treatment indicates the value of further study. The present findings would be strengthened by the addition of a non-specific treatment condition to assess the effects of attention and expectancy on results. Also, the addition of behavioral measures assessing in-program behavior, time to release, and recidivism rate can provide a more comprehensive picture of the effect of Cognitive Processing Therapy for juvenile delinquents with PTSD.

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Wong, P. T., & Weiner, B. (1981). When people ask “why” questions and the heuristics of attributional research. Journal of Personality and Social Psychology, 40, 650-663. Zeiss, R. A., Dickman, H. R., & Nichols, B. L. (1985, August). Posttraumatic stress disorder in former prisoners of war: Incidence and correlates. Paper presented at the 93rd annual meeting of the American Psychological Association, Los Angeles.

A Controlled Study of Eye Movement Desensitization and Reprocessing (EMDR) for Boys with Conduct Problems Glenn B. Soberman Ricky Greenwald David L. Rule

SUMMARY. We suggest that trauma contributes to the development and persistence of conduct problems, and should be addressed. Eye movement desensitization and reprocessing (EMDR) was selected as a promising trauma treatment. Twenty-nine boys with conduct problems in residential or day treatment were randomized into standard care or standard care plus 3 trauma-focused EMDR sessions. The EMDR group showed large and significant reduction of memory-related distress, as well as trends towards reduction of post-traumatic symptoms. The EMDR group also showed large and significant reduction of problem behaviors by 2-month follow-up, whereas the control group showed only slight improvement. These findings provide support for EMDR’s use as a trauma treatment for boys ages 10-16, as well as support for the hyAddress correspondence to: Glenn B. Soberman, PhD, P.O. Box 744, Wallkill, NY 12589 USA (E-mail: [email protected]). [Haworth co-indexing entry note]: “A Controlled Study of Eye Movement Desensitization and Reprocessing (EMDR) for Boys with Conduct Problems.” Soberman, Glenn B., Ricky Greenwald, and David L. Rule. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 217-236; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 217-236. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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pothesis that effective trauma treatment can lead to reduced conduct problems in this population. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Trauma, PTSD, adolescent, therapy, oppositional defiant disorder, conduct disorder, antisocial

Conduct problems (CP) include a broad range of activities, such as disruptive, oppositional, aggressive, and/or criminal behavior, as well as non-compliance with normal community, school, and home expectations. Conduct problems have been studied under a variety of terminologies including: externalizing behaviors, acting out, aggression, oppositional defiant disorder, conduct problems, conduct disorder, delinquency, and antisocial behavior. Such behaviors constitute the basis of one-third to one-half of all child and adolescent clinical referrals (see Kazdin, 1987), and are consistently identified as potential precursors (or contributors) to a range of serious problems, such as conduct disorder and juvenile delinquency (Loeber, 1990; Pakiz, Reinherz, & Giaconia, 1997). Although the various diagnostic distinctions may be valid, there seems to be general agreement regarding shared features across categories; for example, oppositional defiant disorder is often a developmental precursor to conduct disorder, the latter diagnosis being highly predictive of delinquency (Hinshaw, Lahey, & Hart, 1993). We now know a lot about risk factors for the development of conduct disorder–the severe extreme of the CP spectrum. These risk factors include: temperament, gender, low intelligence, ADHD, impulsivity, poor coping skills, social failure, parental psychopathology, inappropriate discipline, affiliation with deviant peers, and socioeconomic disadvantage (see Kazdin, 1995; Moffitt, 1993; Patterson, DeBaryshe, & Ramsey, 1989). We address these factors with a variety of treatment approaches, and help some youth to be successful in socially acceptable ways. Unfortunately, there is as yet no consistently effective treatment for adolescents with conduct disorder; even preferred approaches yield only modest results (Kazdin, 1997b). This may be explained, at least in part, by our failure to address the trauma component. There are several bodies of literature that, together, provide convincing support for the proposition that trauma plays a key role in CP. Since

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(a) violence begets violence, (b) CP youth have high rates of both trauma history and trauma symptoms, and (c) trauma leads to many cardinal features of CP, a causal relationship between trauma exposure and CP can reasonably be hypothesized (see Greenwald, 2002b, for a detailed discussion). One way to test this proposition is by directly treating the traumatic memories of individuals with CP to see if their CP symptoms diminish. We selected eye movement desensitization and reprocessing (EMDR) (Shapiro, 1995) as a promising trauma treatment. Direct comparisons to other recommended treatments have shown EMDR to be at least equal in effect and considerably more efficient (e.g., Ironson, Freund, Strauss, & Williams, in press; Lee, Gavriel, Drummond, Richards, & Greenwald, in press; McFarlane, 2000; Power, McGoldrick, & Brown, 2000; Rogers et al., 1999; Vaughan et al., 1994) in all but one study (Devilly & Spence, 1999). EMDR’s efficacy in trauma treatment is supported by numerous controlled studies and has gained mainstream acceptance (Chambless et al., 1998; Chemtob, Tolin, van der Kolk, & Pitman, 2000). Available data on EMDR with traumatized children and adolescents, including several controlled studies (e.g., Chemtob, Nakashima, Hamada, & Carlson, in press; Puffer, Greenwald, & Elrod, 1998), suggest similar effect across age groups (see Greenwald, 1998). Several studies have more direct relevance to the CP population, for example, Greenwald (2000) anecdotally described the treatment of two incarcerated adolescent boys, in which a trauma-focused treatment approach (including EMDR) apparently led to reduction of anger, acting-out, and other conduct disorder-related symptoms. Greenwald (2002a) also used this treatment in an open trial with six adolescents with conduct and school-related problems, and consistently found reduced post-traumatic symptoms, reduced problem behaviors, and improved school performance. Datta and Wallace (1996) used three EMDR sessions to treat the traumatic memories of 10 incarcerated adolescent sex offenders, and found increased empathy, improved functioning in many areas, and even spontaneous attempts at victim restitution. Scheck, Schaeffer, and Gillette (1998) compared two trauma-focused sessions of EMDR with Active Listening (AL) in a community sample of high-risk acting-out adolescent girls (n = 18) and young women (n = 42). They found, at both post-treatment and 3-month follow-up, that scores on every measure had moved to the normative range for the EMDR group, whereas the more limited post-treatment gains in the AL group deteriorated nearly to baseline by follow-up.

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EMDR’s brief history has been marked by controversy. Early debate focused on efficacy, with several poorly conducted studies contaminating the database and complicating the discussion (see Greenwald, 1996a). Numerous analyses have confirmed that the studies in which a high degree of treatment fidelity (adherence to the protocol) was maintained, consistently show EMDR to be efficacious, whereas the studies with questionable or poor treatment fidelity have much more equivocal findings (Feske, 1998; Greenwald, 1996a; Lee, Gavriel, & Richards, 1996; Maxfield & Hyer, in press; Shapiro, 1996). Now that EMDR’s efficacy in treating trauma has been well documented (Maxfield, 1999; van Etten & Taylor, 1998), the focus of the debate has shifted to mechanisms of effect and the possible role of the various components. EMDR is a complex method that systematically incorporates essential components of other successful trauma treatments (Hyer & Brandsma, 1997; Sweet, 1995) with unique elements. To oversimplify, the method involves having the client concentrate intensely on the most upsetting part of the traumatic memory while moving his/her eyes from side to side (by following the therapist’s moving hand or other object), at the rate of approximately one round trip per second, for a variable duration of approximately 20-60 seconds. Following a set of eye movements, the client is asked to report whatever came to awareness; this commonly includes changes in imagery, thought, emotion, or physical sensation related to the trauma. This report becomes the focus of the next set of eye movements. For example, if the client reports feeling more anger, the therapist may ask the client to concentrate on that feeling for the next set. This procedure is repeated until the client can identify no further distressing elements of the memory and can embrace a more positive or adaptive perspective regarding the memory. For full effect, related memories may also require similar treatment, as more than one traumatic memory may be driving the presenting symptoms. Although formal training is required for safe and effective practice (Greenwald, 1996a), detailed procedural information is widely available (Shapiro, 1995). A possible disadvantage of EMDR is that some therapists may have difficulty performing it adequately, even following what has been considered standard training (Greenwald, 1996a, 1997). Now a post-training period of supervised practice has been additionally designated as essential to competent practice (EMDR International Association, 1999). Furthermore, EMDR, like any treatment that involves focusing on traumatic memory, can be challenging for the client. Although most EMDR-trained therapists prefer EMDR and believe that it involves

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fewer risks than other trauma treatments (Lipke, 1992), it is an intensive method that requires clinical skill and judgment. Finally, it should be understood that in clinical practice, EMDR is not typically offered in place of psychotherapy, but is provided on a case-by-case basis as one intervention within the context of an overall treatment plan (Shapiro, 1995). We had three goals in the present study. First, we wanted to see if we could replicate previous findings regarding EMDR’s efficacy as a trauma treatment for children and adolescents, and second, to extend those findings to a CP population. Although the contribution of trauma to CP seems likely to be substantial, to the best of our knowledge this relationship has not been directly tested in a controlled study by applying an effective trauma treatment and then measuring behavioral outcomes. Our third goal was to test the hypothesis that successful trauma treatment–as indicated by reduction in trauma-related distress–would lead to a reduction in CP symptoms. METHOD Participants Participants were 29 boys ages 10-16 with acting out behaviors who were placed in either a residential or day treatment program at the same facility. Program intake procedures included comprehensive evaluations by both a psychologist and a psychiatrist. Primary diagnoses included Conduct Disorder (59%) as well as Post-Traumatic Stress Disorder (31%), Attention Deficit Hyperactive Disorder (17%), Learning Disability (14%), Substance Abuse (13%), and Oppositional/Defiant Disorder (3%). Consent was sought from all 80 of the facility’s clients (and parents/guardians), but was obtained from only 32. Exclusion criteria included psychosis, suicidal or homicidal ideation, epilepsy, medical instability, low motivation to participate (3 or lower on a 0-10 scale), or inability to identify a sufficiently traumatic memory (rating of 4 or higher on the 0-10 SUDS, see below). No consenting participants had to be excluded. The only incentive offered was a certificate of completion. With an attrition of three, the sample was reduced to 29 youths, with 14 participants in the experimental group and 15 in the control group. For the follow-up, only 23 participants were included because the rest had been discharged and were no longer available.

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Measures Subjective Units of Distress Scale (SUDS) The SUDS (adapted from Wolpe, as described in Shapiro, 1995) measures intensity of subjective distress in response to a particular stimulus, such as a traumatic memory. It is a widely used measure that has been shown to correlate with several physiological measures of stress (Thyer, Papsdorf, Davis, & Vallecorsa, 1984; Wilson, Silver, Covi, & Foster, 1996). Non-reactivity to a traumatic memory is considered a primary indicator of recovery (Horowitz, 1986). This 11-point scale uses 10 as the highest level of distress and 0 as the lowest level, or absence of distress. Impact of Events Scale-8 Items (IES-8) The Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979) is a widely used measure of avoidance and intrusion (post-traumatic stress) symptoms associated with a specific, identified past trauma. The scale has demonstrated construct validity and adequate reliability with children and adolescents (Dyregrov, Kuterovac, & Barath, 1996). A subset of 8 items appears to identify children and adolescents with severe post-traumatic symptoms more efficiently than the full scale (Dyregrov & Yule, 1995). The items offer four levels of endorsement, with weighted scores (0, 1, 3, 5) for a total possible range of 0-40, with 17 or over indicating a clinically significant stress reaction. Child Report of Post-Traumatic Symptoms (CROPS) The CROPS is a 25-item self-report questionnaire covering the broad spectrum of post-traumatic symptoms found in traumatized children (Fletcher, 1993) as well as symptoms of child/adolescent PTSD listed in the DSM-IV (American Psychiatric Association, 1994). The respondent is asked to endorse current symptoms on a 0-2 scale of intensity (none, some, or lots). Total scores range from 0-50, with a score of 19 or above indicating clinical concern. Preliminary studies indicate that the CROPS has excellent internal consistency, good test-retest reliability, and also has documented criterion validity and convergent/discriminant validity (Greenwald & Rubin, 1999; Wiedemann & Greenwald, 2000).

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Parent Report of Post-Traumatic Symptoms (PROPS) The PROPS is a 30-item companion measure to the CROPS, also a broad-spectrum measure with similar validity and reliability to the CROPS (Greenwald & Rubin, 1999; Wiedemann & Greenwald, 2000), with the limitation that the studies have all been with parents or parent figures, not residential staff. An adult who is familiar with the child’s behavior must fill it out, in this case, the parents of the day treatment participants and the direct care staff of those in the residential program. The respondent is asked to endorse current symptoms on a 0-2 scale of intensity, with total scores ranging from 0-60, with a score of 16 or above indicating clinical concern. Problem Rating Scale (PRS) The PRS (Greenwald, 1996b) is an individualized 3-item parent (or caretaker) report scale covering the parent’s primary concerns regarding the child. With interviewer guidance, the parent identifies the child’s major problems and provides a 0-10 rating of current severity, with 10 being the most severe and 0 representing no problem. This method of quantifying the primary presenting complaints is an inverse variant of the Goal Attainment Scale, which has documented validity and adequate to excellent reliability depending on the sample studied (Emmerson & Neely, 1988). The PRS has been used successfully to track treatment progress (Greenwald, 1994, 2002a). Behavioral Reward Scale (BRS) Both the residential and day treatment programs administer a daily rating of numerous desired and undesired behaviors, allowing the clients to earn privileges according to their level of performance. The BRS represents a uniform, system-wide aggregate rating of the participants’ overall behavior on a daily basis within the program. Treatment All participants were given the same milieu treatment, including weekly individual psychotherapy (provided primarily by Master’slevel therapists), weekly group psychotherapy, special education services, a behavior modification point system, and, on an individual basis as needed, medication and/or psychoeducational parent/family coun-

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seling. All participants went through the screening session, which covered possible exclusion criteria, as well as the rationale for the experimental treatment: that unresolved trauma can cause stress buildup and reactivity, which may drive acting-out behaviors. The only differential treatment between groups was the addition of three EMDR sessions for the experimental group. The EMDR treatment followed the procedures outlined by Shapiro (1995) along with selected population-specific variations suggested by Greenwald (1999). For example, children and adolescents may not be pressed to provide as much memory detail as the standard protocol dictates, because they may have a hard time articulating such details, and may become frustrated and impatient in their attempt. They also seem to require eye movement sets of shorter duration than adults. In this study, following any incomplete sessions (SUDS > 0), the participant was directed to visualize (during eye movements) packing the memory into a container of his choice; this was intended to reduce the risk of post-session volatility. At the end of the final session, each EMDR participant was directed to visualize (during eye movements) an image representing a positive long-term personal outcome; this was intended to instill motivation for behavioral change. The therapist providing the EMDR treatment was a pre-doctoral psychology intern with 10 years of Master’s-level psychotherapy experience. He had undergone the complete EMDR training (Levels 1 and 2 from the EMDR Institute) four years prior to the study, and had already used EMDR in approximately 100 sessions. Procedures Following the consent and screening procedures, participants were randomly assigned to experimental or control groups after being matched to ensure equivalence on age, type of treatment program (residential versus day), length of time in the program, use of medication, and the social worker’s rating of level of family involvement (low, medium, or high). The first author (GS) provided three weekly 1-hour EMDR sessions to participants in the experimental group. For those participants in the EMDR group who felt they had completely resolved the designated trauma prior to the end of the third session, one or more additional traumatic memories were selected and addressed until three sessions were completed. The SUDS was used differentially for the two groups, because it served additionally as a process measure during the EMDR treatment.

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Also, the SUDS was only administered at the first two assessment intervals. Otherwise, all measures were administered according to the same schedule and procedures for all participants, at three intervals: one week pre-treatment, one week post-treatment, and two months post-treatment. The self-report scales (SUDS, CROPS, IES) were administered by the first author (GS). The parent (or care staff) report scales (PROPS, PRS) were completed by the parents of participants in day treatment, and by the care staff of participants in the residential program. For each participant, the same respondent completed the forms on each occasion. The BRS was derived from archival program data completed routinely by staff; this measure was taken at two weeks pre-treatment, two weeks post-treatment, and two months post-treatment. Because only the first author and the participants themselves were aware of group membership, all assessment was blind except for the self-reports. Following the final assessment, participants in the control group were offered the opportunity for EMDR treatment. Although all participants had expressed willingness to participate regardless of group assignment, only one participant from the control group requested the EMDR treatment when it was offered. RESULTS There were no significant group differences at pre-treatment in age, ethnicity, diagnosis, use of medication, placement in day versus residential treatment, length of stay, or level of family involvement. There were also no significant group differences at pre-treatment assessment on any of the outcome measures. Separate analyses were performed for the pre- to post-treatment mean change scores on each measure (see Table 1), and for the pre-treatment to follow-up mean change scores (see Table 2). In each analysis, MANOVA was used for the four trauma symptom measures (SUDS, IES, PROPS, CROPS), and independent t-tests were used for each of the behavioral measures (BRS, PRS). Only two results reached statistical significance. From pre- to posttreatment, the EMDR group’s mean SUDS score dropped 6.1 points, compared to the control group’s drop of only 0.38 points, p = .0001. At two-month follow-up, the EMDR group’s mean PRS score dropped 8.7 points, compared to the control group’s drop of only 2.6 points, p = .024. Since both the SUDS and the PRS are scored from 0-10, these reductions clearly represent substantial changes. The IES went from clini-

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TABLE 1. Pre/Post-Test Change Score Means–MANOVA and t-Test Results Group Dependent Variable PROPS

Descriptive Statistics Mean SD

CROPS

Mean SD

IES SUDS

⫺5.40

.73

3.95

7.70

⫺4.00

⫺3.36

4.62

6.20

Inferential Statistic F (1,19) = 5.10

p = .036 F (1,19) = .07

p = .794

Mean

⫺5.50

⫺5.73

F (1,19) = .002

10.20

12.39

p = .964

Mean

⫺6.10

⫺1.79

.38

2.11

p = .0001*

.14 (n = 11)

t = .868 ++

2.06

p = .168

⫺2.50 (n = 14)

t = ⫺.558

6.00

p = .291

Mean SD

PRS

Control (n = 11)

SD SD BRS

Treatment (n = 10)

Mean SD

.78 (n = 9) .87 ⫺3.92 (n = 13) 7.22

F (1,19) = 44.30

++ Unequal variance estimate used * Statistically significant

cal to non-clinical levels in both groups, with a trend favoring EMDR at follow-up. Other results include some trends favoring EMDR, with none favoring the control group (see Figure 1). DISCUSSION These findings answer the research questions tentatively but affirmatively: EMDR did work for these boys with CP in reducing reactivity to treated traumatic memories; and treating traumatic memories with EMDR did lead to reduced CP symptoms. This study’s strengths include: random assignment, use of a therapist with full EMDR training and substantial experience in the method, blind independent assessment for most measures, and multiple assessment methods and sources of information. However, some features of this study may limit internal validity, and there were some puzzling findings as well. Treatment fidelity has been identified as a critical feature of controlled studies, both in general (Foa & Meadows, 1997), and specifi-

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TABLE 2. Pre-Test–2-Month Change Score Results Group Dependent Variable

Descriptive Statistics

IES Mean (2-month Change) SD CROPS Mean (2-month Change) SD PROPS Mean (2-month Change) SD PRS Mean (2-month Change) SD BRS Mean (2-month Change) SD

Treatment ⫺12.83 (n = 12) 8.10 ⫺8.83 (n = 12) 11.01 ⫺2.33 (n = 9) 8.54 ⫺8.7 (n = 10) 6.99 1.36 (n = 7) 1.18

Control ⫺6.78 8.14 ⫺4.00 (n = 11) 7.68 ⫺2.00 (n = 9) 4.85 ⫺2.57 (n = 7) 2.99 .21 (n = 7) 1.29

Inferential Statistic +

t = ⫺1.69 p = .054 t = ⫺1.21 p = .120 t = ⫺1.02 p = .460 t = ⫺2.17 p = .024* t = 1.73 p = .054

+ Statistics are one-tailed tests unless otherwise noted * Statistically significant

cally regarding EMDR (Greenwald, 1996a; Maxfield & Hyer, in press). In this study, the therapist’s EMDR training and experience argue in favor of the assumption of treatment fidelity, but unfortunately, no independent assessment of fidelity was available. A related limitation of this study was the use of a single EMDR therapist, making it difficult to distinguish the effect of this therapist’s skill from the specific effect of the treatment under study. Limited resources led to some assessment shortcuts that weaken the study. For example, the trauma history of participants was not systematically evaluated, so there is no way to be sure that the groups were equivalent on that dimension (although the initial equivalency on post-traumatic symptom measures suggests equivalency of trauma history). Also, the principal investigator directly administered the self-report measures, precluding blindness in that instance. This was somewhat mitigated by the fact that the measures were completed with paper-and-pencil rather than interview (except for the SUDS), reducing the potential for experimenter influence. An additional assessment problem was the differen-

TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

FIGURE 1 IES Treatment vs. Control

Raw Score

25 20 15

Treatment

10

Control

5 0 Pre-Test

Post-Test 2 Month

Time

CROPS Treatment vs. Control

25

Raw Score

228

20 15

Treatment

10

Control

5 0 Pre-Test

Post-Test 2 Month

Time

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FIGURE 1 (continued) P R O P S Tr e a t m e n t v s . C o n t r o l

Raw Score

25 20 15

Treatment

10 Control 5 0

Pre-Test

Post-Test 2 Month Time

PRS Treatment vs. Control

Raw Score

25 20 15

Treatment Control

10 5 0 Pre-Test

Post-Test 2 Month Time

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tial administration of the SUDS, which was used as a process measure during EMDR treatment, in addition to its use in the standardized assessment. It is not known what effect this repeated administration for the experimental group might have had, if any. There is no evidence of experimenter influence, in that results were generally consistent with expectations (based on the literature) across measures. Still, blind, independent, and consistent administration of the self-report measures would have been preferable. One puzzling finding was that the control group’s IES scores declined so much during the five weeks between the first two assessment intervals. Although we are unable to definitively account for this, two possible explanations come to mind. First, since about half of the identified traumatic memories had occurred within the past year, it is possible that the initial IES scores partially represented an acute post-traumatic reaction that would naturally diminish over time. However, in that case, one would presumably expect a continued trend in that direction, which was not found in the control group over the next two months. It is perhaps more likely that the preparation for the study inadvertently created a system-wide interest in treating traumatic memories. The principal investigator made a presentation on the study to the clinical staff; and all study participants were exposed to the rationale for the EMDR treatment of trauma. Therefore, our best guess is that this inadvertent systemic psychoeducational intervention led to a competitive non-EMDR treatment of traumatic memories among participants in the control group. This hypothesis is consistent with the overall pattern of results in a somewhat similar study (Scheck, Schaeffer, & Gilette, 1998), with a brief non-EMDR trauma-focused treatment leading to modest initial gains with little apparent long-term benefit. Another somewhat puzzling finding is the substantial behavioral improvement following EMDR treatment focused on a single (or small number of) traumatic memory(ies) in a presumably multiply traumatized population. Although this is consistent with the findings of the most highly similar studies (Datta & Wallace, 1996; Scheck, Schaeffer, & Gilette, 1998) it is also inconsistent with other somewhat similar studies, for example, those using brief EMDR treatment with chronically traumatized veterans (see Shapiro, 1996). One possible explanation for this divergent pattern of findings is that adolescents may be less fixed than adults in their symptomatology, and thus respond more positively to apparently equivalent treatment. Alternately, it is plausible that, despite the presumed multiple traumatization of participants in the adolescent studies, the targeted traumatic memory may have been of key

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importance to those individuals in the development and persistence of the conduct symptoms; thus, targeting that memory would be sufficient for change. Finally, external factors such as disability benefits may encourage adults with chronic PTSD to retain their symptoms, whereas external factors may encourage adolescents with conduct problems to relinquish their symptoms. The finding that those measures that focused explicitly on the targeted traumatic memory (SUDS and IES-8) responded much more dramatically than the broad-spectrum trauma measures (CROPS and PROPS) was expected. This is consistent with the assumption that treating a single trauma (or only a few) with a multiply traumatized population will have only limited effect on global trauma measures, because other untreated trauma memories remain to drive the symptoms. We hypothesize that a larger sample size and/or a longer course of treatment would yield statistically significant changes on these global measures rather than the non-significant trends we found; however, this hypothesis remains to be tested. Despite the apparent effectiveness of this brief treatment, we are skeptical of its lasting value in lieu of a comprehensive treatment approach. Even though a key traumatic memory may have been treated to resolution, this population’s presumed history of multiple traumatization may leave them inordinately vulnerable to behavioral deterioration following new trauma. Therefore, we do not wish these findings to be viewed as prescriptive, but rather hope to indicate the potential value of using EMDR to treat the entire trauma history, in addition to the single self-selected trauma memory. Furthermore, we believe it is significant that the improvement in the EMDR group grew noticeably between the post-treatment and follow-up assessments, a pattern also found in other child/adolescent studies (Greenwald, 1994; Puffer et al., 1998; Scheck et al., 1998). To speculate, this may reflect a positive feedback cycle of reduced reactivity leading to improved environment, with each reinforcing the other and leading to further progress. In the present study, we suspect that the post-treatment reduced reactivity of the EMDR participants allowed them to benefit much more from the milieu treatment, thus magnifying the ongoing improvement over time that might otherwise be expected over the course of the regular program. In other words, perhaps the effective trauma treatment allowed participants to respond more fully to other interventions.

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If this is correct, then appropriate treatment for youth with conduct problems might include comprehensive trauma treatment, as well as cognitive-behavioral training and reinforcement for positive behaviors (e.g., Greenwald, 2000, 2002a). This combination of addressing trauma while also addressing other key aspects of the conduct problem syndrome may prove to yield much greater benefit than the sum of the effects of each approach in isolation. CONCLUSION This study’s strengths include randomization, generally appropriate (but not ideal) assessment, and a therapist with credibility as an EMDR practitioner. The study’s limitations include use of a single therapist for the EMDR group, as well as a sample too small, and a course of treatment too short, for adequate power on the global measures. Although the trends were in the expected direction, only two of the outcome measures were statistically significant. Thus, these findings may be considered encouraging but not definitive. The present findings replicate and extend previous findings supporting EMDR’s effectiveness in resolving the distress and reactivity associated with traumatic memories in child and adolescent populations, in this case, boys ages 10-16 with serious conduct problems. The present findings also replicate and extend previous findings supporting the effectiveness of brief EMDR treatment of key traumatic memories, leading to substantial behavioral improvement among acting-out child and adolescent populations, again, in this case, boys ages 10-16 with serious conduct problems. The theoretical foundation for this study supports theory development in addition to merely testing the effectiveness of a specific intervention. Theory-driven research is essential to the development of intervention approaches (Kazdin, 1997a). The prevalence of trauma history was indicated in that all potential participants reported at least one distressing traumatic memory, although details regarding the traumatic memory are unavailable (e.g., whether it would qualify under Criterion A of the DSM-IV [American Psychiatric Association, 1994]). The brief EMDR treatment led first to resolution of the selected traumatic memory, along with reduced memory-related post-traumatic symptoms, followed by reduced conduct symptoms. The present find-

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ings provide support for the theory that post-traumatic symptoms contribute to the development and persistence of conduct problems, and that effective trauma treatment can pave the way for meaningful symptom reduction. These findings are sufficiently promising to warrant a larger replication. They also indicate the potential value of studying a more thorough approach to trauma treatment for youth with conduct problems. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author. Chambless, D. L., Baker, M., Baucom, D., Beutler, L., Calhoun, K., Crits-Christoph, P., Daiuto, A., DeRubeis, R., Detweiler, J., Haaga, D., Johnson, B., McCurry, S., Mueser, K., Pope, K., Sanderson, W., Shoham, V., Stickle, T., Williams, D., & Woody, S. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3-16. Chemtob, C. M., Nakashima, J., Hamada, R., & Carlson, J. (in press). Brief treatment for elementary school children with disaster-related PTSD: A field study. Journal of Clinical Psychology. Chemtob, C. M., Tolin, D. F., van der Kolk, B. A., & Pitman, R. K. (2000). Eye movement desensitization and reprocessing. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 139-154). New York: Guilford. Datta, P. C., & Wallace, J. (1996, June). Enhancement of victim empathy along with reduction in anxiety and increase of positive cognition of sex offenders after treatment with EMDR. Paper presented at the annual meeting of the EMDR International Association, Denver, CO. Devilly, G. J., & Spence, S.H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive behavior trauma treatment protocol in the amelioration of Posttraumatic Stress Disorder. Journal of Anxiety Disorders, 13 (1-2), 131-157. Dyregrov, A., Kuterovac, G., & Barath, A. (1996). Factor analysis of the impact of event scale with children in war. Scandinavian Journal of Psychology, 37, 339-350. Dyregrov, A., & Yule, W. (1995, November). Screening measures: The development of the UNICEF screening battery. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, Boston, MA. EMDR International Association. (1999). Requirements for certification in EMDR. Available Internet: . Emmerson, G. J., & Neely, M. A. (1988). Two adaptable, valid, and reliable data-collection measures: Goal attainment scaling and the semantic differential. The Counseling Psychologist, 16, 261-271. Feske, U. (1998). Eye movement desensitization and reprocessing treatment for posttraumatic stress disorder. Clinical Psychology: Science and Practice, 5, 171-181.

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Fletcher, K. E. (1993, October). The spectrum of post-traumatic responses in children. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX. Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480. Greenwald, R. (1996a). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72. Greenwald, R. (1994). Applying eye movement desensitization and reprocessing (EMDR) to the treatment of traumatized children: Five case studies. Anxiety Disorders Practice Journal, 1, 83-97. Greenwald, R. (1996b). Psychometric review of the Problem Rating Scale. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 242-243). Lutherville, MD: Sidran. Greenwald, R. (1997). A better approach to training: Why you should teach EMDR in your hometown. Eye-2-Eye. Available Internet: . Greenwald, R. (1998). Eye movement desensitization and reprocessing (EMDR): New hope for children suffering from trauma and loss. Clinical Child Psychology and Psychiatry, 3, 279-287. Greenwald, R. (1999). Eye movement desensitization and reprocessing (EMDR) in child and adolescent psychotherapy. Northvale, NJ: Jason Aronson. Greenwald, R. (2000). A trauma-focused individual therapy approach for adolescents with conduct disorder. International Journal of Offender Therapy and Comparative Criminology, 44, 146-163. Greenwald, R. (2002). The Motivation-Adaptive Skills-Trauma Resolution (MASTR) individual therapy approach for adolescents with conduct problems: An open trial. Journal of Aggression, Maltreatment & Trauma 6(1), 237-261. Greenwald, R. (2002). The role of trauma in conduct disorder. Journal of Aggression, Maltreatment & Trauma 6(1), 5-23. Greenwald, R., & Rubin, A. (1999). Brief assessment of children’s post-traumatic symptoms: Development and preliminary validation of parent and child scales. Research on Social Work Practice, 9, 61-75. Hinshaw, S. P., Lahey, B. B., & Hart, E. L. (1993). Issues of taxonomy and comorbidity in the development of conduct disorder. Development and Psychopathology, 5, 31-49. Horowitz, M. J. (1986). Stress response syndromes (2nd ed.). Northvale, NJ: Jason Aronson. Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Events Scale: A measure of subjective stress. Psychological Medicine, 41, 209-218. Hyer, L., & Brandsma, J. M. (1997). EMDR minus eye movements equals good psychotherapy. Journal of Traumatic Stress, 10, 515-522. Ironson, G. I., Freund, B., Strauss, J. L., & Williams, J. (in press). A comparison of two treatments for traumatic stress: A pilot study of EMDR and prolonged exposure. Journal of Clinical Psychology. Kazdin, A. (1987). Treatment of antisocial behavior in children: Current status and future directions. Psychological Bulletin, 102, 187-203. Kazdin, A. (1995). Conduct disorder in childhood and adolescence (2nd ed.). Thousand Oaks, CA: Sage.

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Kazdin, A. (1997a). A model for developing effective treatments: Progression and interplay of theory, research, and practice. Journal of Clinical Child Psychology, 26, 114-129. Kazdin, A. (1997b). Practitioner review: Psychosocial treatments for conduct disorder in children. Journal of Child Psychology and Psychiatry, 38, 161-178. Lee, C. W., Gavriel, H., & Richards, J. (1996). Eye movement desensitisation: Past research, complexities, and future directions. Australian Psychologist, 31 (3), 168-173. Lee, C., Gavriel, H., Drummond, P., Richards, J., & Greenwald, R. (in press). Treatment of PTSD: Stress Inoculation Training with Prolonged Exposure compared to EMDR. Journal of Clinical Psychology. Lipke, H. J. (1992). A survey of EMDR-trained practitioners. Paper presented at the annual convention of the International Society for Traumatic Stress Studies, Los Angeles, CA. Loeber, R. (1990). Development and risk factors of juvenile antisocial behavior and delinquency. Clinical Psychology Review, 10, 1-41. Maxfield, L. (1999). Eye Movement Desensitization and Reprocessing: A review of the efficacy of EMDR in the treatment of PTSD. TraumatologyE, 5 (4). Available Internet: . Maxfield, L., & Hyer, L. A. (in press). The relationship between efficacy and methodology in EMDR treatment of PTSD. Journal of Clinical Psychology. McFarlane, A. (2000, November). Comparison of EMDR and CBT for PTSD. In B. van der Kolk (chair), Current research on EMDR. Symposium presented at the annual meeting of the International Society of Traumatic Stress Studies, San Antonio. Moffitt, T. (1993). Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100, 674-701. Pakiz, B., Reinherz, H. Z., & Giaconia, R. M. (1997). Early risk factors for serious antisocial behavior at age 21: A longitudinal community study. American Journal of Orthopsychiatry, 67, 92-101. Patterson, G. R., DeBaryshe, B. D., & Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44, 329-335. Power, K., McGoldrick, T., & Brown, K. (2000, September). A controlled comparison of eye movement desensitization and reprocessing vs. exposure plus cognitive restructuring vs. waiting list in the treatment of post-traumatic stress disorder. Poster session presented at the annual meeting of the EMDR International Association, Toronto. Puffer, M. K., Greenwald, R., & Elrod, D. E. (1998). A single session EMDR study with twenty traumatized children and adolescents. Traumatology, 3 (2). Available Internet: Robins, L. N. (1981). Epidemiological approaches to natural history research: Antisocial disorders in children. Journal of the American Academy of Child Psychiatry, 20, 566-580. Rogers, S., Silver, S., Goss, J., Obenchain, J., Willis, A., & Whitney, R. (1999). A single session, controlled group study of flooding and eye movement desensitization and reprocessing in treating posttraumatic stress disorder among Vietnam war veterans: Preliminary data. Journal of Anxiety Disorders, 13, 119-130.

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Scheck, M. M., Schaeffer, J. A., & Gillette, C. S. (1998). Brief psychological intervention with traumatized young women: The efficacy of eye movement desensitization and reprocessing. Journal of Traumatic Stress, 11, 25-44. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford Press. Shapiro, F. (1996). Errors of context and review of eye movement desensitization and reprocessing research. Journal of Behavior Therapy and Experimental Psychiatry, 27, 313-317. Sweet, A. (1995). A theoretical perspective on the clinical use of EMDR. The Behavior Therapist, 18, 5-6. Thyer, B. A., Papsdorf, J. D., Davis, R., & Vallecorsa, S. (1984). Autonomic correlates of the subjective anxiety scale. Journal of Behavior Therapy and Experimental Psychiatry, 15, 3-7. van Etten, M., & Taylor, S. (1998). Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126-145. Vaughan, K., Armstrong, M. S., Gold, R., O’Connor, N., Jenneke, W., & Tarrier, N. (1994). A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 25, 283-291. Wiedemann, J., & Greenwald, R. (November, 2000). Child trauma assessment with the CROPS and PROPS: Construct validity in a German translation. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX. Wilson, D., Silver, S. M, Covi, W., & Foster, S. (1996). Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. Journal of Behavior Therapy and Experimental Psychiatry, 27, 219-229.

Motivation-Adaptive Skills-Trauma Resolution (MASTR) Therapy for Adolescents with Conduct Problems: An Open Trial Ricky Greenwald

SUMMARY. Trauma is proposed as a key to understanding the development and persistence of adolescent conduct problems, in conjunction with other contributing factors. A trauma-focused individual therapy approach is presented as one example of how this population might be more effectively treated. This approach features motivational interviewing, self-control training (cognitive-behavioral therapy), and trauma resolution (eye movement desensitization and reprocessing). This paper reports on an open trial of six adolescents with school and conduct problems who received school-based Motivation-Adaptive Skills-Trauma Resolution (MASTR) treatment. Reductions in post-traumatic stress, related symptoms, and problem behaviors, along with improved school performance, indicate the value of further study of this treatment approach. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.] Address correspondence to: Ricky Greenwald, PsyD, Department of Psychiatry, Box 1228, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029-6574 USA (E-mail: [email protected]). [Haworth co-indexing entry note]: “Motivation-Adaptive Skills-Trauma Resolution (MASTR) Therapy for Adolescents with Conduct Problems: An Open Trial.” Greenwald, Ricky. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 237-261; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 237-261. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

KEYWORDS. Conduct disorder, disruptive behavior disorder, violence, trauma therapy, EMDR, school, cognitive-behavioral, motivational interviewing, relapse prevention, anger management

Conduct problems (CP) include a broad range of activities, such as disruptive, oppositional, aggressive, and/or criminal behavior, as well as non-compliance with normal community, school, and home expectations (Soberman, Greenwald, & Rule, 2002). Such behaviors constitute the basis of one-third to one-half of all child and adolescent clinical referrals (see Kazdin, 1987) and are consistently identified as potential precursors (or contributors) to a range of serious problems, such as conduct disorder and juvenile delinquency (Loeber, 1990; Pakiz, Reinherz, & Giaconia, 1997). Our present inability to effectively treat adolescents with conduct disorder (Kazdin, 1997), the severe extreme of the CP spectrum, may be explained at least in part by our failure to address trauma’s contribution to CP (Greenwald, 2002). There are several bodies of literature which together provide convincing support for the proposition that trauma plays a key role in CP (Greenwald, 2002). A role for trauma in the development of CP can reasonably be hypothesized, considering that: (a) violence begets violence, (b) CP youth have high rates of both trauma history and post-traumatic symptoms, and (c) trauma leads to many cardinal features of CP. One way to test this proposition is by providing trauma treatment to individuals with CP to see if their problem behaviors diminish. Trauma treatment generally involves two phases: establishing a sense of safety, and working through the traumatic material (James, 1989; Peterson, Prout, & Schwartz, 1991; Pynoos & Eth, 1986). Although trauma is rarely systematically addressed with CP, those treatment approaches with documented effectiveness can arguably be characterized as indirect trauma treatments. For example, training parents to discipline consistently, which works fairly well with younger children (Kazdin, 1997), can be described as trauma treatment (Greenwald, 1999) because it makes the environment more predictable and supportive, and helps the child to feel more safe and secure. Similarly, the cognitive-behavioral approaches, which have met with modest success (Kazdin, 1997), also serve to make the environment more favorable, predictable, and supportive. It is important to note that, although these approaches may address the safety component, they are not complete trauma treatments because

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there is no working through of the traumatic material. Negative impulses may still be extremely powerful unless trauma resolution is achieved. Of course, a comprehensive treatment approach should also address other concerns, such as interpersonal, educational, and vocational competence. However, unless the post-traumatic effects are mitigated, youth with CP may be less likely to respond to these otherwise important components of treatment. EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR) One promising trauma therapy that focuses on the working through component is eye movement desensitization and reprocessing (EMDR; Shapiro, 1995). EMDR’s efficacy has been demonstrated in a sufficient number of controlled studies to gain mainstream acceptance (Chambless et al., 1998; Chemtob, Tolin, van der Kolk, & Pitman, 2000; van Etten & Taylor, 1998), despite a history of controversy (Greenwald, 1996a). Direct comparisons to other recommended treatments have shown EMDR to be more efficient and at least as effective (e.g., Ironson, Freund, Strauss, & Williams, in press; Lee, Gavriel, Drummond, Richards, & Greenwald, in press). Although formal supervised training is required for safe and effective practice (Greenwald, 1996a), detailed procedural information is widely available (Shapiro, 1995; for a synopsis, see Soberman et al., 2002). Available data on EMDR with traumatized children and adolescents, including several controlled studies (e.g., Chemtob, Nakashima, Hamada, & Carlson, in press; Puffer, Greenwald, & Elrod, 1998), appear to indicate similar effects across age groups (Greenwald, 1998b). Several studies have more direct relevance to the CP population. For example, Jameson (1998) anecdotally reported positive results with the trauma-focused EMDR treatment of 70 adult male prisoners. Datta and Wallace (1996) used three EMDR sessions to treat the traumatic memories of 10 incarcerated adolescent sex offenders, and found increased empathy, improved functioning in many areas, and even spontaneous attempts at victim restitution. Scheck, Schaeffer, and Gillette (1998) compared two trauma-focused sessions of EMDR to Active Listening with a community sample of high-risk acting-out adolescent girls (n = 18) and young women (n = 42). At post-treatment and three-month follow-up, they found that scores on every measure had moved to the normative range for the EMDR group. Behavioral measures were not

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included in this study. Soberman et al. (2002) compared standard care plus three sessions of EMDR to standard care only for 29 boys (ages 10-16) with serious conduct problems who were either in residential or day treatment. They found that EMDR led to significant reductions in both reactivity to the targeted memories and severity of the primary identified problem behaviors. Although the above studies found positive and clinically meaningful effects following brief EMDR treatment, among chronically traumatized and/or multi-problem populations such effects would not normally be expected without extending the duration of treatment sufficiently to address the entire trauma history as well as additional treatment needs. Indeed, other EMDR studies with similarly challenging populations show more equivocal results (see Greenwald, 1996a; Shapiro, 1996). For example, Rubin and colleagues (in press) reported only non-significant trends favoring EMDR with a challenging child guidance center population (N = 39, ages 6-15); however, they relied on a single outcome measure (Child Behavior Checklist; Achenbach & Edelbrock, 1984), which does not assess post-traumatic stress, and which is known to be relatively insensitive to change. Also, in the Soberman et al. study in this issue noted above, even though the subjective distress regarding the targeted memory was highly responsive to EMDR, the global measures of post-traumatic symptoms were less so, presumably indicating that additional trauma remained untreated in many cases. In these studies, EMDR appears to have made a positive contribution, but not to the extent that we see in some of the literature. Several issues must be considered in relating EMDR’s somewhat variable results to the adolescent CP population, the first being duration of treatment. The literature has identified distinct sub-groups within the CP population, with some youth showing chronic conduct problems from an early age, and others showing adolescent onset (Moffitt, 1993). These different developmental pathways may reflect, among other things, very different kinds of trauma histories, with the late-onset group possibly reacting to more discrete, recent trauma (this hypothesis has yet to be tested). Thus, the varying rapidity and magnitude of response to EMDR may reflect the variable trauma chronicity of the participants, both between and possibly within studies. Because EMDR is typically applied to one memory at a time, EMDR treatment with CP youth should probably be brief only with those known to be suffering from discrete traumatic incidents; and if the distinction has not been made, more extended treatment should be available. On the other hand,

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it is conceivable that treating a major identified trauma can have substantial positive effects even for a multiply traumatized individual. The adolescent CP population also tends to be volatile, and understandably fearful of trauma-focused treatment (i.e., talking about upsetting memories) because of the perceived risk of becoming more upset, which might lead to acting-out and negative consequences. Due to these safety issues, EMDR is probably not advisable as a stand-alone treatment with this population. Indeed, the standard EMDR protocol (Shapiro, 1995) calls for client preparation adequate for self-soothing and self-control so that the trauma resolution work can be tolerated. Clinical observation indicates that, with this population, this issue is sufficiently prominent to require special attention (Greenwald, 2000). Finally, the adolescent CP population is highly resistant to even engaging in treatment (Kazdin, Mazurick, & Bass, 1993; Sommers-Flanagan & Sommers-Flanagan, 1995). Trauma effects may help to account for these youths’ impaired trust, anger towards adults, hypersensitivity to emotionally charged material, interest in avoiding reminders of upsetting memories, limited expectation for treatment’s potential benefit, and a preference for immediate gratification. Thus, engagement with the therapist and commitment to treatment activities is also sufficiently challenging as to require special attention (Greenwald, 2000). It is not clear to what extent the equivocal results noted in some EMDR studies may reflect EMDR’s limited efficacy with chronically traumatized populations, or on the other hand, may actually reflect inadequate attention to duration of treatment, safety issues, and commitment to treatment. THE MOTIVATION-ADAPTIVE SKILLS-TRAUMA RESOLUTION (MASTR) TREATMENT The Motivation-Adaptive Skills-Trauma Resolution (MASTR) treatment approach for adolescents with CP is designed to systematically address the treatment issues noted above, while incorporating EMDR in some typical and some innovative ways. It was developed and refined with approximately 50 incarcerated male adolescents, and has been described (but not named) in more detail elsewhere (Greenwald, 1999, 2000). MASTR begins with a modified motivational interviewing approach, since commitment to treatment is the first obstacle. The second phase involves cognitive-behavioral training and coping skills development, which helps the youth to trust the therapist and to gain the confi-

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dence, strength, and sense of control necessary to face the trauma directly. The final phase involves working through the traumatic material. To enhance continuity across treatment activities, and to procedurally prepare the youth for the trauma resolution activities, eye movements are used during the visualization activities occurring in each phase of treatment. Although EMDR is best known as a treatment for traumatic memories, there is clinical as well as theoretical support for the Accelerated Information Processing hypothesis (Shapiro, 1995; Stickgold, 1998), which applies not only to resolution of disturbing memories, but to other forms of information processing, such as learning. Thus, EMDR has also been used for visualization, affirmations, and performance enhancement in a variety of applications (e.g., Foster & Lendl, 1996; Greenwald, 1998a, 1999; Shapiro, 1995). The present approach uses EMDR’s hypothesized accelerated information processing effect to attempt to enhance a range of interventions. Following is a summary of treatment components. The first phase, Motivation, starts with the initial encounter. The systematic interview is designed both to obtain needed data and to enhance rapport. Then the Future Movies technique is used to help the client identify and invest in positive short-term and long-term goals. This entails asking the client to fill in the details of a movie of the next 10 years of his life, including the positive actions he can take, leading to a happy ending. The movie is imaginally viewed during eye movements. Then an unhappy ending is identified and focused on during eye movements, along with the statement, “It’s not worth it.” Once this is accomplished, the treatment plan can be offered in the service of the client’s stated goals of choosing to work towards the positive outcome. Subsequent interventions build on this phase. The second phase, Adaptive Skills, includes a number of cognitive-behavioral techniques. For example, the Early Warning System helps the client to become more aware of the various internal steps (e.g., angry thoughts, racing heartbeat) leading to escalation of feelings and loss of control. This entails interviewing the client to identify these steps, and then having the client imaginally view them in sequence. Choices Have Consequences helps the client to develop a constant awareness, even during challenging moments, of the consequences of various behavioral options. This entails having the client imaginally view a “movie” of a challenging situation in which a positive behavioral choice leads to a positive outcome, and then again with a negative choice leading to a negative outcome. Tease Proofing includes a series

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of techniques that help the client to become less reactive to provocation. First, the client is asked to imagine a fantasy scenario in which he is able to overpower his antagonist. Then, he is taught to erect an imaginary wall to keep his antagonist’s barbs from getting through to him. Finally, he is asked to consider, and then picture himself imitating, a role model’s effective coping. These exercises all include eye movements during the imaginal portion. The third phase, Trauma Resolution, includes some typical and some innovative uses of EMDR to address underlying trauma and loss issues, and to further develop coping skills. For example, rather than plunging prematurely into work on a major traumatic memory, EMDR may first be applied to recent, relatively minor, upsetting experiences such as getting in trouble in school. This allows the client to develop a track record with EMDR under relatively low-stress circumstances, while learning to talk about current issues, reduce stress, and problem-solve. In addition to EMDR’s promising track record with adolescent CP and related populations, other components of MASTR have also gained empirical support. Motivational Interviewing (MI), featured in the first phase of this approach, has been applied successfully to engaging clients in treatment for substance abuse, as well as risky behaviors and sex offending; it has also contributed to positive outcomes even in lieu of subsequent treatment (see Miller, 1996, 2000). Recent controlled studies of brief MI interventions with adolescents found that it significantly reduced smoking (Colby et al., 1998) and alcohol-related problems (Monti et al., 1999), and improved treatment attendance and drug abstinence (Lawendowski, 1998). Also, research has shown that imagining doing the specific activities which are required to achieve a desired outcome can lead to increased implementation of the required activities (Taylor, Pham, Rivkin, & Armor, 1998). The Adaptive Skills phase features cognitive-behavioral training in self-control skills, which has been moderately effective with the CP population (Kazdin, 1997), as well as with volatile traumatized adults (Chemtob, Novaco, Hamada, & Gross, 1997). This set of interventions includes elements of covert sensitization as well as variants of the imaginal rehearsal practiced in the Motivation Phase. It also includes elements of the relapse prevention approach, which has been used successfully in addiction treatment (Marlatt & Gordon, 1985), as well as with sex offending adolescents (Marshall, 1996). MASTR is more than just an aggregation of established treatment approaches; it includes some novel interventions as well as innovative variants and combinations of existing methods. Furthermore, these

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treatment components have been systematically sequenced to optimally address the treatment needs of the (presumably traumatized) adolescent CP population. The MASTR treatment itself has only a limited, but encouraging, track record to date. Stewart (1998) reported anecdotal success with this approach with adolescent girls in residential treatment. Greenwald (2000) presented two case vignettes of incarcerated adolescent boys in which MASTR led to reduction of anger, acting-out, and other symptoms. Using a repeated measures design, all clinicians in a residential facility were trained in this approach, and after two months, all critical incident (e.g., assault, property destruction) counts were down by 50% or more on all units (male, female, conduct disorder, sex offender), compared to any of the six months pre-training (Greenwald, Lundberg, & Smyth, 2001). Although those clinicians had previously been trained in EMDR, it was still not possible to discern to what extent the introduction of the MASTR treatment contributed to the change, because other influences on the program may have occurred around the same time. The purpose of the present open trial was to begin to study the effect of MASTR as the centerpiece of an eclectic treatment approach, using standardized measures and behavioral outcomes. METHOD Participants Participants were drawn from a population of students, grades 7-12, referred for school-related problems in a public school system in Hawaii under federal and state laws designed to ensure that students with disabilities (including psychological/behavioral ones) receive the assistance they need to achieve their educational potential. On the basis of an interdisciplinary team meeting, which includes parents, some of the students in this population are referred for psychological evaluations, sometimes leading to individual and/or family therapy. These psychological services were provided on the school campuses in the context of a demonstration project designed to improve support services to special needs students. The author served as a clinical psychologist for a middle school and a high school in this system, providing psychological evaluations as well as psychotherapy (as specified by the individual’s treatment plan). Participants were selected for this study by being the first six students with

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CP on the author’s caseload who completed the full MASTR treatment. Many students were referred for other types of problems, and many students with CP who began the MASTR treatment did not complete it (see Discussion section below for more on this issue). Consent for participation in the study was obtained from participants and their parents following completion of treatment, and amounted to consent to use existing data for this article. Case details have been altered to protect confidentiality. Measures State-Trait Anger Expression Inventory (STAXI) is a widely used and well validated 40-item self-report questionnaire, which, although developed for adults, has separate norms for adolescents (Spielberger, 1996). Only the State and Trait scales were used in this study. Children’s Depression Inventory (CDI) is a widely used and well-validated 27-item measure of depression (Kovacs, 1981). One of three statements in each item-box is selected as being most true for the respondent, and represents varying levels of the symptom in question. Revised Children’s Manifest Anxiety Scale (RCMAS) is a widely used and well validated 39-item measure of anxiety (Reynolds & Richmond, 1978). It is dichotomously scored based on yes/no responses to statements. Only the total scale was used here. Trauma Symptom Checklist for Children (TSCC) is a widely used and well validated 54-item self-report questionnaire yielding scale scores for many trauma-related areas of concern including post-traumatic stress, anger, depression, and anxiety (Briere, 1996). Only the total scale score was used here. Child Report of Post-traumatic Symptoms (CROPS) is a 26-item self-report questionnaire covering the broad spectrum of post-traumatic symptoms found in traumatized children. Preliminary studies indicate good validity and reliability (Greenwald & Rubin, 1999; Wiedemann & Greenwald, 2000). Parent Report of Post-traumatic Symptoms (PROPS) is a 32-item companion measure to the CROPS, also broad-spectrum and with similar validity and reliability (Greenwald & Rubin, 1999; Wiedemann & Greenwald, 2000). Because children and adolescents are best at describing their own internal states, while others are best at describing the youth’s behavior, the dual perspective is essential to comprehensive assessment of post-traumatic symptoms (see Newman, 2002).

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Problem Rating Scale (PRS) is an individualized parent rating of the severity of the child’s primary presenting problems (Greenwald, 1996b). The PRS is an inverse variant of the goal attainment scale, which has been found to be a valid and reliable assessment format (Emmerson & Neely, 1988). The PRS is administered in an interview by having the parent describe the main concerns and rate them on a 0-10 scale of severity. Grades were available for each quarter of the school year in which treatment occurred. Procedures Assessment All measures were completed at the initial psychological evaluation, along with clinical interviews of both the student and the parent(s). Following the evaluation, initiation of treatment began from one week to two months later, depending on circumstances. In some cases, treatment was terminated following completion of treatment goals; in other cases, when goals had been achieved, a few additional sessions were scheduled on an infrequent basis as a safeguard. In one case, termination was not appropriate and treatment was continued. All measures were repeated, along with a termination interview, either just prior to termination or sometime during the tapering-off phase. For the participant who did not terminate, the measures and interview were completed at the end of the school year. Treatment The author provided all treatment, including a range of interventions, as needed, in addition to the MASTR approach. For example, parent consultation was provided in all cases (some more than others), and the author also participated in school meetings at which class placements and other educational accommodations were discussed. The MASTR approach itself is sufficiently flexible to allow responsiveness to situational demands, such as discussing a pressing issue even if it was not on the therapist’s agenda. Thus, this is not a “pure” test of the MASTR treatment so much as an exploration of MASTR as the core of an eclectic treatment approach. The author is accredited by the EMDR International Association as an EMDR trainer, and he is the developer of the MASTR treatment ap-

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proach. Although adherence to the EMDR and MASTR protocols can be expected on this basis (the sessions were not recorded or observed), independent confirmation of treatment fidelity did not occur. CASES 1. “Fred” was a 15-year old boy who had received a social promotion after having failed to pass his grade for the past two years, and was placed in a special education class for students with behavior problems. His history included long-term exposure to neglect, abuse, abandonment, and chaotic home life. He had engaged in years of disruptive behavior, truancy, substance abuse, and violence, and had previously been incarcerated on burglary and assault charges. He was diagnosed with conduct disorder. Due to difficulty scheduling a treatment-planning meeting (including father and school personnel), two months elapsed before treatment was initiated. Initial interventions included anger management training for father, as well as problem-solving a high-risk situation regarding an angry sibling. Over the next several months, Fred only appeared occasionally, missing scheduled appointments due to truancy, but showing up in times of crisis for help calming down or solving a problem. On two occasions, he was introduced to the Choices Have Consequences exercise, in which he was able to identify the positive and negative outcomes associated with different behavioral choices and endorse the positive. Although he continued to do poorly in school, he was at least staying out of fights, which for him was an achievement. He eventually started bringing his friends in for assistance with anger management. With two months left to the school year, Fred finally became engaged in treatment. This followed his father’s release from prison after four months, father’s abstinence from substance abuse, and his insistence that Fred also abstain and attend school regularly. By being in school Fred was more available for regularly scheduled appointments. At this time the MASTR protocol was followed in an orderly fashion, moving through the steps specified above over the course of six sessions. Once the two primary identified traumatic memories were worked through, Fred reported that none of the others bothered him anymore (there was minimal opportunity to explore this). He also reported that he was not getting angry as easily, that he was abusing substances only rarely (monthly instead of daily), and that he was doing at least some of his schoolwork now. Subsequent sessions were focused on various

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pressing and practical issues, such as solving relationship problems, obtaining medical care, and applying for summer jobs. He did pass some of his classes, and planned to return to school even though he was old enough to drop out. He and his father noted reduced but continuing problems with temper and self-discipline and agreed that they would like Fred to have the continued support of a therapist in the following year. 2. “Anna” was a 13-year-old girl repeating the seventh grade who was referred early in the school year at imminent risk of out-of-home placement. Her teachers and her mother reported a range of problematic behaviors, including fighting, stealing, inconsistent schoolwork, and incessant disobedience. Her history included the death of her father two years before in a motor vehicle accident. Anna said she wanted to do well in school and to “be good,” but acknowledged that she was often angry and out of control since her father’s death. In addition to a long-standing diagnosis of Attention Deficit/Hyperactive Disorder, she was diagnosed with Dysthymia and Oppositional Defiant Disorder. Treatment began in the week following the evaluation (without waiting for the usual meetings) due to the urgency of the situation. One focus was parent consultation and follow-up phone contact to help her mother acquire more effective disciplinary habits. Anna was also started immediately with the MASTR treatment. The first individual session was spent with the Motivation activities and the next three with Choices Have Consequences. Approximately a month into treatment, Anna’s mother disclosed that she had unilaterally discontinued Anna’s medications (Ritalin and Paxil). Anna also reported that she was doing more of her homework and that her mother was yelling at her less frequently. In one of these sessions, Anna tried EMDR regarding a recent, minor, upsetting event and had a positive experience. Over the next four sessions she did EMDR with the memory of her father’s death. She was not able to tolerate extended EMDR sessions, but was willing to do it for 15 or 20 minutes at a stretch if she could look forward to playing a game for the rest of the session. When she reported no remaining distress regarding the memory of her father’s death, two more sessions were used to address sibling conflict and other anger-related issues, using Tease Proofing and Choices Have Consequences. By then she was doing consistently well in school and at home, and sessions were scheduled much farther apart, mainly because her mother was not feeling confident enough in Anna’s stability to agree to termination until more time passed. Anna finished the school year with all A’s and a stable home life.

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3. “Dan” was a 12-year-old boy who had been doing progressively more poorly in school for several years and was failing most of his classes when he was referred about halfway through the school year. He had been exposed to a history of family instability, domestic violence, and the loss of a cherished grandparent. He currently lived in a stable home with his uncle. Dan was quick to anger, was involved with negative peers and minor delinquency, showed disrespect to teachers, was disruptive in class, and got in fights with siblings and peers. He was diagnosed with Dysthymia and Disruptive Behavior Disorder NOS. In the first individual session, Dan did the Motivation component and started on Choices Have Consequences to help him get his homework done. In the next session, he did Tease Proofing to become less reactive to his little brother. In the next two sessions he did EMDR with memories of his grandmother’s death and memories of witnessing his mother being physically abused by her boyfriend. Another two sessions were spent with additional Adaptive Skills and Trauma Resolution work as additional possible obstacles to success were identified and addressed. At this point, Dan reported that he was doing much more of his homework, that his brother was not getting on his nerves anymore, and that he had not been angry enough to swear for several weeks. Frequency of sessions was cut to once every several weeks for another few short sessions until termination. Virtually no more individual work was accomplished despite this occasional contact. At this phase, parent/guardian consultation was the primary intervention to facilitate the use of incentives to encourage Dan to be even more consistent with his homework. Despite further family instability during this time (uncle’s divorce, Dan moving to live with another relative), his morale did not decline and his final grades were As and Bs, except for one D. He had also renewed an old interest by joining a football team. His uncle reported decreased but continuing temper problems. 4. “Allen” was a 15-year-old boy who was failing all subjects in a special class for students with behavior problems. He was living with relatives because of conflict with his mother. His history included exposure to intense parental conflict, as well as harsh discipline, family instability, and abandonment. He had done well in past years, but since his parents’ divorce three years ago, he had done worse in school, associated with problem peers, and had gotten arrested on a variety of charges, including theft and selling marijuana. He also acknowledged that he was quick to lose his temper and act-out at school or home. He was diagnosed with Oppositional Defiant Disorder.

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The first session included Allen, his relatives, and his mother, who were able to make a good show of support for him. The first and second individual sessions were devoted to the Motivation activities, as well as Choices Have Consequences for self-control when angry in the classroom or at home. The next session was devoted to EMDR with a memory of being harshly disciplined by his aunt (not the one with whom he was staying). Around this time, he moved back with mother, who called frequently to consult on discipline issues. The next two sessions were mixed and included additional trauma resolution work regarding his sense of abandonment by father, along with repetition of some of the motivational and self-control activities. Finally, there were several brief “check-in” meetings scheduled on an occasional basis prior to termination. Allen earned all As and Bs by the end of the year, was getting along well with his mother, and his rule violations were limited to an occasional “tardy” for class. 5. “George” was a 12-year-old boy with a generally positive school and social history. His behavior and school performance had deteriorated markedly several months prior to referral to the point that he was getting Ds and Fs in all classes. His history included the death of a cherished grandmother many years previously, and exposure to parental conflict which led to divorce. However, his symptoms did not flourish until his father was hospitalized for surgery several months prior to the evaluation. Since then, his temper had become more quick and explosive, he stopped doing his schoolwork, and he became highly disruptive in class. He reported feelings of preoccupation, difficulty concentrating, nightmares, poor self-image, and belief in an unfavorable future. He was diagnosed with Adjustment Disorder with post-traumatic features. By the time treatment began a month after the evaluation, George reported that he was already starting to do better in school (he said this was a response to what he learned in the evaluation). Two sessions were spent in the Motivational phase. Since self-control did not seem to be a pressing problem at that time, Trauma Resolution was the next step. George was nervous about facing his upsetting memories, so a fortification strategy (Greenwald, 1993) was used: He was asked to imagine that the bad memory was a dream, and to identify what he would need “to be okay” if he had to go back into that dream. He said, “I’d need to be stronger.” Then he was asked to imaginally view, during eye movements, activities leading to getting stronger, as well as the image he selected to represent strength: himself lifting up a house.

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By the third session, he was willing to use EMDR with the memory of his grandmother’s death. In the fourth session, he worked through several additional memories with EMDR, including the precipitating event of his father’s hospitalization. At the next session, he finally did Choices Have Consequences to help him continue to stay on track with completing his schoolwork and restraining his disruptive classroom behavior. By the sixth session, there was little more to do. George’s mother reported that he was passing all his classes (no more Ds) and seemed less angry and easier to be around. 6. “Edward” was a 13-year-old boy in the eighth grade, with a generally positive history and home life, who was failing many of his classes. He had been traumatized by a hurricane six years before, and three months later had lost a favored aunt and uncle in an auto accident. Then, three years ago he witnessed a good friend’s death by drowning. Since that time, his mood, temper, and school performance had progressively deteriorated. At the time of the evaluation, his parents reported that he had threatened suicide on numerous occasions and that he was able to get his way at home with his angry outbursts because his parents were afraid to upset him. He had also become so frustrated with school that he was often angry there, and quick to give up. He was diagnosed with Dysthymia. Based on the findings of the comprehensive evaluation, which revealed that some of his classes were beyond his ability, he was placed in some special education classes at about the same time that psychotherapy was initiated. In the first individual session, Edward completed the Motivation activities and began Choices Have Consequences with a focus on trying, as opposed to giving up when challenged in school. He reported very quick progress on this, probably in part due to a change to easier classes with more individual attention. The next three sessions were devoted to the Trauma Resolution phase in which he worked through all identified major losses and traumatic memories. In this time, additional anger-related issues were also addressed by asking him what else made him angry, and targeting those items with standard EMDR. The Future Movies exercise was also repeated. Treatment was terminated when Edward seemed happier and less volatile, and was doing well in school. RESULTS Every participant made some progress on his/her primary presenting complaints, with some problems being substantially resolved, although

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significant problem areas often remained (see Figure 1). However, following the MASTR treatment, five of the six families reported that they no longer perceived a need for therapy, indicating that they may have viewed some degree of problematic behavior as normative. In general, family life became calmer, school discipline problems decreased, and grades increased. The one participant who did not pass all his classes at least stayed in school, although he had been at risk of dropping out. No identified presenting problem worsened. The overall experience of participants seemed very positive. The pre-treatment to post-treatment changes on the various standardized measures show essentially the same results (see Figure 2). As expected with trauma-focused treatment, the trauma-specific measures (TSCC, PROPS, CROPS) showed the greatest and most consistent benefit from treatment, whereas the measures of anger (STAXI), anxiety (RCMAS) and depression (CDI) showed more modest and inconsistent benefit. Again, no measured symptoms worsened meaningfully (in two instances, scores crept up very slightly). Although statistical analyses were not performed due to a small sample size and lack of a control group, clinical significance can reasonably be assumed in those instances in which a score moved from the clinical to the normal range, there was a major drop within a single range, or presenting problems were resolved. DISCUSSION The purpose of this open trial was to examine the MASTR treatment with an outpatient adolescent CP population, using standardized measures and clinically relevant behavioral outcomes. As predicted, this trauma-focused treatment led to substantial reductions in post-traumatic stress symptoms as well as some reductions in related symptomatology. As predicted by the theoretical model that posits that post-traumatic effects contribute to CP symptoms (Greenwald, 2002), problem behaviors were considerably reduced as well. Also as predicted by this model, responsiveness to the MASTR treatment approach was shown by every participant in this small but heterogeneous sample, representing both genders, a range of diagnoses, and varying chronicity of both trauma history and CP history. There are many limitations inherent in a small-N open trial conducted by a single investigator. There was no alternate treatment or wait-list group to control for the generic effects of treatment or the pas-

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FIGURE 1. Problem Rating Scale (PRS) changes for each participant from pre-treatment to post-treatment. PRS–Fred

PRS–Anna

Note: Initial “10+” ratings are scored as “12”

12 10 8 6 4 2 0 Pre-Tx

10 8 6 4 2

Post-Tx self-est lazy vulgar

up late temper school

0 Pre-Tx annoys social

PRS–Allen 10

8 6

8 6

4 2

4 2 Post-Tx temper respect

0 Pre-Tx

school

school

PRS–Edward

PRS–George 10

8 6

8 6

4 2

4 2 Post-Tx grades secretive

Post-Tx temper respect

10

0 Pre-Tx

school

PRS–Dan

10

0 Pre-Tx

Post-Tx

school sad/mad

0 Pre-Tx

Post-Tx school moody

temper disobey

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FIGURE 2. Participant change from pre-treatment to post-treatment, as measured by the Problem Rating Scale (PRS) means, Trauma Symptom Checklist for Children (TSCC), Parent Report of Post-Traumatic Symptoms (PROPS), Child Report of Post-Traumatic Symptoms (CROPS), Revised Children’s Manifest Anxiety Scale (RCMAS), Children’s Depression Inventory (CDI), and State-Trait Anger Expression Inventory (STAXI) State and Trait Scales. PRS Means 10 8 6 4 2 0 Pre-Tx

TSCC No full-scale normative data available

Post-Tx Fred Allen George

80 70 60 50 40 30 20 10 0 Pre-Tx

Anna Dan Edward

Clinical cutoff = 19

Post-Tx Fred Allen George

35 30 25 20 15 10 5 0 Pre-Tx

RCMAS

Anna Dan Edward

CDI

Post-Tx Fred Allen George

Post-Tx Fred Allen George

Anna Dan Edward

Clinical cutoff = about 18 (varies by norm group)

20 15 10 5 0 Pre-Tx

Anna Dan Edward

CROPS

PROPS Clinical cutoff = 16

50 40 30 20 10 0 Pre-Tx

Post-Tx Fred Allen George

Anna Dan Edward

Clinical cutoff = about 22 (varies by norm group)

25 20 15 10 5 0 Pre-Tx

Post-Tx Fred Allen George

Anna Dan Edward

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FIGURE 2 (continued)

STAXI State Anger

STAXI Trait Anger

Clinical cutoff = 16

20 15 10 5 0 Pre-Tx

Clinical cutoff = 27

Post-Tx Fred Allen George

Anna Dan Edward

40 35 30 25 20 15 10 5 0 Pre-Tx

Post-Tx Fred Allen George

Anna Dan Edward

sage of time. The use of a single therapist also precludes distinguishing the influence of personal style and competence from the effect of the treatment approach. On the other hand, the lack of independent assessment was probably not a fatal drawback here. First, the study was conducted as something of an afterthought, so the assessments were completed before the topic of research was introduced. Second, many of the measures were paper and pencil instruments, which are completed independently. Third, parents seemed to have no compunction about reporting a higher severity of post-treatment problem ratings than expected by the investigator. Finally, the picture was fairly consistent across multiple sources and types of measures, including behavioral ratings and grades. Thus, although independent assessment is important, there can be at least some confidence in the measurement in this study. Selection of participants is also an important issue in this study. Could the MASTR completers be the self-selected “star” clients of the author’s caseload? Which potential participants were non-completers, and why? There were three main factors contributing to non-completion of the MASTR treatment. First, a small proportion of those referred for treatment never showed up, or only came once or twice. Most of those teens with CP who were referred for treatment completed the Motivation phase and a good portion of the Adaptive Skills phase; quite a few did part of the Trauma Resolution as well. When things were going better, they decided they were done, so they stopped coming. This premature termination upon apparent resolution of current problems was

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the second factor. Some of these youth continued to do well while others deteriorated again. Adolescents with CP are notorious for being unwilling to show up for therapy sessions unless they are compelled by others to do so. Such external pressure has not interfered with MASTR treatment success, for example, when clients are required to attend sessions as part of a residential program (Greenwald, 2000). In the present study, it was easier to stop going to sessions because treatment was provided in a relatively looser school setting and external pressure was less consistent, which was the third factor in non-completion. Since many of these clients were doing better in school and staying out of trouble, school staff and parents saw little reason to push for further treatment when the client resisted. Those who completed the entire MASTR treatment tended to be among the youngest on the caseload and, on that account, relatively more compliant with therapist and parent demands. For older adolescents, more concerted external pressure may be essential to ensuring completion of the treatment. The present findings are inconclusive regarding the agents of change for those positive effects that seem to have occurred. Although a trauma-based model was used and appeared to be supported, alternative explanations would be plausible, specifically regarding the Motivation and Adaptive Skills phases of the treatment, as well as the additional non-MASTR treatment components, such as parent consultation. However, the present findings are sufficiently encouraging to warrant more systematic study of the MASTR treatment approach. Tentative support was found for the notion that trauma treatment, broadly conceived, can lead to reductions of post-traumatic symptoms, as well as CP symptoms, in a heterogeneous adolescent CP population. Support for MASTR’s ability to lead CP adolescents to accomplish trauma resolution work was more tenuous, given the high rate of premature termination. It may be most successful when the clients are compelled to attend treatment sessions. Further study of the MASTR approach should feature independent assessment, multiple-source post-traumatic stress and behavioral measures, a standard care control group, manual-based therapist training, multiple therapists, and consistent external pressure for treatment attendance. Since CP youth often have treatment needs beyond what can be provided within the individual therapy context (for example, family therapy, special education, or vocational training), further study of MASTR should probably be conducted within a comprehensive treatment approach.

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If the trauma-based model of CP is on target and if MASTR is an effective treatment for CP, then follow-up assessment will be particularly important because those receiving MASTR treatment would be expected to show continued improvement over time (as has been seen in other EMDR studies: e.g., Puffer et al., 1998; Scheck et al., 1998; Soberman et al., 2002). This may be due to the spiraling effect that an improving CP youth and an increasingly favorable environment can have on one another. Alternately or in addition, it may be that the resolution of trauma makes the youth less impervious to other treatment components within a program, which are then more likely to be effective, leading to continued progress over time. It would be interesting to compare MASTR to standard EMDR within the context of a comprehensive treatment program that already includes motivational and cognitive-behavioral components. If the groups had equal outcomes, then MASTR would be superfluous; however, if MASTR was superior, this design would not yield conclusive explanations. In that case it would be possible that MASTR offers some improvement on standard motivational or cognitive-behavioral approaches, that one or more components of MASTR has a particularly significant effect, or that MASTR’s special value is to facilitate participation in standard EMDR for youth who might otherwise refuse. Attempting to identify possibly effective components with repeated measurement during treatment is not recommended, because the effects of specific interventions may not fully manifest in the brief period between one session and the next. Traditional component analysis studies, in which different elements are omitted in different groups, should not be attempted until MASTR has been shown to have more value than standard care plus EMDR. CONCLUSION The MASTR approach represents several possible advances in treating CP youth. This may be the first time that motivational interviewing has been systematically used with the CP population, and with an innovative format designed to appeal to these youth. MASTR also includes some innovative variants of standard cognitive-behavioral training methods, likewise designed to appeal. Although this is not the first time that EMDR has been used with CP youth, MASTR offers a unique preparatory sequence of interventions that may make EMDR more acceptable to this resistant population.

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The essence of the MASTR approach, however, goes beyond the inclusion of effective components. Any of these components may ultimately be discarded, refined, or replaced. MASTR offers a comprehensive, systematic individual psychotherapy approach based on the traumagenic model of CP (Greenwald, 2002). A theory-based method allows for theory development, in addition to merely testing the method’s effectiveness, and guides further development of the intervention (Kazdin, 1997). These preliminary findings are consistent with both theoretical and practical expectations: All participants did report significant trauma history; following treatment, post-traumatic stress symptoms were reduced as were problem behaviors. It is hoped that further study of CP youth and the MASTR approach to treatment will contribute to both theory development and effective practice. REFERENCES Achenbach, T. M., & Edelbrock, C. S. (1984). Child Behavior Checklist. Burlington, VT: University of Vermont. Briere, J. (1996). Trauma Symptom Checklist for Children: Professional manual. Odessa, FL: Psychological Assessment Resources. Chambless, D. L., Baker, M., Baucom, D., Beutler, L., Calhoun, K., Crits-Christoph, P., Daiuto, A., DeRubeis, R., Detweiler, J., Haaga, D., Bennett-Johnson, S., McCurry, S., Mueser, K., Pope, K., Sanderson, W., Shoham, V., Stickle, T., Williams, D., & Woody, S. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3-16. Chemtob, C. M., Nakashima, J., Hamada, R., & Carlson, J. (in press). Brief treatment for elementary school children with disaster-related PTSD: A field study. Journal of Clinical Psychology. Chemtob, C. M., Novaco, R. W., Hamada, R. S., & Gross, D. M. (1997). Cognitivebehavioral treatment for severe anger in posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 65, 184-189. Chemtob, C. M., Tolin, D. F., van der Kolk, B. A., & Pitman, R. K. (2000). Eye movement desensitization and reprocessing. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 139-154). New York: Guilford. Colby, S. M., Monti, P., Barnett, N. P., Rohsenow, D. J., Weissman, K., Spirito, A., Woolard, R. H., & Lewander, W. J. (1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study. Journal of Consulting and Clinical Psychology, 66, 574-578. Datta, P. C., & Wallace, J. (1996). Enhancement of victim empathy along with reduction in anxiety and increase of positive cognition of sex offenders after treatment with EMDR. Paper presented at the annual meeting of the EMDR International Association, Denver, CO.

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Emmerson, G. J., & Neely, M. A. (1988). Two adaptable, valid, and reliable data-collection measures: Goal attainment scaling and the semantic differential. The Counseling Psychologist, 16, 261-271. Foster, S., & Lendl, H. (1996). Four case studies of a new tool for executive coaching and restoring employee performance after setbacks. Consulting Psychology Journal, 48, 155-161. Greenwald, R. (1993). Magical installations can help clients to slay their dragons. EMDR Network Newsletter, 3 (2), 16-17. Greenwald, R. (1996a). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72. Greenwald, R. (1996b). Psychometric review of the Problem Rating Scale. In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 242-243). Lutherville, MD: Sidran. Greenwald, R. (1998a). EMDR cures kidney stones?: A case report. EMDRIA Newsletter, 3 (3), 32. Greenwald, R. (1998b). Eye movement desensitization and reprocessing (EMDR): New hope for children suffering from trauma and loss. Clinical Child Psychology and Psychiatry, 3, 279-287. Greenwald, R. (1999). Eye movement desensitization and reprocessing (EMDR) in child and adolescent psychotherapy. Northvale, NJ: Jason Aronson. Greenwald, R. (2000). A trauma-focused individual therapy approach for adolescents with conduct disorder. International Journal of Offender Therapy and Comparative Criminology, 44, 146-163. Greenwald, R. (2002). The role of trauma in conduct disorder. Journal of Aggression, Maltreatment & Trauma, 6(1), 5-23. Greenwald, R., Lundberg, D., & Smyth, N. J. (2001). Trauma treatment for reduction of problem behaviors in an adolescent residential facility. Manuscript in preparation. Greenwald, R., & Rubin, A. (1999). Brief assessment of children’s post-traumatic symptoms: Development and preliminary validation of parent and child scales. Research on Social Work Practice, 9, 61-75. Ironson, G. I., Freund, B., Strauss, J. L., & Williams, J. (in press). A comparison of two treatments for traumatic stress: A pilot study of EMDR and prolonged exposure. Journal of Clinical Psychology. James, B. (1989). Treating traumatized children: New insights and creative interventions. Lexington, MA: Lexington Books. Jameson, M. (1998, July). Effects of EMDR in a male correctional facility. Paper presented at the annual meeting of the EMDR International Association, Baltimore, MD. Kazdin, A. E. (1987). Treatment of antisocial behavior in children: Current status and future directions. Psychological Bulletin, 102, 187-203. Kazdin, A. E. (1997). Practitioner review: Psychosocial treatments for conduct disorder in children. Journal of Child Psychology and Psychiatry, 38, 161-178. Kazdin, A. E., Mazurick, J. L., & Bass, D. (1993). Risk for attrition in treatment of antisocial children and families. Journal of Clinical Child Psychology, 22, 2-16. Kovacs, M. (1981). The Children’s Depression Inventory. Pittsburgh, PA: University of Pittsburgh Press.

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Lawendowski, L. A. (1998). Motivational interviewing with adolescents presenting for outpatient substance abuse treatment. Dissertation Abstracts International, 59-03B, 1357. Lee, C., Gavriel, H., Drummond, P., Richards, J., & Greenwald, R. (in press). Treatment of PTSD: Stress Inoculation Training with Prolonged Exposure compared to EMDR. Journal of Clinical Psychology. Loeber, R. (1990). Development and risk factors of juvenile antisocial behavior and delinquency. Clinical Psychology Review, 10, 1-41. Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Strategies in the treatment of addictive behaviors. New York: Guilford. Marshall, W. L. (1996). Assessment, treatment and theorizing about sex offenders: Developments during the past twenty years and future directions. Criminal Justice and Behavior, 23, 162-199. Miller, W. R. (1996). Motivational interviewing: Research, practice, and puzzles. Addictive Behavior, 21, 835-842. Miller, W.R. (2000). Rediscovering fire: Small interventions, large effects. Psychology of Addictive Behavior, 14, 6-18. Moffitt, T. (1993). Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100, 674-701. Monti, P. M., Colby, S. M., Barnett, N. P., Spirito, A., Rohsenow, D. J., Myers, M., Woolard, R., & Lewander, W. (1999). Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. Journal of Consulting and Clinical Psychology, 67, 989-994. Newman, E. (2002). Assessment of PTSD and trauma exposure in adolescents. Journal of Aggression, Maltreatment & Trauma, 6(1), 59-77. Pakiz, B., Reinherz, H. Z., & Giaconia, R. M. (1997). Early risk factors for serious antisocial behavior at age 21: A longitudinal community study. American Journal of Orthopsychiatry, 67, 92-101. Peterson, K. C., Prout, M. F., & Schwarz, R. A. (1991). Post-traumatic stress disorder: A clinician’s guide. New York: Plenum Press. Pynoos, R. S., & Eth, S. (1986). Witness to violence: The child interview. Journal of the American Academy of Child Psychiatry, 25, 306-319. Puffer, M. K., Greenwald, R., & Elrod, D. E. (1998). A single session EMDR study with twenty traumatized children and adolescents. Traumatology, 3 (2). Available Internet: . Reynolds, C., & Richmond, B. (1978). What I think and feel: A revised measure of children’s manifest anxiety. Journal of Abnormal Child Psychology, 6, 271-280. Rubin, A., Bischofshausen, S., Conroy-Moore, K., Dennis, B., Hastie, M., Melnick, L., Reeves, D., & Smith, T. (in press). The effectiveness of EMDR in a child guidance center. Research on Social Work Practice. Scheck, M. M., Schaeffer, J. A., & Gillette, C. S. (1998). Brief psychological intervention with traumatized young women: The efficacy of eye movement desensitization and reprocessing. Journal of Traumatic Stress, 11, 25-44. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocol and procedures. New York: Guilford Press.

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Shapiro, F. (1996). Errors of context and review of eye movement desensitization and reprocessing research. Journal of Behavior Therapy and Experimental Psychiatry, 27, 313-317. Soberman, G. S., Greenwald, R., & Rule, D. L. (2002). A controlled study of eye movement desensitization and reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment & Trauma, 6(1), 215-234. Sommers-Flanagan, J., & Sommers-Flanagan, R. (1995). Psychotherapeutic techniques with treatment-resistant adolescents. Psychotherapy, 32, 131-140. Spielberger, C. D. (1996). State-Trait Anger Expression Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources. Stewart, K. (1998, July). Incorporating EMDR in a residential setting for abused adolescent females. Paper presented at the annual meeting of the EMDR International Association, Baltimore, MD. Stickgold, R. (1998). Sleep, memory, PTSD and EMDR. EMDRIA Newsletter, 3 (3), 16. Taylor, S. E., Pham, L. B., Rivkin, I. D., & Armor, D. A. (1998). Harnessing the imagination: Mental simulation, self-regulation, and coping. American Psychologist, 53, 429-439. van Etten, M., & Taylor, S. (1998). Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126-145. Wiedemann, J., & Greenwald, R. (2000, November). Child trauma assessment with the CROPS and PROPS: Construct validity in a German translation. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.

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Conclusion Ricky Greenwald

This volume appears at a time in history when we are beginning to comprehend the extent of trauma’s impact on children and adolescents on all levels including biological, psychological, and social. We are beginning to move from the mere recognition that juvenile delinquents have often faced extreme adversity in their childhood, to the understanding that such adversity has had specific effects which contribute to the delinquency lifestyle. In this volume and elsewhere, we are integrating the knowledge and theory of the burgeoning field of traumatic stress studies with the research on juvenile delinquency. We have learned quite a bit about trauma’s contribution to conduct disorder and juvenile delinquency. The evidence supporting trauma’s role is voluminous and derives from multiple lines of study. The challenge now is to integrate this knowledge into one or more coherent theories which can guide prevention and intervention efforts. This volume includes credible preliminary efforts in that regard, which can be tested and further developed. It would not be surprising, as progress is made in this area, to discover that different theories more accurately capture the delinquency processes for different sub-populations. We know relatively little about how to treat the trauma component of those youth with severe behavior problems. To the best of my knowledge, this volume represents the state of the art in trauma-focused treatment for juvenile delinquents and related populations. Although the reported findings are encouraging, the studies are clearly preliminary. These treatment approaches (and others) need to be more fully tested [Haworth co-indexing entry note]: “Conclusion.” Greenwald, Ricky. Co-published simultaneously in Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 6, No. 1 (#11), 2002, pp. 263-264; and: Trauma and Juvenile Delinquency: Theory, Research, and Interventions (ed: Ricky Greenwald) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2002, pp. 263-264. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

© 2002 by The Haworth Press, Inc. All rights reserved.

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and possibly further developed. Of course, such treatment outcome studies must track both post-traumatic symptomatology and antisocial behavior. Although the preliminary results reported in this volume are encouraging regarding both the capacity of various trauma-focused treatment approaches to ameliorate adolescents’ post-traumatic stress and to lead to improved behavior, much more remains to be done. One of the goals in this volume was to emphasize the interplay of research, theory, and intervention in the service of reducing the problem of juvenile delinquency. The importance of theory cannot be overemphasized. The better we understand the phenomenon of juvenile delinquency, the better we can target our prevention and treatment efforts. The plethora of trauma-related research findings is enough to formulate a theory. Now further research should be guided by theory and in the service of testing it and filling it in. Intervention studies can not only be guided by theory, but can further contribute to theory development. For example, some of the outcome studies reported here did at least support the broadest tenet of the theories presented, in that the trauma-focused treatment which led to reduced post-traumatic symptoms also led to reduced problem behaviors. There is another value to the recognition of trauma’s role in juvenile delinquency that has not been substantively addressed here. If unresolved trauma is a significant risk factor in juvenile delinquency–possibly a key factor–then prevention and early intervention efforts should be modified accordingly. Fortunately, there are already some efforts being made to prevent child victimization, as well as to respond to children’s exposure to traumatic events by providing treatment. Much more can be done in each of these areas, and perhaps the recognition of trauma’s role in juvenile delinquency will serve as additional inspiration in that regard. Also, treatment for younger children with conduct problems might benefit from inclusion of a trauma component. Clearly, there’s plenty of work to do! The good news is that there is already sufficient evidence to suggest that this will be a rewarding line of inquiry. There is reason to hope that we will be able to utilize the trauma perspective to deepen our understanding of the dynamics driving juvenile delinquency, to prevent more children from becoming juvenile delinquents, and to help more delinquent youth to choose a more productive and pro-social path.

Index Numbers followed by “f” indicate figures; “t” following a page number indicates tabular material.

Abuse physical, PTSD following, 202-204 sexual in ecopathological model of delinquent behavior among incarcerated adolescents, 134 PTSD following, 202-204 Accelerated Information Processing hypothesis, 242 Acute stress disorder (ASD), in adolescents, assessment of, 70-72 ADHD. See Attention deficit/hyperactive disorder (ADHD) Adolescence, violence and delinquency during, childhood trauma as pathway to, xix-xxv. See also Trauma, childhood, as pathway to adolescent violence and delinquency Adolescent(s) acute stress disorder in, assessment of, 70-72 female, antisocial behavior and delinquency in, chaos and trauma related to, 79-108 incarcerated delinquent behavior among, ecopathological model of, 127-147. See also Delinquent behavior, among incarcerated adolescents, ecopathological model of

mental health problems in, prevalence of, 129-130 problems related to, 128-130 with PTSD, cognitive processing therapy for, 201-216. See also Post-traumatic stress disorder (PTSD), incarcerated adolescents with, cognitive processing therapy for as victims of and witnesses to violence, 128-129 PTSD in, 59-77. See also Post-traumatic stress disorder (PTSD), in adolescents trauma exposure in, assessment of, 59-77 trauma in, 6-9 traumatic victimization in, oppositional-defiance problems related to, 26-31 AEIII. See Assessing Environments-III (AE-III) Age, as factor in delinquent activity, 120-121,122t Aggression, relational, 92-96,93t, 96t-98t Aggressive behaviors, among adolescent girls, 110-111 Aggressive youth catecholamine production in, 164-165 psychophysiological studies of, 163-164 Ahrens, J., xv,2,201 Aichhorn, A., 176

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Amaya-Jackson, L., 206 Andrews, B., 87 Anthony, B.A., 84 Antisocial behavior and delinquency in adolescent females, chaos and trauma related to, 79-108 in Oregon study, 95-96,96t-98t severe and delinquency in adolescent females gender differences in history and treatment response, 88-90 long-term implications of, 84-86 trauma transmission to next generation, 86-88 types of, 82-90 prevalence of, 82-90 ASD. See Acute stress disorder (ASD) Assessing Environments-III (AEIII), 91,116 in ecopathological model of delinquent behavior among incarcerated adolescents, 136 Attention deficit/hyperactive disorder (ADHD), and conduct disorder, 14

Basal cortisol responses, to stress, in aggressive youth, studies of, 160-163,162t Bates, J.E., xxii Baum, A.S., 156 BDI. See Beck Depression Inventory (BDI) Beck, A.T., 205 Beck Depression Inventory (BDI), in PTSD cognitive processing therapy assessment, 208 Behavior(s) aggressive, among adolescent girls, 110-111

antisocial, and delinquency in adolescent females, chaos and trauma related to, 79-108 delinquent, among incarcerated adolescents. See also Delinquent behavior, among incarcerated adolescents, ecopathological model of ecopathological model of, 127-147 drug-related, risky, in delinquent adolescent girls, 120 in Oregon study antisocial, 95-96,96t-98t criminal, 95-96,96t-98t Behavior disorders, disruptive, in children and adolescents, traumatic victimization and, 26-31 Behavioral Reward Scale (BRS), in EMDR for boys with conduct problems, 223 Bell, C., 202 Best, C.L., 204-205 Bialik, R.J., 158 Björkquist, K., 82 Boston VA PTSD Outpatient Clinic, 183 Brain, developing, early childhood trauma effects on, 153-155 Brief Symptom Inventory (BSI), 95 Brown, G.W., 87 BRS. See Behavioral Reward Scale (BRS) BSI. See Brief Symptom Inventory (BSI) Burton, D., 129 Butter, H.J., 158 Bwanausi, C., 129

Cairns, B.D., 82,85 Cairns, R.B., 82,83,85 California Youth Authority, 84 Callaghan, M., 203

Index

Cambridge Study of Delinquent Development, 163 Capaldi, D.M., 86 CAPS-CA. See Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) Carlson, J., 203 Carrey, N.J., 158 Caseau, D.L., 81 Catecholamine, production of, in aggressive youth, 164-165 CDI. See Children’s Depression Inventory (CDI) CETV Scale. See Community Violence (CETV) Scale Chamberlain, P., xv,79,88 Chaos, in adolescent females with antisoical behavior and delinquency, 79-108 Chemtob, C.M., 178,203 Chesney-Lind, M., 81 Child PTSD Checklist, 184-185 Child Report of Post-Traumatic Symptoms (CROPS) in EMDR for boys with conduct problems, 222 in MASTR therapy trial, 245 Childhood Sexual Experience Questionnaire, 91,92,93t Children maltreated catecholamine production in, 159-160 neurobiological findings in, 157-159 psychophysiological studies in, 157-159 trauma in, 6-9 traumatic victimization in, oppositional-defiance problems related to, 25-58. See also Oppositional-defiance disorders, traumatic victimization in childhood and persistent problems with

267

traumatized, neurobiological disturbances in, 149-174. See also Neurobiological disturbances, in youth with childhood trauma Children’s Depression Inventory (CDI), in MASTR therapy trial, 245 Choices Have Consequences, 242 Chrousos, G.P., 156 Cicchetti, D., 43,151,156,178 Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA), 167 Cobham-Portorreal, N.K., 84 Coercive behavior model, reinforcement for, 11-12,13f Cognitive processing therapy for incarcerated adolescents with PTSD, 201-216. See also Post-traumatic stress disorder (PTSD), incarcerated adolescents with, cognitive processing therapy for study of, 2 Coie, J.D., 85 Combating Violence and Delinquency: The National Juvenile Justice Action Plan, 178 Community Violence (CETV) Scale, 184-185 Compas, B., 111 Conduct disorders ADHD and, 14 among adolescent girls, 110-111 boys with, EMDR for, controlled study of, 217-236. See also Eye movement desensitization and reprocessing (EMDR), for boys with conduct problems, controlled study of children with, neurobiological disturbances in, 149-174. See also Neurobiological

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disturbances, in youth with childhood trauma described, 6,218,238 developmental models of coercive behavior model, 11-12,13f trauma in, 11-14,13f EMDR for, 239-241 gender as factor in, 16 MASTR therapy for, open trial of, 237-261. See also Motivation-adaptive skills-trauma resolution (MASTR) therapy, for conduct disorders, open trial of neurobiological findings in, 160-165,162t predictors of, 14 risk factors for, 6 subtypes of, 16 trauma and, 5-23,238 treatment of, issues related to, 14-16 Conflict, family, defined, 29 Connelly Treatment Unit (CTU), 184 Coping, after traumatic victimization, 36-41. See also Oppositional-defiance disorders, traumatic victimization in childhood and persistent problems with, coping as victim Corrigan, S.A., 7 Cortisol responses, to stress, in aggressive youth, studies of, 160-163,162t Courtois, C.A., 204 Creasey, L., 87 Crick, N.R., 83 Criminal behavior, in Oregon study, 95-96,96t-98t CROPS. See Child Report of Post-Traumatic Symptoms (CROPS) CTU. See Connelly Treatment Unit (CTU)

Cumulative risk model, 12,14 Cusack, J., 180

Datta, P.C., 219,239 DBDs. See Disruptive behavior disorders (DBDs) De Bellis, M.D., 154,156 Deblinger, E., 206 Dekirmenjian, H., 165 Delinquency in adolescence, childhood trauma as pathway to, xix-xxv antisocial behavior and, and delinquency in adolescent females, chaos and trauma related to, 79-108 trauma and, 177-178 Delinquent activity, violence exposure and, relationship between, 130 Delinquent behavior, among incarcerated adolescents, ecopathological model of, 127-147 present studies AEIII in, 136 community violence exposure in, 134 delinquent activity in, 136-137 described, 131-132 discussion of, 141-144 high school sample, 133 implications of, 144-145 incarcerated sample, 132-133 measures in, 136 method of, 132-137,135t posttraumatic stress symptoms in, 134 results of, 137-141,138f,139f, 141t,142t SAEQ in, 136 sexual abuse in, 134 Delinquent girls

Index

age of onset of delinquent activity in, 120-121,122t aggressive behaviors in, 110-111 conduct disorders in, 110-111 correlates of, summary of, 113-114 gang-involved, recent research on, 112-113 incarcerated, 110-112 prevalence of, 110 recent research on, 112-113 involvement in delinquent activity, antecedents and trajectories of, 110-112 violence exposure and PTSD among, 109-127 research related to, 124-125 study of case example, 121-122 depression in, 119t,120 described, 114-115 discussion of, 122-125 levels of exposure to traumatic violence in, 117-118,118t measures in, 115-117,116t method of, 115-117,116t overview of, 117 posttraumatic distress in, 119-120,119t psychological distress levels in, 119-120,119t results of, 117-122,118t, 119t,122t risky drug-related behavior in, 120 subsample in, 115 Dembo, R., 113 Department of Youth Service (DYS), of Massachusetts, 182-189 Depression, in delinquent adolescent girls, 119t,120 DESNOS. See Disorders of Extreme Stress Not Otherwise Specified (DESNOS) Deviant cycle, 180

269

Diagnostic and Statistical Manual of Mental Disorders, 27 DISC-2 Interview, 95 Disorders of Extreme Stress Not Otherwise Specified (DESNOS), 45 Disruptive behavior disorders (DBDs), neurobiological findings in, 160-165,162t Dodge, K.A., xxii,41-42,47 Drug-related behavior, risky, in delinquent adolescent girls, 120 Dubrow, N., 176 DYS. See Department of Youth Service (DYS) Dysregulation of emotion and information processing, oppositional-defiance and, 36-37

Early Warning System, 242 EBC. See Elliott Behavior Checklist (EBC) Elliott Behavior Checklist (EBC), 96, 97t EMDR. See Eye Movement Desensitization and Reprocessing (EMDR) Emery, G., 205 Emotion(s), dysregulation of, oppositional-defiance and, 36-37 Evans, W., 113 Eye movement desensitization and reprocessing (EMDR) for boys with conduct problems controlled study of, 217-236 BRS in, 223 CROPS in, 222 discussion of, 226-227, 230-232 goals of, 221 IES-8 in, 222

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measures in, 222-223 method in, 221-225 participants in, 221 procedures in, 224-225 PROPS in, 223 PRS in, 223 results of, 225-226,226t, 227t,228f-229f SUDS in, 222 treatment protocol in, 223-224 data on, 219 for conduct disorders, 239-241 controversies associated with, 220 disadvantages of, 220-221 historical background of, 220 for PTSD, 181-182

Family conflict, defined, 29 Family psychopathology, defined, 29 Farrington, D.P., 163 FBI’s Uniform Crime Reports, 128 Ferguson, L.L., 82 Foa, E.B., 205 Ford, J.D., xv,2,25,30-31,46 Foy, D.W., xv,109,127,129,139 Freeman, L.N., 203

Gang(s), delinquent girls in, recent research on, 112-113 Gang Affiliation index, 116-117 Garbarino, J., xix,xv,176 Garcia, 129-130 Gariepy, J.L., 82 GC. See Group Care (GC) Gender as factor in conduct disorder, 16 as factor in history and treatment response of adolescents with severe antisocial behavior, 88-90 as factor in Oregon TFC model, 96-101 George, W.H., 179

Gerhardt, C., 111 Giaconia, R.M., 10 Giedd, J.N., 154 Gillette, C.S., 219,239-240 Goguen, C.A., xv-xvi,109 Gray, A.S., 180 Green, A.H., 203 Greenwald, R., xvi,xx,xxiv,1,2-3, 5, 217,237,244,263,619 Group Care (GC), 90 Guerny, B.G., 176 Gunnar, M., 156

Hamada, H., 203 Hansen, D., 130 Hart, J., 156 Henggeler, S., 111 Henry, D., 203 Hinden, B., 111 Hypothalamic pituitary adrenal (HPA) axis, 155 Hypothalamic pituitary gonadal (HPG) axis, 150

IES. See Impact of Events Scale (IES) IES-8. See Impact of Events Scale-8 Items (IES-8) Impact of Events Scale (IES), in PTSD cognitive processing therapy assessment, 208 Impact of Events Scale-8 Items (IES-8), in EMDR for boys with conduct problems, 222 Information processing dysregulation of, oppositional-defiance and, 36-37 social/emotional, as link between victim coping and oppositional-defiance, 41-43

James, C.B., xvi,109,127

Index

Jaycox, L., 111 Jenkins, E., 202 Johnson, J., 129 Juvenile justice, referrals from, gender differences, 94-95 Juvenile Justice Update, xx Juvenile offenders, incarcerated trauma in, treatment of, 181-182 first intervention trial in, 182-189 results of, 192-194 second intervention trial in, 189-192 trauma-focused treatment groups for case examples, 193-194 preliminary development of, 175-199 study of, limitations of, 194-195 treatment of, 178-180

Kagan, J., 161 Keshavan, G.P., 154 Keshavan, M.S., 154 Khan, A.U., 165 Kidd, P., 46 Kilpatrick, D.G., 204-205 King, D., 139 King, L., 139 Klorman, R., 43 Kostelny, K., 176 Kozak, M.J., 205 Krinsley, K., xvi,175 Kroth, R.L., 81 Kupersmidt, J.B., 85

LaFratta, J., 180 Lahey, B., 35 Lang, P.J., 205 LASC. See Los Angeles Symptom Checklist (LASC) Lauterbach, D., 7

271

Layne, C., xvi,127,136 LC. See Locus coeruleus (LC) Leisen, M.B., xvi,175,180 Leskin, G., 139 Lewis, D.O., 84,112,130 Lifetime Childhood Sexual Experiences Questionnaire, 91,92,93t Linehan, M.M., 99-100 Lippman, J., 206 Lipschitz, D.S., xvi,2,149 Litwin, P., 180 Locus coeruleus (LC), 159 Los Angeles Symptom Checklist (LASC), 116,134 Lost Boys: Why Our Sons Turn Violent and How We Can Save Them, xix Luckasson, R., 81 Lynch, M., 43 Lyons-Ruth, K., 47

Magnusson, D., 111 Malinkosky-Rummell, R., 130 Mallah, K., 41 Mallouh, C., 130 “Manhattan’s Child Criminals Are My Job,” xx MANOVAs. See Multivariate analyses of variance (MANOVAs) March, J.S., 206 Marlatt, G.A., 179 MASTR therapy. See Motivation-adaptive skills-trauma resolution (MASTR) therapy Matthews, 129-130 McCann, I.L., 209 McLeer, S.V., 203 McMackin, R.A., xvi-xvii,2,175,180 Mental health problems among incarcerated adolescents, prevalence of, 129-130 in Oregon study, 95

272

TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

Mihalic, S.F., 88 Minuchin, S., 176 Mokros, H., 203 Moore, K.J., xvii, 79 Moore, L., 129 Morgan, C.A., III, xvii,2,149 Motivation-adaptive skills-trauma resolution (MASTR) therapy, for conduct disorders described, 241-244 open trial of, 237-261 adaptive skills in, 242-243 case examples, 247-251 CDI in, 245 CROPS in, 245 discussion of, 252,255-257 measures in, 245-246 method of, 244-247 motivation in, 242 participants in, 244-245 phases of, 242-243 procedures in, 246-247 PROPS in, 245 PRS in, 246 RCMAS in, 245 results of, 251-252,253f-255f STAXI in, 245 trauma resolution in, 243 Motivational Interviewing (MI), 243 Multivariate analyses of variance (MANOVAs), 120 in PTSD cognitive processing therapy assessment, 210-211, 211t Murray, M.C., 206

Nagin, D., 34 National Center for Posttraumatic Stress Disorder (NC-PTSD), 183 National Institute of Mental Health (MH54257), 90 NC-PTSD. See National Center for Posttraumatic Stress Disorder (NC-PTSD)

Neckerman, H.J., 82,85 Neurobiological disturbances in youth with childhood trauma, 149-174 future directions in, 165-168 introduction to, 150-152 in youth with conduct disorder, 149-174 future directions in, 165-168 New York Times, xx Newman, E., xvii,2,59 Noradrenergic activity, hormonal measures of, 164-165 Norris Traumatic Stress Schedule, 91 Novaco, R.W., 178

Offender cycle, 180 Offense cycle, 180 trauma-informed, 12,13f Ontario Child Health Study, 83 Oppositional-defiance disorders in children and adolescents, 26-31 coping as victim, social/emotional information processing and, 41-43 dysregulation of emotional and information processing in, 36-37 problematic, 35 problems associated with, 35-36 traumatic victimization in childhood and persistent problems with, 25-58 causes of, 31-35 coping after, 38-41 social/emotional information processing and, 41-43 coping as victim, 36-41 course of, 31-35 impact of, 37-38 imprint imposed by, 36-41 prevention and treatment of, 43-46

Index

research related to, 46-48 Oregon Social Learning Center (OSLC), 94 Oregon Social Learning Center (OSLC) TFC model, 88 Oregon State Corrections Division, 88 Oregon study of female delinquency antisocial behavior in, 95-96, 96t-98t characteristics of, 91-92 criminal behavior in, 95-96,96t-98t family instability in, 92 gender differences in referrals from juvenile justice, 94-95 history of childhood sexual experiences in, 92 mental health problems in, 95 process and outcomes of, 90-101, 93t,96t-98t relational aggression in, 92-96,93t, 96t-98t risk factors associated with, 91-92 Oregon TFC model, gender-related adaptations to, 96-101 Oregon Youth Authority (OYA), 88 Oregon Youth Study, 86 OSLC. See Oregon Social Learning Center (OSLC) OYA. See Oregon Youth Authority (OYA)

PACS program. See Parents’ and Children Series (PACS) program Pardo, C., 176 Parent Daily Report (PDR), 89 Parent Report of Post-Traumatic Symptoms (PROPS) in EMDR for boys with conduct problems, 223 in MASTR therapy trial, 245 Parents’ and Children Series (PACS) program, 44 Patterson, G.R., 32-33

273

PC. See Pilgrim Center (PC) PDR. See Parent Daily Report (PDR) Perry, B.D., 154,157-158,166 Persinger, M.A., 158 Pettitt, G.S., xxii Physical abuse, PTSD following, 202-204 Pilgrim Center (PC), 184 Pithers, W.D., 180 Pollak, S., 43 Ponitrakis, A., 161 Post-traumatic stress in delinquent adolescent girls, 119-120,119t symptoms of, in ecopathological model of delinquent behavior among incarcerated adolescents, 134 Post-traumatic stress disorder (PTSD) in adolescents, assessment of, 59-77 cormorbidity in, 63 interviews in, 68,68t multi-modal approach to, 64-72, 66t,68t parental reports in, 69-70,71t process in, 61-63 rapport building and clinician demeanor in, 61-62 safety in, 62-63 self-report measures in, 68-69, 69t in adults, treatment of, 204-206 among delinquent girls, 109-127. See also Delinquent girls, violence exposure and PTSD among complex, in adolescents, assessment of, 70-72 development of, 177 diagnosis of, 202 incarcerated adolescents with, 177-178 cognitive processing therapy for, 201-216 discussion of, 211-212

274

TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

group, 207-208 instrumentation in, 208 introduction to, 202 procedure for, 209-210 rationale for, 206-207 repeated measures analyses of, 210-211,211t results of, 210-211,211t self-report inventories in, 208 subjects for, 207 therapists in, 207-208 treatment of, 178-180 efficacy of, 206 neurobiological findings in, 155-157 in sexually and physically abused children, 202-204 studies of, 202 Poznanski, E.O., 203 Price, R.K., 84 Problem Rating Scale (PRS) in EMDR for boys with conduct problems, 223 in MASTR therapy trial, 246 Problematic oppositional-defiance, 35 PROPS. See Parent Report of Post-Traumatic Symptoms (PROPS) PRS. See Problem Rating Scale (PRS) PSS-SR. See PTSD Symptom Scale Self-Report (PSS-SR) Psychological distress, in delinquent adolescent girls, 119-120, 119t Psychopathology, family, defined, 29 PTSD. See Post-traumatic stress disorder (PTSD) PTSD Symptom Scale Self-Report (PSS-SR), in PTSD cognitive processing therapy assessment, 208 Putnam, F.W., 71,151,157 Pynoos, R., xvii,109,127

Quinton, D., 86

Raine, A., 163-164 Rapoport, J.L., 165 RCMAS. See Revised Children’s Manifest Anxiety Scale (RCMAS) Reisck, P.A., 205 Relapse prevention, 180 Relational aggression, 92-96,93t, 96t-98t Repetti, R., 111 Resick, P.A., 209 Revised Children’s Manifest Anxiety Scale (RCMAS), in MASTR therapy trial, 245 Rexford, L., xvii,2,201 Reznick, J.S., 161 Riggs, D.S., xvii,175 Riise, K.S., 7 Robins, L.N., 84 Rochester Youth Development Study, 112-113,130 Rogers, K., 85 Roitblat, H.L., 203 Rule, D.L., xvii-xviii,217 Rutter, M., 86,99

SAEQ. See Sexual Abuse Exposure Questionnaire (ASEQ) Safety, in assessment of PTSD and trauma exposure in adolescents, 62-63 Sattler, L., xviii,175 Saturday Evening Post, xx SCECV. See Survey of Children’s Exposure to Community Violence (SCECV) Schaeffer, J.A., 219,239-240 Scheck, M.M., 219,239-240 Schnicke, M.K., 205,209 Schulte, A., 206 Self-report inventories, in PTSD cognitive processing therapy assessment, 208 Sexual abuse

Index

in ecopathological model of delinquent behavior among incarcerated adolescents, 134 PTSD following, 202-204 Sexual Abuse Exposure Questionnaire (SEAQ), 116 Sexual Abuse Exposure Questionnaire (SAEQ), in ecopathological model of delinquent behavior among incarcerated adolescents, 136 Shapiro, F., 224 Shepherd, R., xx Showalter, B.A., 84 Snidman, N., 161 Snyder, H., 110 Soberman, G.B., xviii,2,217,240 Social/emotional information processing, as link between victim coping and oppositional-defiance, 41-43 Southwick, S.M., xviii,2,149 State-Trait Anger Expression Inventory (STAXI), in MASTR therapy trial, 245 Stattin, H., 111 STAXI. See State-Trait Anger Expression Inventory (STAXI) Steer, R., 206 Steiner, H., 129-130,166 Stress in aggressive youth, basal cortisol and cortisol responses to, studies of, 160-163,162t posttraumatic, in delinquent adolescent girls, 119-120,119t Subjective Units of Distress Scale (SUDS), in EMDR for boys with conduct problems, 222 SUDS. See Subjective Units of Distress Scale (SUDS) Survey of Children’s Exposure to Community Violence (SCECV), 116,134

275

Susman, E.J., 161 Sutler, P.B., 7

Taylor, T.L., 203 Tease Proofing, 242-243 Teicher, M.H., 154 Terr, L.C., 202,203 TFC. See Treatment Foster Care (TFC) Tolan, P., xxiii Toth, S.L., 151,178 Trauma in adolescent females with antisocial behavior and delinquency, 79-108. See also Adolescent(s), female, antisocial behavior and delinquency in, chaos and trauma related to in children, 6-9,202-204 effects of, 7-9 effects on developing brain, 153-155 neurobiological disturbances in, 153-155 as pathway to adolescent violence and delinquency, xix-xxv prevalence of, 7 in conduct disorders, 5-23,238. See also Conduct disorders, trauma in defined, 6 and delinquency, 177-178 effect on future, 9 examples of, 6 overwhelming nature of, 7-8 transmission to next generation, 86-88 treatment of, 181-182,238 violations imposed by, 9 Trauma exposure, in adolescents, assessment of, 59-77 cormorbidity in, 63 interviews in, 68,68t

276

TRAUMA AND JUVENILE DELINQUENCY: THEORY, RESEARCH, AND INTERVENTIONS

multi-modal approach to, 64-72, 66t,68t parental reports in, 69-70,71t process in, 61-63 rapport building and clinician demeanor in, 61-62 safety in, 62-63 self-report measures in, 68-69,69t Trauma resolution, 243 Trauma Symptom Checklist for Children (TSCC), 72 in MASTR therapy trial, 245 Traumatic victimization causes of, 26 in children, oppositional-defiance problems related to, 25-58. See also Oppositional-defiance disorders, traumatic victimization in childhood and persistent problems with and disruptive behavior disorders in children and adolescents, 26-31 Traumatic violence, exposure to, in study of violence exposure and PTSD among delinquent girls, 117-118,118t Treatment Foster Care (TFC), 90 Tremblay, R., 34 Trickett, P.K., 151,157 TSCC. See Trauma Symptom Checklist for Children (TSCC) Twentyman, C., 203

Uddo, M., 7 Underwood, M.K., 83,85 Unis, A.S., 151

Oppositional-defiance disorders, traumatic victimization in childhood and persistent problems with; Traumatic victimization, in children Violence in adolescence, childhood trauma as pathway to, xix-xxv. See also Trauma, childhood, as pathway to adolescent violence and delinquency exposure to among delinquent girls, 109-127. See also Delinquent girls, violence exposure and PTSD among and delinquent activity, relationship between, 130 traumatic, exposure to, in study of violence exposure and PTSD among delinquent girls, 117-118,118t victims of and witnesses to, incarcerated youth as, 128-129 Vrana, S., 7

Wallace, J., 219,239 Webb, V., 130 Weiner, B., 205 Widom, C., 130 Williams, M., 163-164 Wilson, J., 166 Wolfe, D.A., 203 Wong, P.T., 205 Wood, J., xviii,2,10,109,115-116,127 Wozniak, J., 30

Yeager, C.A., 84 van Goozen, S.H.M., 161 Venables, P.H., 163-164 Victimization, traumatic, in children, 25-58. See also

Zoccolillo, M., 82,85