by Michael D. Anestis, M.S.
The vast majority of the material on Psychotherapy Brown Bag has focused on adult populations. Today, however, I would like to discuss a recent study examining mental health issues in children. In a study published in the most recent issue of Behaviour Research and Therapy, Matthews, Dempsey, and Overstreet (2009) examined the role of post-traumatic stress disorder (PTSD) symptoms in the previously reported relationship between exposure to community violence (ECV) and school performance.
ECV, which can include being the victim of violence as well as witnessing violence against others, is most common among minorities living in impoverished neighborhoods (Overstreet, 2000) and has previously been linked to a variety of problematic psychological and academic outcomes in children and adolescents (e.g., Overstreet, Dempsey, Graham, & Moely, 1999; Schwartz & Procter, 2000). Additionally the link between ECV and problematic mental health outcomes has been shown to remain significant even when controlling for other important variables, such as poverty, living in a single-parent home, and living in inadequate housing conditions (Gorman-Smith & Tolan, 1998; Kliewer, Lepore, Oskin, & Johnson, 1998; Overstreet et al., 1999). With respect to academic outcomes, ECV has been shown to predict poorer school performance as measured by grades, standardized test scores, and attendance (e.g., Hurt et al., 2001; Schwartz & Gorman, 2003).
Clearly, research has demonstrated a strong link between ECV and mental health and academic outcomes; however, prior to this study, no research had investigated whether mental health outcomes were, in fact, the mechanism through which ECV impacts school performance. In other words, up until now, there was no data that tested the hypothesis that ECV negatively impacted school performance because of its effect on mental health outcomes.
In this study, the authors were interested in examining whether symptoms of PTSD explained the relationship between ECV and school performance. PTSD, which has previously been linked to ECV (Overstreet, 2000), involves several symptoms that could severely impact school performance. Re-experiencing the trauma, a symptom of PTSD that involves hallucinatory perceptual experiences that leave the individual feeling as though the traumatic event is literally re-occurring in the moment, could make it difficult for students to focus in school. Avoidance of cues that remind the individual of the traumatic event, another PTSD symptom, could cause a student to skip school entirely or at least particular classes, thereby decreasing school performance. Sleep difficulties, another characteristic of PTSD, could leave students fatigued and unable to focus on assignments and classes. As such, Matthews and colleagues (2009) believed that PTSD symptoms would explain the relationship between ECV and poor school performance, even when controlling for other important variables like poverty.
Participants in this study were 47 African American students in public schools, all of whom had been exposed to various degrees of community violence. The students ranged in age from 10-13 and were in the fifth or sixth grade at the time of the assessments. The findings from this study firmly supported the authors' hypotheses. As expected, ECV was negatively correlated with school performance. In other words, the greater the amount of ECV, the worse the student performed in school. Additionally, and more importantly, the authors found that PTSD symptoms did, in fact, mediate the relationship between ECV and school performance. In other words, the data showed that, once PTSD symptoms were accounted for, the relationship between ECV and school performance was no longer statistically significant, meaning that PTSD symptoms were the mechanism through which exposure to violence impacted school performance. The PTSD mediational analysis was only true for grades and standardized test score, not absenteeism. In fact, poverty was the only variable related to absenteeism, with higher levels of poverty predicting higher levels of absenteeism.
These results are important for a variety of reasons. First, they provide us with a framework within which to understand how witnessing or experiencing violence might impact performance in school. It appears that it is not the violence itself that impacts the child, but rather the resulting symptoms of mental illness that many witnesses and victims of violence develop. In this case, only symptoms of PTSD were measured. This does not mean that other mental illnesses do not maintain a similar function in the relationship between ECV and school performance, but it does highlight the importance of PTSD. A second reason these findings are important is because it provides a potential solution to the problem. In recent years, empirically supported treatments (ESTs) for PTSD have been developed, namely cognitive processing therapy and prolonged exposure. Although more research is needed on the relative effectiveness of these therapeutic approaches for children, the existence of ESTs for PTSD offers a reason for hope that victims of ECV can be treated quickly and effectively, thereby allowing for enhanced academic performance.
As always, there were limitations to this study that must be considered when interpreting the results. Chief among these limitations is the small sample size. Small samples sizes make it impossible for researchers to detect meaningful effects. Think of it this way: if you see a baseball player in three at bats, you will not be able to accurately predict his overall performance across the season; however, i you see him for 200 at bats, your confidence will increase. Alternatively, if you flip a coin six times and get heads five times, you might conclude that it was simply a coincidence; however, if you flip that coin six hundred time and get heads five hundred times, a distribution no different than you had with just six flips, you will feel more comfortable that the coin is, in fact, weighted improperly. The same principles apply to measurements in clinical psychology. Additionally, the homogeneous sample makes it difficult to generalize the findings to the world in general, as it is unclear if cultural differences might play a role in the manner in which ECV impacts school performance. Despite these weaknesses, this study offered an interesting glimpse into why two variables - ECV and school performance - are related. Research that attempts to answer that question rather than simply looking at correlations is highly valuable, as it lends itself to real world solutions.
As impressed as I was by these findings, I still have several lingering questions and I would love to hear your thoughts on them.
First, do you think that other mental illnesses would also mediate the relationship between ECV and school performance? In other words, is it just PTSD that makes the difference or might other diagnoses be equally important?
Also, to what degree do you think these results generalize to other racial and ethnic groups and socioeconomic levels? The authors were careful to control for poverty, but in a single public school, there is likely a restricted range on income and, as such, the data is not capable of answering whether the relationship remains the same for individuals in a different social class.
Finally, what impact do you think ECV has on the acquired capability for suicide. Suicide rates in school age children are low, but not non-existent. Plus, an increased acquired capability is something that could impact the trajectory of an individual's behavioral choices across their life. That being said, do you think that ECV has an indirect impact on suicide rates?
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
