Self‐reported violence amongst adolescents in Denmark: is alcohol a serious risk factor?

AIM: To describe the prevalence of adolescents' exposure to different types of violence (at home and outside the home) and associations between severe violence and alcohol consumption, taking account of gender and the influence of other factors. METHODS: A multimedia computer-based survey amongst a nationally representative sample of 9th grade pupils included comprehensive data on exposure to physical violence, use of alcohol and additional socio-demographic and behavioural factors. Analyses included gender disaggregated cross tabulations and logistic regressions. RESULTS: Around 9.3% of girls and 12.3% of boys reported being victims of physical violence within the last 12 months. Also, 2.7% of girls and 3.5% of boys reported severe violence. Gender differences existed in place of occurrence; girls were more frequently assaulted at home, boys outside the home. Alcohol was only associated with violence exposure outside the home for boys, not girls. CONCLUSIONS: About one-tenth of adolescents in Denmark reported exposure to any physical violence and 3% to severe violence during the last year. Alcohol consumption was not a risk factor for girls and only a risk factor for boys regarding violence occurring outside the home.     

Intergenerational continuity of child abuse among adolescent mothers: authoritarian parenting, community violence, and race

Among the negative sequelae of child maltreatment is increased risk for continuity of maltreatment into subsequent generations. Despite acknowledgment in the literature that the pathways toward breaking the cycle of maltreatment are likely the result of dynamic interactions of risk and protective factors across multiple ecological levels, few studies have followed high-risk samples of maltreated and nonmaltreated parents over time to evaluate such processes. In the current investigation, exposure to community violence and authoritarian parenting attitudes were evaluated as predictors of the intergenerational continuity of abuse, and the moderating effect of African American race was examined. The sample included 70 mothers and their 18-year-old children, who have been followed longitudinally since the third trimester of the adolescent mothers' pregnancy. Results revealed that among mothers with a child abuse history, higher exposure to community violence and lower authoritarian parenting attitudes were associated with increased risk for intergenerational continuity of abuse. The relation of authoritarian parenting attitudes to intergenerational continuity was moderated by race; the protective effects of authoritarian parenting were limited to the African American families only. The salience of multiple ecological levels in interrupting the intergenerational continuity of child abuse is discussed, and implications for preventive programs are highlighted.     

Exposure to violence and its relationship to psychopathology in adolescents

OBJECTIVES: This study aimed to establish prevalence of adolescents' exposure to violence and related symptoms in the South African context and to explore relationships between exposure and symptoms. SETTING: Four high schools in Cape Town, South Africa. METHODS: Self report questionnaires were administered to 104 students. Types of violence explored included: witnessing or being a victim of violence perpetrated by someone known to the child or in the home and witnessing or being a victim of violence perpetrated by a stranger. The Harvard Trauma Scale, Beck Depression Inventory, and Zung Self-Rating Anxiety Scale were used to assess potentially related symptoms. RESULTS: The majority of children had been exposed to at least one type of violence, and exposure to the one type of violence was related to the other type. Symptoms of post-traumatic stress disorder and depression appear to be related to most types of exposure to violence, but anxiety symptoms only to exposure to violence perpetrated by someone known to the child or in the home. CONCLUSIONS: Rates of exposure to violence, and related symptoms, were unacceptably high. Symptoms were associated with exposure to violence.     

Prospective effects of violence exposure across multiple contexts on early adolescents’ internalizing and externalizing problems

Background: Violence exposure within each setting of community, school, or home has been linked with internalizing and externalizing problems. Although many children experience violence in multiple contexts, the effects of such cross‐contextual exposure have not been studied. This study addresses this gap by examining independent and interactive effects of witnessing violence and victimization in the community, home, and school on subsequent internalizing and externalizing problems in early adolescence. Methods: A community sample of 603 boys and girls (78% African American, 20% Caucasian) participated in a longitudinal study of youth violence. During two assessments 16 months apart, adolescents reported on witnessing violence and victimization in the community, school, and home, and their internalizing and externalizing problems. Results: Multiple regressions tested the independent and interactive effects of witnessing violence or victimization across contexts on subsequent adjustment, after controlling for initial levels of internalizing and externalizing problems and demographic covariates. Witnessing violence at school predicted anxiety and depression; witnessing at home was related to anxiety and aggression; and witnessing community violence predicted delinquency. Victimization at home was related to subsequent anxiety, depression, and aggression; victimization at school predicted anxiety; and victimization in the community was not independently related to any outcomes. Finally, witnessing violence at home was associated with more anxiety, delinquency, and aggression only if adolescents reported no exposure to community violence. Conclusions: Violence exposure at home and school had the strongest independent effects on internalizing and externalizing outcomes. Witnessing community violence attenuated the effects of witnessing home violence on anxiety and externalizing problems, perhaps due to desensitization or different norms or expectations regarding violence. However, no comparable attenuation effects were observed for victimization across contexts.     

National survey of pediatricians' violence prevention counseling.

BACKGROUND: Recommendations for child health care providers to counsel patients and their families on violence prevention have been issued by a number of major health care organizations. OBJECTIVE: To assess the knowledge, attitudes, training, and practices of pediatricians concerning violence prevention counseling in the areas of family violence, discipline, television viewing, peer violence, and guns in the home. DESIGN: Survey. PARTICIPANTS: A national random sample of 1350 pediatricians, divided equally among residents in their final year of training, practitioners who had completed their residency training within the last 5 years, and those who had completed their training more than 5 years ago. MAIN OUTCOME MEASURES: Knowledge, attitudes, training, and current practices regarding violence prevention counseling. RESULTS: The overall response rate was 41%. When providing health supervision to patients, most pediatricians never or rarely screen for family and community violence, peer violence, and weapons. For example, 68% of residents and 73% of practitioners never or rarely screen for domestic violence, 56% of residents and 67% of practitioners never or rarely ask adolescents about their involvement in physical fighting, and 54% of residents and 56% of practitioners never or rarely identify families who have guns in the home. Regarding preparation for providing violence prevention counseling, 76% of residents and 83% of practitioners rated their training as inadequate. Receiving training in the prevention of child/adolescent violence in medical school (P<.001), residency (P<.001), or fellowship/continuing medical education (P=.002) were major determinants of more frequent violence prevention counseling. Pediatricians who believed that parents rarely or never follow through on a physician's advice about safe gun storage, switching to nonviolent disciplining techniques, or limiting their child's television viewing were less likely to ask or advise patients in these areas. CONCLUSIONS: Pediatricians are not adequately prepared to provide violence prevention counseling, and few currently screen for exposure to family and community violence, peer violence, and access to weapons. Comprehensive information about violence prevention should be integrated into medical education, and the efficacy of violence prevention counseling strategies should be evaluated.     

Violence exposure, trauma, and IQ and/or reading deficits among urban children

BACKGROUND: Exposure to violence in childhood has been associated with lower school grades. However, the association between violence exposure and performance on standardized tests (such as IQ or academic achievement) in children is unknown. It is also not known whether violence exposure itself or subsequent symptoms of trauma are primarily responsible for negative outcomes. OBJECTIVE: To examine the relationship between violence exposure and trauma-related distress and standardized test performance among early school-aged urban children, controlling for important potential confounders. DESIGN: A total of 299 urban first-grade children and their caregivers were evaluated using self-report, interview, and standardized tests. MAIN OUTCOME MEASURES: The child's IQ (Wechsler Preschool and Primary Scale of Intelligence--Revised) and reading ability (Test of Early Reading Ability, second edition) were the outcomes of interest. RESULTS: After controlling for confounders (child's gender, caregiver's IQ, home environment, socioeconomic status, and prenatal exposure to substance abuse) violence exposure was related to the child's IQ (P =.01) and reading ability (P =.045). Trauma-related distress accounted for additional variance in reading ability (P =.01). Using the derived regression equation to estimate effect sizes, a child experiencing both violence exposure and trauma-related distress at or above the 90th percentile would be expected to have a 7.5-point (SD, 0.5) decrement in IQ and a 9.8-point (SD, 0.66) decrement in reading achievement. CONCLUSION: In this study, exposure to violence and trauma-related distress in young children were associated with substantial decrements in IQ and reading achievement.     

Parenting characteristics of women reporting a history of childhood sexual abuse

This article reviews research on the parenting characteristics of female survivors of childhood sexual abuse (CSA). Various aspects of parenting are considered, including (a) childbearing patterns, (b) the intergenerational transmission of CSA, (c) maternal reactions to child CSA disclosure, (d) parenting skills and behaviors, (e) parental violence toward children, (f) attitudes toward parenting, and (g) adjustment of survivors' children. Overall patterns suggest CSA survivors may experience difficulties with some aspects of parenting. Among the more consistent trends are findings that survivors may have difficulties establishing clear generational boundaries with their children, may be more permissive as parents, and may be more likely to use harsh physical discipline. Despite associations between CSA and parenting difficulties, the limited research addressing specific aspects of parenting, and limitations in study design, preclude causal inferences and make conclusions tentative at the present time. The clinical implications of this work and directions for future research are discussed.     

Ongoing maternal drug use, parenting attitudes, and a home intervention: effects on mother-child interaction at 18 months

This prospective study examined the effects of ongoing maternal drug use, parenting attitudes, and a home-based intervention on mother-child interaction among drug-using women and their children. At 2 weeks postpartum, mothers and infants were randomly assigned to either an Intervention (n = 67) or Control (n = 64) Group. Intervention families received weekly visits until 6 months postpartum and biweekly visits from 6 to 18 months by trained lay visitors. The home intervention was designed to increase maternal empowerment and promote child development. Control families received brief monthly tracking visits. Mother-child interaction was evaluated at 18 months through observation of play. Mothers who continued to use cocaine and/or heroin had lower competence scores (p <.05); poor parenting attitude was also associated with lower competence scores during mother-child interaction (p <.05). Although the intervention had no measured effect, ongoing maternal drug use and poor parenting attitudes were associated with less optimal maternal behavior during mother-child interaction.     

Mitigating the effects of gun violence on children and youth

Countless children and youth are exposed to gun violence each year--at home, at school, in their communities, or through the media. Gun violence can leave lasting emotional scars on these children. This article reviews research regarding the psychological effects of gun violence on children and youth, and offers suggestions for how parents, school administrators, and mental health workers can mitigate these negative effects. Children exposed to gun violence may experience negative short- and long-term psychological effects, including anger, withdrawal, posttraumatic stress, and desensitization to violence. All of these outcomes can feed into a continuing cycle of violence. Certain children may be at higher risk for negative outcomes if they are exposed to gun violence. Groups at risk include children injured in gun violence, those who witness violent acts at close proximity, those exposed to high levels of violence in their communities or schools, and those exposed to violent media. Parents, school administrators, and mental health workers all can play key roles in protecting children from gun violence and helping them overcome the effects of gun-related trauma. The authors recommend a number of strategies that adults can adopt to help children cope with gun violence, such as increasing parental monitoring, targeting services to youth at risk of violent activity, and developing therapeutic interventions to help traumatized young people.     

Mothers' and health care providers' perspectives on screening for intimate partner violence in a pediatric emergency department

OBJECTIVE: To determine the attitudes, feelings, and beliefs of mothers and pediatric emergency department health care providers toward routine intimate partner violence screening. METHODS: This qualitative project employed focus groups of mothers who brought their children to a children's hospital emergency department for care, and physicians and nurses who staffed the same department. We held 6 ethnically homogeneous mother focus groups (2 white, 2 African American, and 2 Latina) and 4 provider focus groups (2 predominately female nurse focus groups and 2 physician groups: 1 male and 1 female). Professional moderators conducted the sessions using a semistructured discussion guide. All groups were audiotaped and videotaped, and tapes were reviewed for recurring themes. RESULTS: A total of 59 mothers, 21 nurses, and 17 physicians participated. Mothers identified intimate partner violence as a common problem in their communities, and most remarked that routine screening for adult intimate partner violence is an appropriate activity for a pediatric emergency department. However, many expressed concern that willingness to disclose might be affected by a fear of being reported to child protective services. They stressed the importance of addressing the child's health problem first, that screening be done in an empathetic way, and that immediate assistance be available if needed. Themes identified in the provider groups included concerns about time constraints, fear of offending, and concerns that unless immediate intervention was available, the victim could be placed in jeopardy. Many said they would feel obligated to notify child protective services on disclosure of intimate partner violence. CONCLUSIONS: Intimate partner violence screening protocols in the pediatric emergency department should take into consideration the beliefs and attitudes of both those doing the screening and those being screened. Those developing screening protocols for a pediatric emergency department should consider the following: (1) that those assigned to screen must demonstrate empathy, warmth, and a helping attitude; (2) the importance of addressing the child's medical needs first, and a screening process that is minimally disruptive to the emergency department; (3) a defined, organized approach to assessing danger to the child, and how and when it is appropriate to notify child protective services when a caregiver screens positive for intimate partner violence; and (4) that resources must be available immediately to a victim who requests them.     

Multiple Mediators for Peer-Directed Aggression and Happiness in Arab Adolescents Exposed to Parent–child Aggression

This study aimed to examine a multi-mediator model explaining how exposure to parent-child physical aggression may link with adolescents’ peer-directed physical aggression and their own subjective happiness, in an understudied Israeli Arab population. Mediators included hostility, anger, need to belong, and self-control. Arab adolescents from northern Israel (N?=?155; 62 % girls, aged 16-17) completed questionnaires regarding parents’ physical violence toward them, their own aggression toward peers, need to belong, happiness, positive emotions, and selfcontrol skills. (a) Parent-child physical aggression linked positively with peerdirected aggression through the mediating associations of hostility with anger; (b) parent-child physical aggression linked negatively with peer-directed aggression and happiness through the mediation of adolescents’ increased need to belong; and (c) parent-child physical aggression was not directly linked with self-control, but selfcontrol directly linked negatively with peer-directed aggression and positively with happiness. Findings highlight pathways through which parent-child physical aggression may simultaneously influence adolescents’ aggressive behavior and happiness. The mediation detected possible process variables (e.g., yearning for belonging, self-control skills, hostile thoughts, and angry feelings) that researchers and clinicians can consider in designing prevention and treatment interventions to break the inter-generational cycle of violence.     

School Absenteeism Among Middle School Students With High Exposure to Violence

ObjectiveChronic school absenteeism is linked to failure to graduate high school and poor health in adulthood. Contextual factors associated with absenteeism may be under-recognized in school and clinical settings. We examined the prevalence of self-reported absenteeism and violence exposure and their association among middle school students with identified risk of trauma.MethodsWe analyzed baseline data from a dating violence prevention program. Participants completed surveys identifying lifetime exposure to 10 types of violence and past 30-day absence. Violence exposure and absenteeism were summarized and compared across demographic groups. Generalized linear models examined associations between 1) any history of violence exposure, 2) each type of violence exposure, and 3) summed exposures to different types of violence, and frequent absenteeism (≥2 absences in past 30 days).ResultsOf all participants (overall n = 499), 45.5% reported frequent absenteeism and 71.5% reported violence exposure. Any self-reported violence exposure was associated with absenteeism (aRR = 1.43, 95%CI: 1.06–1.92). However, no specific type of violence exposure predicted absenteeism. Comparing summed exposures to different types of violence to no violence exposure, exposure to 1 type of violence was associated with absenteeism (aRR = 1.59, 95%CI: 1.15–2.20), with no evidence of stronger associations with greater exposure (2–3 types: aRR = 1.37, 95%CI: 1.00–1.88; ≥4 types: aRR = 1.31, 95%CI: 0.98–1.74).ConclusionsYouth in this sample reported both high rates of violence exposure and absenteeism. Prior violence exposure was associated with absenteeism. Resources and contextual support for youth exposed to family or community violence may play a role in school attendance, emphasizing need for trauma-sensitive approaches to absenteeism.     

Adolescent violence prevention practices among California pediatricians

OBJECTIVES: To examine pediatricians' provision of violence prevention services to their adolescent patients and to identify factors associated with pediatricians' implementation of these services. DESIGN: A cross-sectional sample of California pediatricians completed a self-report questionnaire. The "Precede/Proceed" theoretical model guided the questionnaire in identification of factors associated with pediatricians' screening and intervening practices in preventing adolescent violence. RESULTS: Two hundred twenty pediatricians (54% female, 66% white, 24% Asian, 5% Latino, and 5% other) participated in the study. On average, participants screened their patients for violence-related risk factors 31% of the time for fighting, 39% of the time for violence in the home, and 29% of the time for weapon carrying. Participants provided their at-risk patients with violence-related interventions less than 50% of the time (on average) implementing the following interventions: written materials, follow-up appointments, discipline counseling, or referral to a community organization, Child Protective Services, or a specialized adolescent clinic. Factors associated with violence prevention screening practices included the following: positive attitudes and beliefs regarding screening for violence, familiarity with violence prevention guidelines, use of prompts in medical records, perceptions of greater skills, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.44; P<.001). Factors associated with violence prevention intervention practices included: positive attitudes and beliefs in screening for violence, availability of resources, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.37; P<.001). CONCLUSIONS: California pediatricians are not widely screening their adolescent patients for risk factors associated with adolescent violence, nor are they providing interventions to their adolescent patients who may be at risk for violence. The factors associated with pediatricians' implementation of violence prevention services may assist in the development of effective interventions designed to enhance their delivery of these services to their adolescent patients.     

Exposure to violence and associated health-risk behaviors among adolescent girls.

OBJECTIVE: To examine the relationship between exposure to violence and health-risk behaviors. DESIGN: Cross-sectional survey. SETTING: University-based outpatient family planning clinic. PATIENTS: Sexually active adolescent girls younger than 18 years (N = 517) who presented for contraceptive care. MAIN OUTCOME MEASURES: Prevalence of witnessing or experiencing violence and the associations with health-risk behaviors, including high-risk sexual behaviors, substance use, and self-injury. RESULTS: Compared with adolescents who had not been exposed to violence, those who had only witnessed violence were 2 to 3 times more likely to report using tobacco and marijuana, drinking alcohol or using drugs before sex, and having intercourse with a partner who had multiple partners. Those who had experienced, but not witnessed violence were at increased risk of these same behaviors and were 2 to 4 times more likely than those who had neither witnessed nor experienced violence to report early initiation of intercourse, intercourse with strangers, multiple partners, or partners with multiple partners, tobacco, alcohol and drug use, or to have positive test results for a sexually transmitted disease. Individuals who had both witnessed and experienced violence demonstrated the greatest risk of adverse health behaviors. These adolescents demonstrated 3 to 6 times greater risk of suicidal ideation (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.2-4.0) or suicide attempts (OR, 4.5; 95% CI, 2.2-9.4), self-injury (OR, 5.8; 95% CI, 2.6-12.9), and use of drugs before intercourse (OR, 6.2; 95% CI, 3.0-12.9) than those who had neither witnessed nor experienced violence. CONCLUSIONS: Adolescents exposed to violence are at increased risk of multiple adverse health behaviors. Programs designed to improve health outcomes should target this high-risk group.     

Reducing adolescents' aggressive and hostile behaviors: randomized trial effects of a brief family intervention 4 years past baseline

OBJECTIVE: To examine the long-term effects of a brief family intervention on aggressive and hostile behaviors of adolescents in the general population. DESIGN: Randomized trial including 22 public schools assigned to the Iowa Strengthening Families Program or a control condition. Analyses supported sample representativeness and failed to show differential attrition effects 4 years after baseline. INTERVENTION: Seven-session intervention for parents and their sixth-grade children. MEASURES: The multi-informant, multimethod measures included independent observer ratings of adolescent aggressive and hostile behaviors in adolescent-parent interactions, family-member report of aggressive and hostile behaviors in those interactions, and adolescent self-report of aggressive and destructive conduct across settings. Data were collected during the 6th (preintervention and postintervention), 7th, 8th, and 10th grades. RESULTS: All measures showed a generally positive trend in intervention-control group differences over time. During 10th grade, significant intervention-control differences were found for adolescent self-report of aggressive and destructive conduct (P =. 01), with relative reduction rates ranging from 31.7% to 77.0%. Significant differences were shown for observer-rated aggressive and hostile behaviors in adolescent-parent interactions (P =.01); differences in family member reports of those behaviors were not significant. Supplemental analyses of both interactional behavior measures, specific to parent sex, indicated significant experimental group differences in interactions with mothers (P =.04 for both measures) but not with fathers. CONCLUSIONS: Brief family competency-training interventions designed for general populations can reduce aggressive and hostile behaviors in adolescents' interactions with parents and adolescent aggressive behaviors outside of the home setting. Thus, this type of intervention has important public health implications. Arch Pediatr Adolesc Med. 2000;154:1248-1257.     

Beliefs and practices to prevent drowning among Vietnamese-American adolescents and parents.

OBJECTIVE: To determine the beliefs, attitudes and practices regarding water safety among Vietnamese-Americans through focus group interviews. PARTICIPANTS: 15 teenagers (aged 15-19 years) and 20 parents participated, and reported similar attitudes, beliefs and practices regarding water activities. Participants identified a lack of familiarity with water activities and few swimming skills, noting that these activities are not perceived as recreational sports among the Vietnamese. They reported recreating at open water sites because they are free and available, and attributed drowning to fate. Vietnamese youth swim unsupervised, responding to peer pressure despite lack of skills. Participants had negative attitudes toward life jackets using, swimming pools and lessons, because of the costs, but would attend lessons in Vietnamese. They identified schools and Vietnamese media as means of delivering injury-prevention messages. CONCLUSIONS: Decreasing drowning among Vietnamese-Americans requires changing the knowledge, attitudes and safety practices with programs and messages in Vietnamese, as well as targeting the dominant culture.     

Factors associated with significant injuries in youth ice hockey players.

STUDY OBJECTIVE: To assess the implementation of published injury prevention strategies in injured youth ice hockey players, to examine factors contributing to current youth ice hockey injuries, and to assess attitudes of participants toward injury-risk activities. METHODS: Case series describing a convenience sample of 103 children presenting to a children's hospital emergency department with an injury sustained playing youth ice hockey. Using a questionnaire, patients self-reported their compliance with protective equipment guidelines, the circumstances of injury, and their attitudes toward risk-taking in youth ice hockey. RESULTS: A total of 103 patients suffered 113 injuries. For each piece of required equipment, compliance approached 100%. Penalties were assigned on 4% of plays causing injury. An additional 36% of patients injured during game play felt that a penalty should have been assigned. Fifty-seven percent of injuries were caused by checking. Fifty-eight percent of injuries caused by checking met our criteria for significant injury. Significant injury was more likely when initiating or receiving a check perceived to be legal than when receiving a check perceived as illegal (P = 0.032). Twenty-four percent of patients stated spinal cord injury and 45% stated brain injury was not possible given their usual protective equipment. To win, 32% of patients stated that they would check illegally, and 6% stated that they would purposely injure. CONCLUSION: While compliance with protective equipment requirements was good, rule enforcement was perceived to be inadequate. Elimination of checking would potentially reduce the number of significant injuries more than would the enforcement of existing rules. Injured youth hockey players are underinformed about the hazards of their sport and are too willing to engage in potentially injurious activities.     

Exposure to violence: psychological and academic correlates in child witnesses.

BACKGROUND: Inner-city children are frequently exposed to violence; however, there are few data regarding the psychological and academic correlates of such exposure in young children at school entry. OBJECTIVES: To document exposure to violence in inner-city children aged 7 years; assess their feelings of distress; and evaluate the relationships of exposure to violence with school performance, behavior, and self-esteem. SETTING: A study center in an inner-city hospital. PARTICIPANTS: One hundred nineteen inner-city children evaluated at age 7 years; 119 caregivers (biological and foster). DESIGN: As part of a longitudinal study, children were administered the following by a masked examiner: Things I Have Seen and Heard (TISH) to assess exposure to violence; Levonn, a cartoon-based interview for assessing children's distress symptoms; and the Culture-Free Self-Esteem Inventory, Second Edition. School performance was assessed by school reports and child behavior by the Child Behavior Checklist (CBCL), the Parent Report Form, and the Teacher Report Form. Caregivers for children were administered the parent report version of the Checklist of Children's Distress Symptoms (CCDS-PRV) as well as the CBCL Parent Report Form. MAIN OUTCOME MEASURES: Exposure to violence (TISH); feelings of distress (Levonn); school performance; behavior (CBCL Parent Report Form and CBCL Teacher Report Form); and self-esteem (Culture-Free Self-Esteem Inventory). RESULTS: We found that these children were frequently exposed to violence. For example, 75% had heard gun shots, 60% had seen drug deals, 18% had seen a dead body outside, and 10% had seen a shooting or stabbing in the home (TISH). Many showed signs of depression and anxiety; eg, 61% worried some or a lot of the time that they might get killed or die and 19% sometimes wished they were dead (Levonn). Higher exposure to violence (TISH Total Violence score) was correlated with higher Levonn composite scores for depression and anxiety and with lower self-esteem (P< or =.04), and was also associated with lower grade point average and more days of school absence (P< or =.02). Caregiver assessment of child anxiety correlated poorly with child report of anxiety (P =.58). CONCLUSIONS: Young inner-city children have a high exposure to violence by age 7 years; many show signs of distress that frequently are not recognized by caregivers. Further, higher exposure to violence in children correlates with poorer performance in school, symptoms of anxiety and depression, and lower self-esteem.