Journal of American College Health
ISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: http://www.tandfonline.com/loi/vach20
Typologies of Childhood Exposure to Violence: Associations With College Student Mental Health Laura E. Miller-Graff PhD, Kathryn H. Howell PhD, Cecilia Martinez-Torteya PhD & Erin C. Hunter PhD To cite this article: Laura E. Miller-Graff PhD, Kathryn H. Howell PhD, Cecilia MartinezTorteya PhD & Erin C. Hunter PhD (2015): Typologies of Childhood Exposure to Violence: Associations With College Student Mental Health, Journal of American College Health, DOI: 10.1080/07448481.2015.1057145 To link to this article: http://dx.doi.org/10.1080/07448481.2015.1057145
Accepted author version posted online: 07 Jul 2015.
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Date: 05 November 2015, At: 17:41
ACCEPTED MANUSCRIPT Major Article Typologies of Childhood Exposure to Violence: Associations With College Student Mental Health
Laura E. Miller-Graff, PhD1; Kathryn H. Howell, PhD2; Cecilia Martinez-Torteya, PhD3; Erin C.
Downloaded by [Universite Laval] at 17:41 05 November 2015
Hunter, PhD4
1
Department of Psychology, Kroc Institute for International Peace Studies, University of Notre
Dame, Notre Dame, Indiana
2
Department of Psychology, University of Memphis, Memphis, Tennessee
3
Department of Psychology, DePaul University, Chicago, Illinois
4
Department of Psychology, University of Michigan, Ann Arbor, Michigan
1
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Abstract. Objective: This study examined typologies of childhood violence exposure (CVE) and the associations of profiles with current demographic characteristics and mental health in emerging adulthood. Participants: The study evaluated a sample of college students from two U.S. geographic regions (Midwest n=195; Southeast n=200). Methods: An online questionnaire (collected 2013-2014) assessed CVE and current mental health. Latent class analysis was used to identify typologies of CVE. Follow-up analyses were conducted to Downloaded by [Universite Laval] at 17:41 05 November 2015
distinguish differences between typologies in demographic characteristics and mental health. Results: Four distinct profiles emerged: High-Exposed, Domestic-Exposed, CommunityExposed, and Low-Exposed. High- and Domestic-Exposed groups were more likely to be firstgeneration college students and experience symptoms of psychopathology. Conclusions: This study offers a unique presentation of CVE profiles and a nuanced interpretation of their differential relationship to current demographic characteristics and mental health. It may befit university mental health initiatives to engage first-generation students and utilize comprehensive assessments of previous victimization. Keywords: childhood exposure to violence, college students, posttraumatic stress, psychopathology, violence typology
2
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ACCEPTED MANUSCRIPT
Childhood exposure to violence is relatively common, with 71% of American youth experiencing at least one incident of violence in childhood1. Unfortunately, poly-victimization, or the co-occurrence of different types of violence victimization, is also common; those youth with a history of victimization report an average of three incidents in childhood1. Given the high rates of overlap among different types of violence, theoretical frameworks have underscored the Downloaded by [Universite Laval] at 17:41 05 November 2015
importance of testing empirical models that examine poly-victimization in greater depth2. In particular, Hamby and Grych2 suggest that empirical work needs to move from assessing overlap to evaluating the strength of relationships between different patterns of victimization. Although many methods may be employed to achieve this goal, person-centered approaches, such as cluster and latent class analyses, may provide particularly nuanced information regarding the interconnections among various forms of interpersonal violence and links between specific patterns of victimization and mental health outcomes2. Few studies, however, have taken up such approaches. The present study explored the interconnections among various forms of violence exposure using latent class analysis, consequently examining the associations of specific patterns with mental health outcomes. Examining interconnections between various types of violence exposure and psychological functioning might be particularly important among emerging adults because this is a period that constitutes the most common age of onset for multiple psychiatric disorders, including depression3. The presence of these difficulties can significantly impede the successful transition into adulthood, as emerging adults must be able to effectively utilize emotional, social, and cognitive skills4 to navigate their increasing autonomy and responsibility. Generally
3
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT speaking, mental health problems are on the rise among American young adults5. In the U.S., approximately half of college students experience significant psychological symptoms within a two-year period6 with 10% reporting that they seriously considered suicide7. Mental health problems increase risk for other difficulties, including academic problems, drop out, violence, injury, and suicide3,8. This vast toll has led to calls for colleges and universities to implement comprehensive prevention programs9 to improve college student mental health. For many college Downloaded by [Universite Laval] at 17:41 05 November 2015
students, a history of exposure to interpersonal violence may explain the presence of psychopathology10,11. Archambeau and colleagues8 found that both exposure to physical violence and exposure to sexual violence independently predicted risk of posttraumatic stress disorder (PTSD), anxiety, and depression in a diverse cross-section of American young adults, with violence exposure approximately doubling the risk for psychopathology. Further, childhood experiences of interpersonal violence have been found to increase the severity and complexity of mental health problems, even more so than traumatic experiences in adulthood12. On college campuses, the increasing demand for services and limited capacity has resulted in a focus on crisis management and short-term services, which may not be adequate for students experiencing more serious psychopathology. It is therefore especially relevant to assess college students’ histories of childhood exposure to violence to assist in the development of effective and appropriate mental health care in settings that may have limited resources. Decades of research on exposure to interpersonal violence suggest that youth who experience one instance of victimization are likely to have other victimization experiences. The National Survey of Children’s Exposure to Violence (NatSCEV)13 reported a mean of 2.7 childhood victimization experiences among their large, nationally representative sample. They
4
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT found significant overlap between sexual assault, physical assault, maltreatment, property crime, and witnessing violence, such that one type of victimization tripled the child’s risk for additional victimization experiences13. Thus, isolating victimization experiences for research or assessment purposes fails to capture the inter-related nature of victimization2 and may not provide maximally useful information to understand mental health outcomes. To better represent victimization experiences, researchers have employed multiple strategies: summing all instances Downloaded by [Universite Laval] at 17:41 05 November 2015
of interpersonal violence into one total score, summing the different types of victimization that a child has experienced, or classifying individuals’ exposure as none, single-exposure, or multipleexposures/poly-victimization. Although these approaches may capture more information than isolated evaluation of specific types of victimization, they may not reflect naturalistic patterns of victimization co-occurrence. For example, in the NatSCEV physical and sexual victimization were most likely to co-occur, and youth exposed to physical victimization were 7 times more likely to experience sexual victimization, while the co-occurrence of property crime and physical assault was much lower13. Similarly, Hamby and colleagues14 found large co-occurrence of exposure to intimate partner violence (IPV) and child abuse, but small to moderate co-occurrence for exposure to IPV and peer aggression. Person-oriented statistical approaches, like cluster analysis or latent class analysis (LCA) constitute an ideal strategy to identify patterns of victimization co-occurrence or typologies of violence exposure. A small group of studies have attempted to characterize specific profiles of trauma exposure using cluster or LCA methods, in order to establish patterns of risk and relative need for mental health services. Studies vary in the kinds of adversity or victimization they assess, but generally identify 3 to 4 victimization profiles15-19. The identified profiles differ on
5
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT the severity of violence exposure (from low to high), the presence or absence of sexual trauma, and/or the total number of types of victimization experienced (single vs. poly-victimization). Studies have focused on different populations using diverse methods, with participant samples defined broadly to include adolescence and adulthood17, or more narrowly defined to include adolescents only16,18,19, or young adults only15. Despite using different methodologies, findings have been consistent and meaningfully related to psychosocial outcomes. Individuals in the low Downloaded by [Universite Laval] at 17:41 05 November 2015
exposure groups typically experience the fewest mental health problems and the least additional demographic risk. Those with intermediate, high, or poly-victimization experience the highest rates of PTSD and other behavioral and emotional problems. Some studies identify a sexual trauma group, and females are overrepresented within this pattern of victimization15-17,19. The available studies using cluster or LCA methods have not examined violence exposure typologies specific to a college student sample in the United States. In addition, profiles of victimization have been validated using only a small range of psychosocial indicators, including gender, poverty, depression, and PTSD. There are also, however, a number of demographic characteristics that have been liked to higher rates of violence exposure and mental health difficulties (i.e., demographic risk). Known demographic risk factors, such as poverty, however, are often difficult to disentangle from other sociodemographic characteristics. For example, poor youth are more likely to be racial/ethnic minorities and are also more likely to be first-generation college students20. Here, the risk that poverty poses to mental health may in part be explained in racial/ethnic mental health disparities in care21 and the increased risk of first generation college students for depression22. The present study seeks to address some of the gaps in the literature by including a more comprehensive assessment of demographic risk factors as
6
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT they are associated with patterns of victimization exposure and their psychosocial health in college students. Given the high rates of psychopathology among college students and the links between current psychopathology and past trauma exposure or poly-victimization, this study has the potential to highlight the unique needs of college students during this important developmental transition. Current Study Downloaded by [Universite Laval] at 17:41 05 November 2015
While there is a wealth of research linking specific types of childhood violence exposure to poor outcomes in adulthood, constellations of childhood poly-victimization have not been studied in relation to college student psychological functioning. In order to investigate profiles of violence exposure in college students, the current study employed a latent class analysis. Following this analysis, descriptive statistics, mean differences tests, chi-square, and Multivariate analysis of covariance (MANCOVA) tests were conducted to distinguish differences across groups in demographic characteristics and mental health. Based on previous research, we hypothesized the following: (1) Distinct latent classes will emerge, at least one of which is a “high exposure” group and one of which is a “low exposure” group. (2) Demographic risk (i.e., low family income and first generation college students) will be significantly less for the low exposure than for the high exposure group. We do not expect any differences in profile membership by race or gender. (3) Symptoms of anxiety, depressed mood, and posttraumatic stress will be significantly higher for the high exposure than the low exposure group. Method
7
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Participants Participants included 395 college students (71.4% female), age 18 to 24 (M=19.21, SD =1.42). Freshmen composed 48.9% of the sample. Twenty four percent (24.1%) of the sample were sophomores, 14.9% were juniors, 9.4% were seniors and 3% were in their fifth year of college or beyond. Twenty four percent of participants were first generation college students. Participation was not restricted by gender, race, ethnicity, or physical or mental health status. Downloaded by [Universite Laval] at 17:41 05 November 2015
Exclusion criteria included: (1) under age 18 or over age 24 and (2) not able to read English. Participant’s identified racial and ethnic backgrounds were varied, with 65.1% Caucasian, 19.7% African American, 5.8% Biracial/Multiracial, 4.1% Hispanic/Latino, 3.8% Asian, and 1.5% other. Participant’s family income during the previous year showed a relatively bimodal distribution, with 29.9% reporting a family income greater than 150,000 USD and 29.1% endorsing a yearly family income below 60,000 USD. Procedures Participants were recruited through the department of psychology subject pool systems at two universities in the Midwest and Southeast United States. Internal Review Board approval was independently gained at each institution. The subject pools consisted of undergraduates in psychology courses who were invited to participate in research as part of their educational experience. Participants self-selected into this study and were made aware that it would be completed online, that it would take approximately 1.5 to 2 hours, and that they would receive course credit. All aspects of this study, including recruitment, consent, survey administration, and debriefing were conducted online from any location of the participant’s choosing. Measures
8
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Demographics. A demographics questionnaire was administered to each participant to ascertain basic background information, such as gender, past year family income, racial/ethnic identity, and education. Juvenile Victimization Questionnaire - Adult Retrospective (JVQR2). The JVQR2 is a self-report measure that assesses a broad range of victimization experiences, including property Downloaded by [Universite Laval] at 17:41 05 November 2015
crime, physical assault, child maltreatment, violence perpetrated by another child (i.e., peer or sibling victimization), witnessed/indirect victimization, and sexual victimization23. The adult retrospective version examines 34 specific types of victimization that participants may have experienced during childhood, from birth to age 17, using a yes/no response format. The current study also included 6 questions assessing childhood exposure to IPV14. Because of limitations on the number of items that can be entered into a latent class analysis, the current study selected 26 items; removed items included those assessing some types of property crime (e.g., having something stolen) and items assessing indirect exposure (e.g., witnessing a mugging), the latter in part because of the overlap with included items about witnessing intimate partner violence. The included items assessed violence exposure within the following domains: community crime/violence, victimization by another child, sexual violence, child maltreatment and childhood exposure to IPV (See Table 4). The JVQR2 has been used in past research assessing young adults’ recollections of childhood victimization24. Further, its construct validity has been established in national samples, and the measure has shown test-retest reliability of Kappa=.6325. A reliability statistic was not calculated for the JVQR2 because participants’ experiences of violence need not be related.
9
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Center for Epidemiological Studies Depression Scale (CES-D). The CES-D is a 20item self-report measure that assesses depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance in the past week26. Participants estimated how often they experienced these symptoms of depression on a four-point Likert scale, ranging from rarely or none of the time to most or all of the time. Scores range from 0-60 with a clinical cutoff of 16 or greater. The CES-D Downloaded by [Universite Laval] at 17:41 05 November 2015
has good internal consistency reliability and adequate construct and discriminant validity26. In the present study, reliability for the CES-D was α = .91. Depression, Anxiety, and Stress Scale – 21 (DASS-21). The DASS-21 is comprised of three self-report scales, each containing 7 items, designed to measure depression, anxiety and stress in the past week27. Participants estimated how applicable each item was to them on a fourpoint Likert scale, ranging from never to almost always. The DASS-21 has good internal consistency reliability, with alpha coefficients ranging from .80 to .94, as well as adequate construct and discriminant validity28. In the present study, the anxiety subscale was utilized, which had a reliability of α = .87. The cut-off score for moderate symptoms of anxiety is 10. The National Stressful Events Survey PTSD Short Scale (NSESSS). The NSESSS is a 9-item self-report measure assessing symptoms of hypervigilance, re-experiencing, avoidance, and negative mood and cognition in the past week29. This measure has limited psychometric data available as it was recently provided to the clinical and research communities by the Diagnostic and Statistical Manual of Mental Disorders: 5th Edition (DSM-5) Task Force. The NSESSS is one of the only existing quantitative measures to include symptoms of negative mood and
10
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ACCEPTED MANUSCRIPT cognition, which were added to the most recent diagnostic profile of PTSD. In the present study, reliability for the NSESSS was α = .93. Results Violence Exposure and Clinical Outcomes In the current study, 83.46% of participants reported any history of childhood violence exposure (CVE), with an average endorsement of four violent events (M=3.97, SD=3.72, Range: Downloaded by [Universite Laval] at 17:41 05 November 2015
0-19). The most common type of exposure was verbal abuse by other children (37%) and the least common type of exposure was kidnapping (3%). On average, the sample was just below the clinical range for symptoms of depressed mood, in the normal range for symptoms of anxiety, and in the “no to mild” range for symptoms of PTSD. Violence exposure was related to all mental health outcomes (See Tables 1 and 2). Participants at the Southeastern site reported significantly more exposure to violence (t(348.8)=-3.28, p9=moderate symptoms) Posttraumatic 0.88 (.90) 0.68(.82) 1.24(1.01) 0.80(.74) 1.84(1.03) Stress Symptomsc % PTSD 36% 27% 45% 39% 82% (2=moderate symptoms) For the full sample: an=372 participants with complete data, bn=383 participants with complete data, cn=394 participants with complete data
27
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ACCEPTED MANUSCRIPT Table 2. Correlations between violence exposure and mental health
1. Total Violence
1. Total Violence
2. Depressed
3. Anxiety
4. Posttraumatic
Exposure
Mood
Symptoms
Stress Symptoms
1
Exposure 2. Depressed
.26***
1
.27***
.66***
1
.33***
.63***
.53***
Downloaded by [Universite Laval] at 17:41 05 November 2015
Mood 3. Anxiety Symptoms 4. Posttraumatic
1
Stress Symptoms ***p
ISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: http://www.tandfonline.com/loi/vach20
Typologies of Childhood Exposure to Violence: Associations With College Student Mental Health Laura E. Miller-Graff PhD, Kathryn H. Howell PhD, Cecilia Martinez-Torteya PhD & Erin C. Hunter PhD To cite this article: Laura E. Miller-Graff PhD, Kathryn H. Howell PhD, Cecilia MartinezTorteya PhD & Erin C. Hunter PhD (2015): Typologies of Childhood Exposure to Violence: Associations With College Student Mental Health, Journal of American College Health, DOI: 10.1080/07448481.2015.1057145 To link to this article: http://dx.doi.org/10.1080/07448481.2015.1057145
Accepted author version posted online: 07 Jul 2015.
Submit your article to this journal
Article views: 50
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vach20 Download by: [Universite Laval]
Date: 05 November 2015, At: 17:41
ACCEPTED MANUSCRIPT Major Article Typologies of Childhood Exposure to Violence: Associations With College Student Mental Health
Laura E. Miller-Graff, PhD1; Kathryn H. Howell, PhD2; Cecilia Martinez-Torteya, PhD3; Erin C.
Downloaded by [Universite Laval] at 17:41 05 November 2015
Hunter, PhD4
1
Department of Psychology, Kroc Institute for International Peace Studies, University of Notre
Dame, Notre Dame, Indiana
2
Department of Psychology, University of Memphis, Memphis, Tennessee
3
Department of Psychology, DePaul University, Chicago, Illinois
4
Department of Psychology, University of Michigan, Ann Arbor, Michigan
1
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Abstract. Objective: This study examined typologies of childhood violence exposure (CVE) and the associations of profiles with current demographic characteristics and mental health in emerging adulthood. Participants: The study evaluated a sample of college students from two U.S. geographic regions (Midwest n=195; Southeast n=200). Methods: An online questionnaire (collected 2013-2014) assessed CVE and current mental health. Latent class analysis was used to identify typologies of CVE. Follow-up analyses were conducted to Downloaded by [Universite Laval] at 17:41 05 November 2015
distinguish differences between typologies in demographic characteristics and mental health. Results: Four distinct profiles emerged: High-Exposed, Domestic-Exposed, CommunityExposed, and Low-Exposed. High- and Domestic-Exposed groups were more likely to be firstgeneration college students and experience symptoms of psychopathology. Conclusions: This study offers a unique presentation of CVE profiles and a nuanced interpretation of their differential relationship to current demographic characteristics and mental health. It may befit university mental health initiatives to engage first-generation students and utilize comprehensive assessments of previous victimization. Keywords: childhood exposure to violence, college students, posttraumatic stress, psychopathology, violence typology
2
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ACCEPTED MANUSCRIPT
Childhood exposure to violence is relatively common, with 71% of American youth experiencing at least one incident of violence in childhood1. Unfortunately, poly-victimization, or the co-occurrence of different types of violence victimization, is also common; those youth with a history of victimization report an average of three incidents in childhood1. Given the high rates of overlap among different types of violence, theoretical frameworks have underscored the Downloaded by [Universite Laval] at 17:41 05 November 2015
importance of testing empirical models that examine poly-victimization in greater depth2. In particular, Hamby and Grych2 suggest that empirical work needs to move from assessing overlap to evaluating the strength of relationships between different patterns of victimization. Although many methods may be employed to achieve this goal, person-centered approaches, such as cluster and latent class analyses, may provide particularly nuanced information regarding the interconnections among various forms of interpersonal violence and links between specific patterns of victimization and mental health outcomes2. Few studies, however, have taken up such approaches. The present study explored the interconnections among various forms of violence exposure using latent class analysis, consequently examining the associations of specific patterns with mental health outcomes. Examining interconnections between various types of violence exposure and psychological functioning might be particularly important among emerging adults because this is a period that constitutes the most common age of onset for multiple psychiatric disorders, including depression3. The presence of these difficulties can significantly impede the successful transition into adulthood, as emerging adults must be able to effectively utilize emotional, social, and cognitive skills4 to navigate their increasing autonomy and responsibility. Generally
3
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT speaking, mental health problems are on the rise among American young adults5. In the U.S., approximately half of college students experience significant psychological symptoms within a two-year period6 with 10% reporting that they seriously considered suicide7. Mental health problems increase risk for other difficulties, including academic problems, drop out, violence, injury, and suicide3,8. This vast toll has led to calls for colleges and universities to implement comprehensive prevention programs9 to improve college student mental health. For many college Downloaded by [Universite Laval] at 17:41 05 November 2015
students, a history of exposure to interpersonal violence may explain the presence of psychopathology10,11. Archambeau and colleagues8 found that both exposure to physical violence and exposure to sexual violence independently predicted risk of posttraumatic stress disorder (PTSD), anxiety, and depression in a diverse cross-section of American young adults, with violence exposure approximately doubling the risk for psychopathology. Further, childhood experiences of interpersonal violence have been found to increase the severity and complexity of mental health problems, even more so than traumatic experiences in adulthood12. On college campuses, the increasing demand for services and limited capacity has resulted in a focus on crisis management and short-term services, which may not be adequate for students experiencing more serious psychopathology. It is therefore especially relevant to assess college students’ histories of childhood exposure to violence to assist in the development of effective and appropriate mental health care in settings that may have limited resources. Decades of research on exposure to interpersonal violence suggest that youth who experience one instance of victimization are likely to have other victimization experiences. The National Survey of Children’s Exposure to Violence (NatSCEV)13 reported a mean of 2.7 childhood victimization experiences among their large, nationally representative sample. They
4
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT found significant overlap between sexual assault, physical assault, maltreatment, property crime, and witnessing violence, such that one type of victimization tripled the child’s risk for additional victimization experiences13. Thus, isolating victimization experiences for research or assessment purposes fails to capture the inter-related nature of victimization2 and may not provide maximally useful information to understand mental health outcomes. To better represent victimization experiences, researchers have employed multiple strategies: summing all instances Downloaded by [Universite Laval] at 17:41 05 November 2015
of interpersonal violence into one total score, summing the different types of victimization that a child has experienced, or classifying individuals’ exposure as none, single-exposure, or multipleexposures/poly-victimization. Although these approaches may capture more information than isolated evaluation of specific types of victimization, they may not reflect naturalistic patterns of victimization co-occurrence. For example, in the NatSCEV physical and sexual victimization were most likely to co-occur, and youth exposed to physical victimization were 7 times more likely to experience sexual victimization, while the co-occurrence of property crime and physical assault was much lower13. Similarly, Hamby and colleagues14 found large co-occurrence of exposure to intimate partner violence (IPV) and child abuse, but small to moderate co-occurrence for exposure to IPV and peer aggression. Person-oriented statistical approaches, like cluster analysis or latent class analysis (LCA) constitute an ideal strategy to identify patterns of victimization co-occurrence or typologies of violence exposure. A small group of studies have attempted to characterize specific profiles of trauma exposure using cluster or LCA methods, in order to establish patterns of risk and relative need for mental health services. Studies vary in the kinds of adversity or victimization they assess, but generally identify 3 to 4 victimization profiles15-19. The identified profiles differ on
5
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT the severity of violence exposure (from low to high), the presence or absence of sexual trauma, and/or the total number of types of victimization experienced (single vs. poly-victimization). Studies have focused on different populations using diverse methods, with participant samples defined broadly to include adolescence and adulthood17, or more narrowly defined to include adolescents only16,18,19, or young adults only15. Despite using different methodologies, findings have been consistent and meaningfully related to psychosocial outcomes. Individuals in the low Downloaded by [Universite Laval] at 17:41 05 November 2015
exposure groups typically experience the fewest mental health problems and the least additional demographic risk. Those with intermediate, high, or poly-victimization experience the highest rates of PTSD and other behavioral and emotional problems. Some studies identify a sexual trauma group, and females are overrepresented within this pattern of victimization15-17,19. The available studies using cluster or LCA methods have not examined violence exposure typologies specific to a college student sample in the United States. In addition, profiles of victimization have been validated using only a small range of psychosocial indicators, including gender, poverty, depression, and PTSD. There are also, however, a number of demographic characteristics that have been liked to higher rates of violence exposure and mental health difficulties (i.e., demographic risk). Known demographic risk factors, such as poverty, however, are often difficult to disentangle from other sociodemographic characteristics. For example, poor youth are more likely to be racial/ethnic minorities and are also more likely to be first-generation college students20. Here, the risk that poverty poses to mental health may in part be explained in racial/ethnic mental health disparities in care21 and the increased risk of first generation college students for depression22. The present study seeks to address some of the gaps in the literature by including a more comprehensive assessment of demographic risk factors as
6
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT they are associated with patterns of victimization exposure and their psychosocial health in college students. Given the high rates of psychopathology among college students and the links between current psychopathology and past trauma exposure or poly-victimization, this study has the potential to highlight the unique needs of college students during this important developmental transition. Current Study Downloaded by [Universite Laval] at 17:41 05 November 2015
While there is a wealth of research linking specific types of childhood violence exposure to poor outcomes in adulthood, constellations of childhood poly-victimization have not been studied in relation to college student psychological functioning. In order to investigate profiles of violence exposure in college students, the current study employed a latent class analysis. Following this analysis, descriptive statistics, mean differences tests, chi-square, and Multivariate analysis of covariance (MANCOVA) tests were conducted to distinguish differences across groups in demographic characteristics and mental health. Based on previous research, we hypothesized the following: (1) Distinct latent classes will emerge, at least one of which is a “high exposure” group and one of which is a “low exposure” group. (2) Demographic risk (i.e., low family income and first generation college students) will be significantly less for the low exposure than for the high exposure group. We do not expect any differences in profile membership by race or gender. (3) Symptoms of anxiety, depressed mood, and posttraumatic stress will be significantly higher for the high exposure than the low exposure group. Method
7
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Participants Participants included 395 college students (71.4% female), age 18 to 24 (M=19.21, SD =1.42). Freshmen composed 48.9% of the sample. Twenty four percent (24.1%) of the sample were sophomores, 14.9% were juniors, 9.4% were seniors and 3% were in their fifth year of college or beyond. Twenty four percent of participants were first generation college students. Participation was not restricted by gender, race, ethnicity, or physical or mental health status. Downloaded by [Universite Laval] at 17:41 05 November 2015
Exclusion criteria included: (1) under age 18 or over age 24 and (2) not able to read English. Participant’s identified racial and ethnic backgrounds were varied, with 65.1% Caucasian, 19.7% African American, 5.8% Biracial/Multiracial, 4.1% Hispanic/Latino, 3.8% Asian, and 1.5% other. Participant’s family income during the previous year showed a relatively bimodal distribution, with 29.9% reporting a family income greater than 150,000 USD and 29.1% endorsing a yearly family income below 60,000 USD. Procedures Participants were recruited through the department of psychology subject pool systems at two universities in the Midwest and Southeast United States. Internal Review Board approval was independently gained at each institution. The subject pools consisted of undergraduates in psychology courses who were invited to participate in research as part of their educational experience. Participants self-selected into this study and were made aware that it would be completed online, that it would take approximately 1.5 to 2 hours, and that they would receive course credit. All aspects of this study, including recruitment, consent, survey administration, and debriefing were conducted online from any location of the participant’s choosing. Measures
8
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Demographics. A demographics questionnaire was administered to each participant to ascertain basic background information, such as gender, past year family income, racial/ethnic identity, and education. Juvenile Victimization Questionnaire - Adult Retrospective (JVQR2). The JVQR2 is a self-report measure that assesses a broad range of victimization experiences, including property Downloaded by [Universite Laval] at 17:41 05 November 2015
crime, physical assault, child maltreatment, violence perpetrated by another child (i.e., peer or sibling victimization), witnessed/indirect victimization, and sexual victimization23. The adult retrospective version examines 34 specific types of victimization that participants may have experienced during childhood, from birth to age 17, using a yes/no response format. The current study also included 6 questions assessing childhood exposure to IPV14. Because of limitations on the number of items that can be entered into a latent class analysis, the current study selected 26 items; removed items included those assessing some types of property crime (e.g., having something stolen) and items assessing indirect exposure (e.g., witnessing a mugging), the latter in part because of the overlap with included items about witnessing intimate partner violence. The included items assessed violence exposure within the following domains: community crime/violence, victimization by another child, sexual violence, child maltreatment and childhood exposure to IPV (See Table 4). The JVQR2 has been used in past research assessing young adults’ recollections of childhood victimization24. Further, its construct validity has been established in national samples, and the measure has shown test-retest reliability of Kappa=.6325. A reliability statistic was not calculated for the JVQR2 because participants’ experiences of violence need not be related.
9
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ACCEPTED MANUSCRIPT Center for Epidemiological Studies Depression Scale (CES-D). The CES-D is a 20item self-report measure that assesses depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance in the past week26. Participants estimated how often they experienced these symptoms of depression on a four-point Likert scale, ranging from rarely or none of the time to most or all of the time. Scores range from 0-60 with a clinical cutoff of 16 or greater. The CES-D Downloaded by [Universite Laval] at 17:41 05 November 2015
has good internal consistency reliability and adequate construct and discriminant validity26. In the present study, reliability for the CES-D was α = .91. Depression, Anxiety, and Stress Scale – 21 (DASS-21). The DASS-21 is comprised of three self-report scales, each containing 7 items, designed to measure depression, anxiety and stress in the past week27. Participants estimated how applicable each item was to them on a fourpoint Likert scale, ranging from never to almost always. The DASS-21 has good internal consistency reliability, with alpha coefficients ranging from .80 to .94, as well as adequate construct and discriminant validity28. In the present study, the anxiety subscale was utilized, which had a reliability of α = .87. The cut-off score for moderate symptoms of anxiety is 10. The National Stressful Events Survey PTSD Short Scale (NSESSS). The NSESSS is a 9-item self-report measure assessing symptoms of hypervigilance, re-experiencing, avoidance, and negative mood and cognition in the past week29. This measure has limited psychometric data available as it was recently provided to the clinical and research communities by the Diagnostic and Statistical Manual of Mental Disorders: 5th Edition (DSM-5) Task Force. The NSESSS is one of the only existing quantitative measures to include symptoms of negative mood and
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ACCEPTED MANUSCRIPT cognition, which were added to the most recent diagnostic profile of PTSD. In the present study, reliability for the NSESSS was α = .93. Results Violence Exposure and Clinical Outcomes In the current study, 83.46% of participants reported any history of childhood violence exposure (CVE), with an average endorsement of four violent events (M=3.97, SD=3.72, Range: Downloaded by [Universite Laval] at 17:41 05 November 2015
0-19). The most common type of exposure was verbal abuse by other children (37%) and the least common type of exposure was kidnapping (3%). On average, the sample was just below the clinical range for symptoms of depressed mood, in the normal range for symptoms of anxiety, and in the “no to mild” range for symptoms of PTSD. Violence exposure was related to all mental health outcomes (See Tables 1 and 2). Participants at the Southeastern site reported significantly more exposure to violence (t(348.8)=-3.28, p9=moderate symptoms) Posttraumatic 0.88 (.90) 0.68(.82) 1.24(1.01) 0.80(.74) 1.84(1.03) Stress Symptomsc % PTSD 36% 27% 45% 39% 82% (2=moderate symptoms) For the full sample: an=372 participants with complete data, bn=383 participants with complete data, cn=394 participants with complete data
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ACCEPTED MANUSCRIPT Table 2. Correlations between violence exposure and mental health
1. Total Violence
1. Total Violence
2. Depressed
3. Anxiety
4. Posttraumatic
Exposure
Mood
Symptoms
Stress Symptoms
1
Exposure 2. Depressed
.26***
1
.27***
.66***
1
.33***
.63***
.53***
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Mood 3. Anxiety Symptoms 4. Posttraumatic
1
Stress Symptoms ***p
