Violence As A Problem Of Health Research Paper

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In the early 1990s, many policy makers and social scientists related the problem of community violence to neighborhoods trapped in struggles among gangs competing to sell and distribute illegal drugs, especially cocaine and crack cocaine. From this perspective, the challenge for communities was to locate and restrain perpetrators and respond to victims. Gradually, it has been recognized that community violence, however it began, affects many segments of the population. Seemingly clear distinctions between victim and perpetrator seem to have faded. Heightened exposure to violence is assumed to increase acts of aggression in anticipation of violence from another. Effectively, the timing rather than the nature of an act may differentiate victim from victimizer. In such an environment, the sense of unease may seem constant, the need for vigilance continuous, and suspicion of others required. That state may, in turn, disrupt sleep, upset vegetative functions, impair interpersonal relationships, and disable effective concentration on work and studies. Together, these characteristics produce an environment marked by ‘pervasive community violence’ (PCV), an ecological situation with significant impact on emotional, behavioral, and psychological health.

PCV, therefore, negatively alters the essence of community life, broadly disrupts its functioning and presumably thereby impairs residents’ general health. The potential for such broad impact must be appreciated and respected before one can enlist communities to join in investigating PCV’s nature and consequences. Investigators who do not appreciate that quality may be surprised by the reluctance of community leaders (e.g., school administrators, county health officer, and representatives of the mayor’s office) to participate in its study. The leaders may deny the problem’s extent or hesitate to make public the negative quality of their neighborhood or community. For them genuine partnerships require time accumulated through historical involvement and future commitment. History enables disclosure and trust. Intimate aspects of a community are rarely shared with strangers. Assurance that the investigator will be there in the future (even after external funds are gone) is important, given community leaders’ appreciation of the intransigence of social problems and the fickleness of social scientists. Thus, from the outset it must be appreciated that to study and alter the nature and consequence of PCV requires a genuine and long-term partnership between communities and social scientists.

1. Definition Of Terms

As one reviews the growing PCV literature, the need for defining relevant terms becomes apparent. Violence refers to both acts and consequences of the intentional use or threat of use of force to cause injury, harm, or death to another. The qualifier ‘intentional’ excludes unintended or accidental acts and consequences. Determining intent represents an as yet unresolved methodological challenge. For PCV, the consequences of violent acts refer to the rippling health and mental health effects experienced by: (a) individuals directly victimized by an act or threat of violence; (b) individuals indirectly victimized as a bystander, witness, acquaintance, or loved one of a direct victim; and (c) individuals indirectly victimized by their awareness of, and anxiety about, the occurrence of acts or threats of violence. Community violence locates the acts and their consequences in a geographic setting (e.g., a neighborhood or a school), an identifiable social grouping (e.g., a grade cohort, a gang, a nuclear or extended family) or both. Pervasive community violence (PCV ) refers to the chronic and widespread occurrence of acts or threats of violence within such settings or social groups.

Thus, PCV exists when substantial acts and consequences of violence are encountered across multiple settings and circumstances over extended time. To investigate PCV systematically, the qualifiers ‘substantial,’ ‘multiple,’ and ‘extended’ must be operationally defined and rigorously measured. Information must be gathered about a community’s rate of violent acts and about rates of individual encounters with violent acts. For methodological and political reasons, PCV measures vary in their consideration of violence occurring within or outside of the home. The majority of such measures limit their focus to outside encounters. Yet, by definition, PCV implies cross-setting exposure. At its most extreme, PCV represents the absence of any sanctuary or setting in which relief and a sense of safety is possible. Thus, the most serious impacts on physical and psychological health are likely to be observed in those exposed at home, at work or school, and en route between the two.

In a series of papers and chapters, I have proposed consideration of PCV as an Environmental contaminant with measurable effects on health and mental health (Cooley-Quille and Lorion 1999, Lorion 1998, 1999, 2001, Lorion et al. 1998, Lorion and Saltzman 1993). From that perspective, PCV contaminates settings and thereby the actions and interactions of at least some inhabitants. Contamination refers to the corrosive or pathogenic effect of PCV exposure on community climate. Slowly investigators are documenting PCV’s negative effects on: (a) individual assumptions about the threatening quality of others, (b) the need to limit one’s contact with others, and (c) the urgency of responding aggressively to actual or anticipated attacks. This ecological contamination appears to vary in its pace as well as intensity across individuals, situations, and settings. Understanding the determinants and mechanisms of such patterns and their malleability within and across individuals should inform the design of interventions to limit PCV exposure and reduce its consequences.

2. Measuring PCV

Investigation of PCV’s environmental influence requires the availability of measures to estimate its presence and to confirm its impacts. Applying a common measurement approach across diverse populations and settings, Richters and associates (Lorion and Saltzman 1993, Martinez and Richters 1993, Osofsky et al. 1993, Richters and Martinez 1993) scientifically documented the extent of children’s exposure to violence. They also provided early evidence of the relationship between PCV exposure and children’s emotional and behavioral functioning. Subsequent investigations of such relationships (e.g., Hill and Madhere 1996, Singer et al. 1995) confirmed the seriousness of such links.

Measures of exposure to community violence share many similarities with the Survey of Children’s Exposure to Community Violence (Richters and Saltzman 1990). Instructed explicitly not to include media exposure (i.e., what was seen or heard about on radio, television, or in movies), respondents indicate along a five-point Likert scale (from 0 = never to 4 = a lot of the time) how often they have been victimized by, heard about, or witnessed violent events or related activities (e.g., shooting, stabbing, mugging, seeing a dead body). For each instance of reported exposure, respondents provide information about: (a) where the exposure occurred (i.e., in or near school, in or near home, in the neighborhood); (b) who perpetrated the violence (e.g., a stranger, a family member); (c) who, if not the respondent, was victimized (e.g., a stranger, a family member); and (d) when the incident occurred (e.g., one week ago, five years ago).

Variations of this measure were applied by Martinez and Richters (1993) and Osofsky et al. (1993) in studies of mothers of elementary graders and by Richters and Martinez (1993) and Saltzman (1992) in their studies of fifth and sixth graders. A cartoonbased version of this measure was designed by Richters and Martinez (i.e., Things I Have Seen and Heard, 1990) to assess PCV exposure in primary graders. Test–retest reliability was a most acceptable r 0.81. A second cartoon-based measure, Levonn, assessed distress symptoms associated with exposure (Richters et al. 1990). Subsequently, Fox and Leavitt (1995) developed the Violence Exposure Scale for Children (VEX-R) as a cartoon-based measure of PCV exposure in children from preschool through the elementary grades. Using this measure, Shahinfar et al. (2000) documented PCV’s impact on preschoolers. The negative behavioral consequences of such exposure was confirmed in a sample of Israeli elementary school children by Raviv et al. (2001).

A further variation of the Richters and Saltzman (1990) measure was applied by Saltzman (1995) to examine PCV exposure’s link to adolescent involvement in antisocial and delinquent behaviors. Building on these variations, Singer et al. (1995) designed the Recent Exposure to Physical Violence and the Past Exposure to Violence surveys to obtain adolescent reports of exposure during the prior 12 months or ‘while growing up, not including the past year,’ respectively. The acts of violence surveyed by Singer et al. included threats, slapping, hitting, punching, beatings, knife attacks, and shootings. Separate reports for each (other than knife attacks and shootings) were obtained for home, school, and neighborhood. Respondents were also asked how often they had witnessed someone else victimized at each of the aforementioned sites. Two additional items inquired about respondents’ having been ‘made to do a sexual act’ or having witnessed someone else ‘being made to do a sexual act.’ Overall, measurement efforts to date support the conclusion that psychometrically acceptable reports of PCV exposure can be obtained from youth ranging in age from preschoolers to adolescents.

In addition to the above work, Jenkins and associates (Bell et al. 1988, Jenkins and Thompson 1986) designed and conducted qualitative studies of African-American children’s encounters with violence. Results from four studies are summarized in Bell and Jenkins (1993). Using related measures, Jenkins and colleagues obtained information about youth’s exposure in terms of: (a) knowing someone who was a victim of violence; (b) having witnessed violent events in real life; (c) having been a victim of a violent incident; and (d) having perpetrated a violent act. Comparable to the work mentioned above, information about such forms of exposure was obtained from students enrolled in grades 2 through 12.

Although not a universal experience, victimization occurs at levels approaching 50 percent for threats and 40 percent for forced entry into their home. Indirect victimization (e.g., being a witness to a violent act) levels were consistently higher for incidents ranging from drug use to shootings, stabbings, and muggings. Reports of seeing a dead body in the neighborhood ranged from 24 to 40 percent. Using an extension of the Richters and Saltzman measure, Singer and colleagues (Singer et al. 1995, Song et al. 1998) validated these reports in their surveys of high-school students (N 3,735). As expected, considerable variability is present across settings. Nevertheless, levels of victimization and witnessing (both at home and in school) justify recognition of PCV as a major environmental contaminant. Apfel and Simon’s (1996) description of communal violence as referring to settings in ‘which every child has witnessed or expects to witness violence and has been or expects to be violated’ (pp. 4–5), seems to apply to many of the nation’s neighborhoods and schools.

3. Assessing PCV’s Health Impact

The aforementioned studies also report on PCV’s toxicity. Saltzman (1992), for example, observed significantly higher levels of generalized emotional distress in PCV-exposed fifth and sixth graders. This pattern is also reported by Richters and Martinez (1993), Martinez and Richters (1993), Osofsky et al. (1993), and Bell and Jenkins (1993). Across these studies of preadolescents, PCV exposure relates positively to affective and vegetative signs of depression and indices of stress-related disorders. With both preadolescents and adolescents, Singer et al. (1994) linked PCV exposure and increased aggression, conduct disorder, running away, and decreases in self-esteem and social competence. Support for the link between PCV exposure and involvement in violent acts is reported by Saltzman (1995). In Saltzman’s study, PCV exposure significantly related to adolescent involvement in antisocial and violent acts independent of peer, familial, and other recognized predictors of aggression during that developmental period. Rubinetti (1996) linked PCV exposure and violent activity most strongly in youth with decreased empathy, hopefulness, and self-esteem. Provocatively, Song et al.’s (1998) findings suggest that indirect victims are more likely than direct victims to aggress in anticipation of violent acts. Although further study is needed, PCV may create interpersonal distance among the residents of an affected setting, desensitize them to the consequences of violence on others, while heightening the need to defend oneself against assault. Overall, there appears to be substantial evidence that heightened exposure to PCV increases the likelihood that one will engage in violence. In turn, the resulting acts of violence increase levels of PCV exposure, providing a mechanism for a continuing cycle.

Two recent studies (Cooley-Quille and Lorion 1999, Scarpa et al. 2000) have begun to examine the physical impacts of PCV exposure. Each study found physiological concomitants of PCV exposure, including increased heart rate, respiration, and cortisol levels, long-established indices of heightened stress and arousal. Cooley-Quille and Lorion (1999) also reported preliminary evidence of a link between PCV and sleep disorders. Anecdotal reports from youth living in PCV-heightened neighborhoods report difficulty falling asleep, repeatedly waking up in response to gunshots, loud noises, and police activity and, generally, only rarely sleeping throughout the night. If these reports are confirmed along with further information about the vegetative effects of PCV exposure, new understandings may emerge which change existing assumptions about the lack of impulse control and academic failure, often associated with urban poverty, from attributions about personal failure to questions about environmental toxicity. Thus, although examination of the physiological consequences of living or working within settings characterized by high PCV levels is just beginning, preliminary results suggests that these impacts are real, extensive, and potential triggers for further pathogenesis across multiple parameters of functioning.

Such findings support the hypothesized toxicity of PCV exposure which appears to impair cognitive, emotional, behavioral, and biological functioning simultaneously, sequentially, or synergistically. As yet unexamined systematically, however, is the breadth of these ‘PCV-consequences’ (assuming they are causally linked) within settings and communities. In essence, we have yet to study how the toxin spreads and the transmission routes by which the occurrence of violent events (presumably their nature, frequency, and intensity would influence the spread of effects) contaminates the environment. Longitudinal information is necessary to causally link exposure and its observed concomitants. It is also necessary to determine at what point interventions can be introduced to protect against or, if necessary, to treat such effects.

It should be recognized that what is presently known about PCV relates almost entirely to school-aged youth. We know little about the effect of maternal PCV exposure on neonates, of exposure on toddlers and preschoolers, and even less about the nature, extent, and consequences of exposure on adults. What of the parents, grandparents, and others who live in such neighborhoods? Within schools, what of the staff and teachers who may live in such neighborhoods, travel through such neighborhoods, or hear the tales of their students? Work reported to date pays little attention to these members of exposed communities, except perhaps to suggest that they could buffer youth against the impacts of PCV. Whether we can assume the capacity of exposed adults to do so merits careful examination.

We must therefore examine exposure across the entirety of a community’s population and settings. Anecdotal reports, informal focus groups, and clinical encounters suggest that exposure reduces the quality of teachers’ instructional effectiveness, capacity to apply classroom management strategies, and availability to students before or after the school day. Reasonably, one might expect that PCV similarly disrupts parent–child, parent–teacher, and teacher– teacher interactions. As reported above, Song et al. (1998) found a significant link between indirect exposure and anticipatory aggression. Ambiguous interpersonal cues may be interpreted by youth (and perhaps adults?) as threatening, leading to what is assumed by the perceiver as a defensive act. Presumably (although we do not really know), when selfdefense seems unlikely to succeed, ambiguity leads to retreat, avoidance, or perhaps acquiescence with stated or unstated demands.

If this explanation of Singer’s finding is valid, would it not extend to adult interactions within and across generations? Might it not explain, at least in part, what from the outside appears as hypersensitivity to insult or disrespect, the immediacy with which one asserts one’s right, or the reluctance to give way, lest courtesy be mistaken for weakness or fear? Might it not explain urban parents’ use of physical discipline or its reverse, that is, seeming inability or unwillingness to control their children’s behavior? What of neighborhoods in which the elderly limit, and the young have limited, time outside of the home because of concerns about danger and vulnerability? Would not isolated streets facilitate violence with immunity? Would not the biological concomitants related to stress, sleep deprivation, and concentration impair adults’ (be they teachers, storekeepers, bus drivers, or neighbors) capacity to interact comfortably with each other and to neutralize or at least dilute PCV’s toxicity and thereby protect youth? To ignore the status of adults in such settings implies that they are unaffected by PCV or other community toxins.

Albeit at levels of concern, PCV is linked to increased but not universal pathology. Not only does a majority of those exposed not manifest pathology, but most residents do not report exposure. PCV exposure appears to relate not only to the occurrences of violent acts, but also to awareness of those occurrences. Somehow, many exposed are seemingly unaware of that and, potentially, for them there is some bliss in ignorance. What individual and ecological factors determine sensitivity remains to be investigated. That such differences exist, however, argues for attending to issues of adaptation, coping, and wellness. As noted recently:

By implication it seems reasonable to view wellness as representing the outcome of normative developmental processes, in programming terms, as the default option. In the absence of that relatively rare combination of individual and situational circumstances, individual development appears to proceed within socially expected and appropriate boundaries reflecting the general capacity to adapt to situational demands and cope with stressful events. Just as canalization accounts for the limits within which genetic processes emerge within species (Gottlieb 1992), an analogous process may account for the human capacity to adapt to a multitude of settings and circumstances, and to cope with seemingly debilitating and pathogenic stressors. (Lorion 2000, pp. 13–14)

If wellness, adaptation, and adjustment represent the default option in human development, and individuals, families, neighborhoods, schools, and communities in general cope with PCV, economic (dis)advantage, familial instability, critical life events, inadequate school budgets, etc. (the length of one’s list merely underscores the point), understanding those mechanisms may inform the design of interventions to protect those who cannot cope. Answers to questions about how to optimize development and coping must be out there, in the homes, the schools, the classrooms, and the neighborhoods. To find those answers, we in the social sciences must enter the communities to observe, inquire, and learn. I propose we go not as experts bringing esoteric knowledge, but as students and collaborators, hopefully bringing tools and perspectives whose utility will be determined relative to what already exists, and what can be sustained over time and across levels of resources.

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