Child Abuse & Neglect 42 (2015) 1–9

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Child Abuse & Neglect

Attachment as a mediator between community violence and posttraumatic stress symptoms among adolescents with a history of maltreatment夽 Melissa J. London, Michelle M. Lilly ∗ , Laura Pittman Northern Illinois University, USA

a r t i c l e

i n f o

Article history: Received 18 July 2014 Received in revised form 27 October 2014 Accepted 4 November 2014 Available online 25 November 2014 Keywords: Posttraumatic stress symptoms Community violence Attachment

a b s t r a c t Experiences that are detrimental to the attachment relationship, such as childhood maltreatment, may reduce feelings of safety among survivors and exacerbate the effects of exposure to subsequent violence, such as witnessing community violence. Though attachment style has been examined in regard to posttraumatic stress in adults who have a history of exposure to violence in childhood, less is known about the influence of attachment on the relationship between exposure to violence and posttraumatic stress symptoms in children and adolescents. The current study aimed to explore the role of attachment in the link between exposure to community violence and posttraumatic stress symptoms in adolescents with a history of childhood abuse. Participants included adolescents (aged 15–18 years) who had a history of maltreatment (N = 75) and a matched sample without a childhood abuse history (N = 78) from the National Data Archive on Child Abuse and Neglect (Salzinger, Feldman, & Ng-Mak, 2008). A conditional process model using bootstrapping to estimate indirect effects showed a significant indirect effect of insecure attachment on the relationship between exposure to community violence and posttraumatic stress symptoms for adolescents with a history of childhood physical abuse, but not for adolescents without this history. Implications for a cumulative risk model for post-trauma pathology starting in adolescence are discussed. © 2014 Elsevier Ltd. All rights reserved.

Exposure to violence in childhood and adolescence is, unfortunately, relatively common in the United States, with the 2008 National Survey of Children’s Exposure to Violence (NatSCEV; Finkelhor, Turner, Ormrod, & Hamby, 2009) revealing a 60.6% exposure rate to one or more direct or witnessed victimizations in one year alone. According to the NatSCEV, which included a nationally representative sample of 4,549 children and adolescents aged zero to 17 years, 46.3% of respondents reported a history of physical assault; 10.2% reported maltreatment by an important adult in their life; 6.1% reported sexual victimization; and 25.3% reported witnessing family assault or community violence in the past year (Finkelhor, Ormrod, & Turner, 2009; Finkelhor, Turner, et al., 2009). Lifetime exposure rates were approximately one third to one half higher, with adolescents reporting higher rates of maltreatment (32.1%) and witnessing violence (70.2%) than younger children. Although research has indicated that adolescents are often exposed to several types of violence in their lifetime, the majority of the literature has focused on exposure to one type of violence rather than on the cumulative effect of exposure to multiple types of violence (Finkelhor, Ormrod, et al., 2009; Finkelhor, Turner, et al., 2009; Grych & Swan, 2012; Lynch & Cicchetti, 1998; Zinzow et al., 2009).

夽 Funding for this project was provided by the National Institute of Mental Health (Award Number: R01 MH048917 05-08). ∗ Corresponding author at: Northern Illinois University, Psychology-Computer Science Bldg., DeKalb, IL 60115, USA. http://dx.doi.org/10.1016/j.chiabu.2014.11.002 0145-2134/© 2014 Elsevier Ltd. All rights reserved.

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An ecological framework that considers multiple levels of influence, including the community and the family, may be beneficial in understanding the effects of exposure to multiple types of violence among adolescents (Bronfenbrenner, 1979). Recent research has illustrated that witnessing community violence often co-occurs with and increases the likelihood of reporting other forms of violence (Finkelhor, Ormrod, et al., 2009; Finkelhor, Turner, et al., 2009; Hanson et al., 2006). In a nationally representative sample of adolescents, ages 12–17, Hanson et al. (2006) found that exposure to community violence was associated with a twofold to fivefold increase in the likelihood for exposure to other forms of violence. In particular, respondents who witnessed community violence were two times more likely to report physical assault perpetrated by a parent, caregiver, or other family member. Although there are high rates of co-occurrence between community and family violence, few studies examine the impact of exposure to both types of violence. Negative mental health outcomes are frequently identified as consequences of exposure to violence during adolescence (see Lynch & Cicchetti, 1998 or Margolin & Gordis, 2000 for a review). Specifically, the results from a recent meta-analysis on the outcomes of exposure to community violence strongly link exposure to community violence to posttraumatic stress symptoms (PTSS) among adolescents (Fowler, Tompsett, Braciszweski, Jacques-Tiura, & Baltes, 2009). Additionally, a considerable amount of research has shown that childhood maltreatment may result in PTSS (e.g., Ackerman, Newton, McPherson, Jones, & Dykman, 1998; Lansford et al., 2002; Margolin & Vickerman, 2007). However, findings from studies that have compared the impact of familial and community violence on PTSS among children and adolescents have been mixed. Lynch and Cicchetti (1998) examined the outcomes of exposure to both child maltreatment and community violence in a sample of 7–12 year olds. Children exposed to both maltreatment and high levels of community violence had the highest levels of trauma-related symptoms. However, the authors did not find an interactive effect between maltreatment status and exposure to community violence, although both types of violence exerted significant main effects. Similarly, in a sample of maltreated youth in foster care, Garrido, Culhane, Raviv, and Taussig (2010) found that community violence did not interact with family violence to predict trauma symptoms. Rather, community violence was associated with trauma symptoms independent of family violence. Notably, family violence was not associated with trauma symptoms when controlling for exposure to community violence. Conversely, using latent profile analysis with a sample of urban adolescents ages 16–24 years, Cecil, Viding, Barker, Guiney, and McCrory (2014) found that childhood maltreatment and community violence exerted both additive and interactive effects on trauma related symptoms. Given the inconsistencies on the additive and interactive effects of exposure to childhood maltreatment and community violence on PTSS, it is important to continue to investigate these associations. In particular, research should focus on these effects among adolescents, as this group reports the highest rates of family and community violence (Finkelhor, Ormrod, et al., 2009; Finkelhor, Turner, et al., 2009). Moreover, while research has begun to examine the effects of exposure to multiple types of violence in adolescence, less is known about the mechanisms that influence these complex relationships and may serve as risk factors for psychopathology. Poor, or less secure, attachment with caregivers has been proposed as one mechanism for which exposure to violence leads to negative consequences. Bowlby’s attachment theory (1969/1982) suggests that early attachment experiences between children and their caregivers provide the foundation for development. Healthy attachment relationships promote a sense of security and enable the child to feel protected by their caregivers (Cassidy, 1999). Attachment-related experiences are implicated in the formation of working models of multiple ecological levels, including the attachment figure (parent), the self, and the world, and influence how the child responds cognitively, emotionally, and behaviorally to various situations. Violence and maltreatment have been associated with disruptions in these attachment bonds and often results in lower quality attachment (Lynch & Cicchetti, 2002; Muller, Sicoli, & Lemieux, 2000; Pearlman & Courtois, 2005). Children who have been abused are unable to view their caregivers as a source of protection or support and may construct unhealthy, insecure, working models (Hankin, 2005; Haskett, Nears, Sabourin, & McPherson, 2006). Additionally, exposure to community violence has been negatively associated with secure attachment to parents over two years in a sample of urban middle school children (Salzinger, Rosario, Feldman, & Ng-Mak, 2011). Consistent with this finding, exposure to high levels of community violence in children has also been associated with negative perceptions of relationships with maternal caregivers, less positive affect when with the caregiver, separation anxiety, and negative maternal behavior (Lynch & Cicchetti, 2002). Similarly, exposure to violence was strongly associated with lower perceptions of acceptance by maternal caregivers among urban youth (Kliewer et al., 2004). Although research has reported an association between attachment and community violence in the past, typically these studies have not taken into account maltreatment experience, potentially resulting in an overestimation of the effects found. Adolescents exposed to both childhood maltreatment and community violence may find no escape from danger, as neither the home nor the outside environment is viewed as safe. A cumulative risk model that reflects exposure to multiple risk factors, such as exposure to childhood maltreatment, community violence, and less secure attachment, may better predict adverse outcomes such as PTSS. A disruption in the attachment relationship may exacerbate the fear brought on by witnessing community violence and contribute to intrusive thoughts about safety, overestimations about danger, and hyperarousal (Fowler et al., 2009; Lynch, 2003). Previous research has provided evidence illustrating the role of less secure attachment as a mediator between exposure to violence and posttraumatic stress. Disrupted attachment has been shown to mediate the effects of childhood maltreatment (Muller, Thornback, & Bedi, 2012), child sexual abuse (Roche, Runtz, & Hunter, 1999), and a history of interpersonal trauma (Sandberg, Suess, & Heaton, 2010) on posttraumatic stress symptoms among adults. However, to date, no research has assessed less secure attachment as a mediator of the relationship between multiple types of violence exposure and posttraumatic stress using a sample of adolescents.

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The current study sought to determine the role of less secure attachment as a mechanism in the development of PTSS following exposure to multiple forms of violence. Specifically, the study aimed to test whether the mediated role of attachment in the relationship between community violence and PTSS differs by history of maltreatment. Two groups of adolescents were included, one with a history of childhood maltreatment and one without this history. Both groups were also exposed to community violence. The following hypotheses were proposed (1) given previous research, adolescents exposed to both physical abuse and community violence would show higher rates of PTSS and lower levels of secure attachment than nonabused adolescents; (2) positive associations would be observed between exposure to community violence and rates of PTSS in both groups of adolescents; (3) negative associations would be observed between exposure to community violence and level of secure attachment in both groups; (4) level of attachment to parents would mediate the relationship between exposure to community violence and PTSS in both groups; (5) level of attachment would demonstrate a stronger indirect effect for adolescents with a history of physical abuse than adolescents without this history. Method Participants Participants in the current sample consisted of adolescents re-recruited from a sample of preadolescent physically abused and matched non-maltreated children. The original sample included 100 physically abused urban schoolchildren, ages 9–12 years (M = 10.5, SD = 0.96) in grades 4–6, and 100 non-abused classmates matched case by case for gender, age, race, ethnicity, and socioeconomic status. The original abuse sample were all confirmed cases of physical abuse consecutively registered on the New York City Register for Maltreatment from 1992 to 1996. A thorough description of the recruitment procedure of the preadolescent sample can be found in Salzinger, Feldman, Ng-Mak, Mojica, and Stockhammer (2001). During the follow-up phase of the study, 153 of the original 200 families were located and assessed. The follow-up study was designed to assess the adolescents as close to age 16 as possible and the average length of the follow-up period was approximately six years in both the abused (N = 75, M = 6.0, SD = 0.90) and nonabused (N = 78, M = 5.9, SD = 0.91) adolescents. The adolescents ranged in age from 15 to 18 years, with a mean of 16.5 (SD = 0.53). There were no differences between the children retained and those lost to follow-up in the distribution of severity ratings of abuse. Additionally, the original and follow up samples did not differ in the majority of demographic variables, including ethnicity, receipt of public assistance, and family structure. However, more boys were lost to follow-up than girls (2 = 4.33, p < .05), resulting in a sample consisting of 61% male and 39% female, compared with 65% male and 35% female in the original sample. Table 1 illustrates the demographics of the abused and nonabused adolescents. There were no differences in the gender composition among the two group of adolescents (2 = .001, p = .97). The abused (M = 16.0, SD = .46) and the nonabused adolescents did not significantly differ in age, t(151) = −.16, p = .877. Moreover, the abused and nonabused adolescents did not significantly differ in ethnicity (2 = 2.46, p = .48), receipt of public assistance (2 = 115, p = .73), nor number of parent figures in the household (2 = 4.13, p = .25). The follow-up sample identified as 38% Black, 7% White, 54% Hispanic, and 1% Asian. Of the families, 32% received a form of public assistance in the year prior to the follow-up interview. The majority of adolescents at the time of follow-up lived with one (40.5%) or two (51.0%) parent figures in the household. Measures Demographics. Parents or guardians completed a short questionnaire that assessed demographic information including ethnicity, receipt of public assistance, and family structure.

Table 1 Demographics. Variable

Sex Male Female Ethnicity Black Hispanic White Asian Receipt of public assistance (Yes) Number of parent figures in household 1 2 3 4

Abused

Nonabused

n (N = 75)

Percent

n (N = 78)

Percent

45 30

60% 40%

47 31

60% 40%

32 39 3 1 25

43 52 4 1 33

26 44 7 1 24

33 56 9 1 31

35 35 4 1

47 47 5 1

27 43 8 0

35 49 10 0

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History of Maltreatment. Physical abuse of the preadolescent sample was determined using the New York City Register for Maltreatment and coded as a dichotomous variable (non-abused = 0, abused = 1). The nonabused group consisted of classmates whose names did not appear on the NYC register and whose caregivers were screened for physical abuse prior to participation in the study. Children with a history of neglect were included, although children history of sexual abuse were excluded from the sample. The collector of the original data state that sexually abused children were excluded on the basis that different theoretical models have been deemed appropriate for understanding physical and sexual abuse (Salzinger et al., 2002) A thorough description of the coding procedure of the preadolescent sample can be found in Salzinger et al. (2001). Exposure to Community Violence. The Survey of Children’s Exposure to Community Violence-Self Report (ECV; Richters & Saltzman, 1990) is an interview that assesses whether an adolescent has witnessed or experienced exposure to violence in school, in the neighborhood, and at home. The interview measures frequency of exposure to 19 types of violent events (e.g., being chased, gun violence, being threatened, knife attacks). Participants were asked to consider their exposure to these events either since they started high school or since the turned 14 years old. Although there is little psychometric information available on the ECV, a systematic review noted that it is the most extensive measure of exposure to community violence (Brandt, Ward, Dawes, & Fisher, 2005). Consistent with previously noted research (Cecil et al., 2014; Garrido et al., 2010; Lynch & Cicchetti, 1998), exposure was defined as the count of violent events witnessed or experienced in the schools and neighborhood. Attachment. The Inventory of Parent and Peer Attachment (IPPA; Armsden & Greenberg, 1987) consists of 25 items that assess attachment to parents. Although the IPPA also measures attachment to friends, for the purpose of this study only the attachment to parents score was used in analyses. Respondents were asked to complete the inventory by focusing on their primary parent figure during high school and were offered several choices (e.g., biological mother, step mother, grandmother, godmother). The majority of adolescents identified their biological mom (76.5%) as their primary parent figure. There were no differences between the scores on the various primary parent figures (F(8, 144) = 1.51, p = .16). The IPPA assesses the adolescent’s perceptions of the relationship with this parent and the extent to which this parent provides security (e.g., “I trust my parent”; “Talking over my problems with my parents makes me feel ashamed or foolish.”). Response options are on a five point scale: 1: almost never or never true, 2: seldom true, 3: sometimes true, 4: often true, 5: almost always or always true. The score for attachment to parents was the mean rating for the 25 items. Higher scores indicate better quality of attachment. In the present study, internal consistency for the mean attachment to parents score was ˛ = .93. Posttraumatic Stress Symptoms. The Diagnostic Interview of Children and Adolescents-PTSD Section (DICA-IV; Reich, Welner, & Herjanic, 1995) is a 1–2 h interview consisting of 38 items that assess PTSD diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). One additional item was included in the current study about the September 11th terrorist attacks. Participants are asked to identify an event that was “the worst” and answer questions regarding the presence of PTSD symptomatology in response to that event. Total PTSS scores were generated by summing the 25 items related to symptomatology. The interviewer scores responses to the symptom items on a four point scale: 0: no, 1: rarely, or not much, 2: sometimes or somewhat, 3:often or a lot of the time. The DICA-IV has been evaluated as valid and reliable in various samples including general population samples (Boyle et al., 1993; Hawkins & Radcliffe, 2006; Welner, Reich, Herjanic, Jung, & Amado, 1987). In the current study, internal consistency for the PTSS score was ˛ = .93. Procedure The data reported in the current study are a follow-up to data collected on the same subjects in an earlier study. All data, including surveys, self-report questionnaires, and interviews were collected by interviewers with some graduate education that were trained by the primary investigators (Salzinger et al., 2008). Data were collected privately in the homes of the families, unless the family member preferred to be interviewed in the offices of the primary investigators in the adolescent’s school. Informed consents were read and signed by the parents and adolescents in which participants were informed that interviewers were professionally obligated to report any new instances of abuse that were reported. Interviews lasted approximately 1–2 h. Adolescents also provided assent to participate. Compensation was provided to both parents ($150.00) and adolescents ($50.00). Upon completion of the interview, participants were debriefed and provided a list of mental health resources. The project was approved by the institutional review board of the institute where data were collected. Results Participants in the non-abused group were exposed to an average of 12.27 (SD = 7.59) violent events in their communities, while participants in the abused group were exposed to an average of 14.43 (SD = 7.39) violent events in their communities. Adolescents with a history of maltreatment reported higher PTSS (M = 22.19, SD = 17.31) and lower attachment scores (M = 3.44, SD = .90) than adolescents without a history of maltreatment (M = 17.39, SD = 13.49; M = 3.76, SD = .68). To test the first hypothesis, that there would be differences between the adolescents with a history of maltreatment and those without

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Table 2 Correlations between exposure to community violence, attachment, and PTSS among full sample. 1. 1. Exposure to community violence 2. Attachment 3. Posttraumatic stress ** ***

– −.238*** .411**

2. – −.352***

3.

–

p < .01. p < .001.

this history on PTSS and attachment, independent sample t-tests were conducted. Significant differences were observed between the two groups for both PTSS, t(148) = −1.90, p = .048, and attachment, t(151) = 2.50, p = .011. Notably, there was not a significant difference between the two groups on exposure to community violence (t(151) = −1.78, p = .08). Bivariate correlations among study variables are shown in Table 2 for the full sample. All variables were significantly correlated with each other among the full sample. Exposure to community violence demonstrated a significant negative correlation with attachment and a significant positive correlation with PTSS. Attachment levels were significantly negatively correlated to PTSS. Bivariate correlations among study variable are shown separated by group (i.e., adolescents with or without a history of maltreatment) in Table 3. Consistent with the second hypothesis, exposure to community violence demonstrated a significant positive correlation with PTSS in both groups. However, contrary to hypothesis three, exposure to community violence was not significantly correlated to attachment among both groups of adolescents. There was a significant negative correlation between these two variables among adolescents with a history of maltreatment, but not in the group of non-abused adolescents. This suggests that quality of attachment is associated with exposure to community violence only in individuals that have suffered from victimization that more directly impacted their attachment relationship. Bootstrapping methodology with 5,000 replaced samples and 95% confidence intervals estimated around the indirect effect was used to examine the indirect effect of less secure attachment to parents on the relationship between exposure to community violence and PTSS (Mallinckrodt, Abraham, Wei, & Russell, 2006; Shrout & Bolger, 2002). Indirect effects are significant when the 95% confidence interval does not include zero. Bootstrapping methodology has been argued to provide a more powerful alternative to the causal steps method (Baron & Kenny, 1986; Frazier, Tix, & Barron, 2004) for testing mediation effects. Bootstrapping was performed using the PROCESS macro (Preacher & Hayes, 2008). Model 59 of the PROCESS tool described by Hayes (2012, 2013) was used in order to assess the indirect effects model as well as the moderated mediation model. Results showed significant direct effects of exposure to community violence on PTSS among both groups of adolescents without a history of maltreatment (95% CI: .37–1.20; effect = .78, se (boot) = .21), as well as adolescents with a history of maltreatment (95% CI: .14–1.03; effect = .59, se (boot) = .23). Additionally, results showed nonsignificant interactions between exposure to community violence and maltreatment status as well as attachment and maltreatment status (Table 4). However, the index of moderated mediation was significant (95% CI: .03–.56; index = .24, se (boot) = .14). Attachment to parents showed a significant indirect effect on the relationship between exposure to community violence and PTSS (95% CI: .06–.57; effect = .26, se effect = .13) among adolescents with a history of maltreatment. Preacher and Kelly (2011) recommend determining the effect size of the mediation when interpreting the meaning of an indirect effect. The authors highlight the estimated value of the kappa-squared (k2 ), which corresponds to the ratio of the obtained indirect effect of the maximum possible indirect effect as a standardized value that is insensitive to sample size. Given the small sample size of the adolescents with a history of maltreatment, a simple mediation model was performed using model 4 of the PROCESS macro to determine the k2 . Results showed a medium effect size, with k2 = .12 (95% CI: .03–.25). There was no significant indirect effect of attachment to parents in the relationship between exposure to community violence and PTSS among adolescents without a history of maltreatment. These results suggest that insecure attachment to parents increases the risk of PTSS following exposure to community violence only among adolescents with a history of maltreatment.

Table 3 Correlations between exposure to community violence, attachment, and PTSS by group.

1. Exposure to community violence 2. Attachment 3. Posttraumatic stress Abused – mean (SD) Nonabused – mean (SD)

1.

2.

– −.120 .449**

−.298** – −.151

12.27 (7.59) 14.43 (7.39)

3.44 (.90) 3.76 (.68)

3. .365** −.446** – 22.19 (17.31) 17.39 (13.49)

Note. Correlations above the diagonal are for adolescents with a history of maltreatment. Correlations below the diagonal are for adolescents without a history of maltreatment. ** p < .01.

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Table 4 Bootstrapping results for moderated mediation. Predictors

Outcome: attachment

Constant Exposure to community violence (ECV) Attachment History of maltreatment (HM) ECV × HM Attachment × HM R2 History of maltreatment

Direct effects

Abused Nonabused Index of moderated mediation Attachment

**

.59 .78***

Outcome: posttraumatic stress symptoms

Coefficient

SE

LLCI

ULCI

3.90*** −.01

.17 .01

3.55 −.03

4.24 .01

.09 −.03

.26 .02

−.43 −.06

.61 .01

Coefficient 14.85 .78*** −1.93 23.73 −.20 −5.26 .26***

.10**

SE

LLCI

ULCI

9.49 .21 2.31 12.62 .31 2.98

−3.91 .37 −6.49 −1.21 −.81 −11.16

33.61 1.20 2.62 48.67 .41 .64

Boot SE

Boot LLCI

Boot ULCI

Indirect effects (k2 )

Boot SE (k2 )

Boot LLCI (k2 )

.23 .21

.14 .37

1.03 1.20

.26(.12) .02

.13 (.05) .03

.06 (.03) −.01

Boot ULCI (k2 ) .60 (.25) .14

Index

Boot SE

Boot LLCI

Boot ULCI

.24

.14

.03

.58

**

p < .01. *** p < .001.

Discussion The current study explored the role of attachment in the pathway from exposure to community violence to posttraumatic stress symptoms in a group of adolescents with and without a history of maltreatment. Consistent with previous research suggesting an additive effect of exposure to multiple forms of violence (Cecil et al., 2014; Garrido et al., 2010; Lynch & Cicchetti, 1998), adolescents exposed to community violence with a history of childhood physical abuse had higher rates of PTSS than those without a history of maltreatment. Notably, exposure to community violence was significantly associated to PTSS regardless of the history of maltreatment. These findings highlight the unique impact of exposure to community violence among adolescents and support the importance of addressing community violence in adolescent populations. Adolescents with exposure to both community and family violence demonstrated lower attachment scores. Contrary to predictions, exposure to community violence was only significantly correlated to attachment in the group of adolescents with a history of maltreatment. Prior work has demonstrated that community violence is associated with more negative perceptions by children of their caregivers and less feelings of security (Lynch & Cicchetti, 2002). Similarly, using the full sample of adolescents in the present study, results showed that community violence was negatively related to attachment. However, the current study differed from previous research by comparing samples of adolescents with and without a history of child maltreatment, which resulted in different findings. The findings in this study suggest that quality of attachment may only relate to violence that involves both members of the attachment experience rather than distal experiences that affect the perception of one member of the attachment relationship. The results are consistent with research illustrating that early childhood maltreatment has detrimental effects on the attachment relationship (e.g., Muller et al., 2012) and suggests that these effects persist into adolescence. Given the gaps in the current literature on the mechanisms involved in the relationship between exposure to multiple types of violence and posttraumatic stress during adolescence, a mediation model was proposed and examined. Contrary to expectations, mediation could not be established among adolescents without a history of maltreatment as exposure to community violence was not related to attachment in this group. Although exposure to community violence was significantly associated with PTSS among adolescents without a history of maltreatment, attachment does not appear to serve as a mechanism through which exposure to community violence predicts PTSS in the absence of earlier violence exposure. Adolescents without early exposure to violence may feel supported and protected by their caregivers, yet still feel distressed due to the high rates of violence in the community. It is also possible that factors such as poor social support or coping strategies, which have been suggested as mechanisms involved in the path to PTSS following trauma (e.g., Vranceanu, Hobfoll, & Johnson, 2007), may also serve as mediating factors in the relationship between exposure to community violence and PTSS. Future research on these and other mediating mechanism of the relationship between exposure to community violence and PTSS among adolescents without a history of childhood physical abuse is warranted. This study did provide evidence for an indirect effect of attachment on the relationship between exposure to community violence and PTSS among adolescents with a history of maltreatment. These results suggest that the mechanism linking exposure to community violence to posttraumatic stress symptoms through attachment is a function of maltreatment history. Prior work has demonstrated that maltreatment may alter the developmental course by initially disrupting the formation of healthy attachments, which increases the child’s vulnerability in the long-term. These early experiences may lead to unhealthy, insecure working models that put the child at risk for revictimization and/or exacerbate the effects of exposure to additional violence. The additive effect of exposure to family violence followed by exposure to violence in the community

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may promote the idea that the world is unsafe and can never be mastered. Interventions aimed at promoting healthy working models may reduce the possibility of posttraumatic stress following exposure to additional violence. Although this study increases our understanding of the relationships among childhood maltreatment, exposure to community violence, exposure to multiple types of violence, attachment, and PTSS, the significance of these findings must be considered in light of several important limitations. The cross-sectional nature limits the ability to test directional or temporal order. Specifically, less secure attachment may not have been an immediate result of exposure to community violence and may better represent pre-trauma vulnerability for the development of PTSS. Moreover, it is unknown whether the attachment figure reported on during the interview was the perpetrator of the maltreatment during childhood. However, it is likely that violence in the home by caregivers other than the primary caregiver may negatively impact the attachment relationship as the child is unable to feel safe in the home. Further, although the groups were split into history of abuse versus no history of abuse, it is possible that during the time between data collection for the original study and the follow-up study, some of the control participants may have experienced maltreatment as well. Since past-year maltreatment was not entered into the model, it is unknown whether PTSS or attachment quality was a result of exposure to community violence or prior maltreatment. It is also unknown whether exposure to specific types of community violence, such as witnessing or directly experiencing, or in different locations, such as neighborhood or school, would moderate the relationship between violence exposure and trauma symptoms. Moreover, the generalizability of this study is limited due to the gender imbalance among study participants as well as the exclusion of children with a history of sexual abuse. Additionally, the power to detect significant effects may have also been reduced as a result of the modest sample size. Thus, it is possible that the lack of significant interactions in the test for moderated mediation was a result of low statistical power. However, it has been argued that an overall indirect effect could be moderated even if one, or all, of the components of the indirect effect is not moderated (Fairchild & MacKinnon, 2009; Hayes, in press). Nevertheless, regression analyses and bootstrapping were able to identify an indirect effect of attachment on the relationship between exposure to community violence and posttraumatic stress only among adolescents with a history of maltreatment, suggesting moderated mediation. The results of the present study emphasize the importance of addressing attachment quality among survivors of child maltreatment as a method of decreasing PTSS from additional exposure to violence such as community violence. Using a sample of adolescents, the results of the current study add to previous studies with adults that have found that attachment mediates the relationship between violence and negative psychological outcomes (Muller et al., 2012; Roche et al., 1999; Sandberg et al., 2010). The results of this study indicate that targeting and improving attachment relationships or internal working models may decrease PTSS symptoms following exposure to violence. The results support interventions such as Trauma Focused – Cognitive Behavioral Therapy, which works with both the child/adolescent and the caregivers to address difficulties related to traumatic life events, including conjoint sessions to enhance the child-caregiver relationship (Cohen & Mannarino, 2008). Through this treatment of PTSS, as well as other established treatments, the risk of negative consequences may be reduced. Additional longitudinal research that investigates the temporal nature of disruptions of attachment may be beneficial in determining the role of attachment in the relationship between exposure to violence and PTSS. The findings also provide further support for the long-term effects of childhood physical abuse, and the additive effect of exposure to multiple types of violence. Acknowledgements The data used in this publication were made available by the National Data Archive on Child Abuse and Neglect, Cornell University, Ithaca, NY, and have been used with permission. Data from Adolescent Outcome of Physically Abused Schoolchildren were originally collected by Suzanne Salzinger, Richard Feldman, and Daisy S. Ng-Mak. The collector of the original data, the funder, NDACAN, Cornell University and their agents or employees bear no responsibility for the analyses or interpretations presented here. References Ackerman, P. T., Newton, J. E. O., Mcpherson, W. B., Jones, J. G., & Dykman, R. A. (1998). Prevalence of posttraumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse & Neglect, 22, 759–774. http://dx.doi.org/10. 1016/S0145-2134(98)00062-3 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders—4th edition, text revision (DSM-IV-TR). Washington, DC: Author. Armsden, G., & Greenberg, M. (1987). The inventory of parent and peer attachment: Individual differences and their relationship to psychological well-being in adolescence. Journal of Youth and Adolescence, 16, 427–454. http://dx.doi.org/10.1007/BF02202939 Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality & Social Psychology, 51, 1173–1182. http://dx.doi.org/10.1037/0022-3514.51.6.1173 Bowlby, J. (1969/1982). Attachment and loss, Vol. 1: Attachment. New York: Basic Books. Boyle, M. H., Offord, D. R., Racine, Y., Sanford, M., Szatmari, P., Fleming, J. E., & Price-Munn, N. (1993). Evaluation of the diagnostic interview for children and adolescents for use in general population samples. Journal of Abnormal Child Psychology, 21, 663–681. http://dx.doi.org/10.1007/BF00916449 Brandt, R., Ward, C. L., Dawes, A., & Fisher, A. J. (2005). Epidemiological measurement of children’s and adolescents’ exposure to community violence: Working with the current state of the science. Clinical Child and Family Psychology Review, 8, 327–342. http://dx.doi.org/10.1007/s10567-005-8811-4 Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Cassidy, J. (1999). The nature of the child’s ties. In J. Cassidy, & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 3–20). New York, NY: The Guilford Press.

8

M.J. London et al. / Child Abuse & Neglect 42 (2015) 1–9

Cecil, C. A. M., Viding, E., Barker, E. D., Guiney, J., & McCrory, E. J. (2014). Double disadvantage: The influence of childhood maltreatment and community violence exposure to adolescent mental health. Journal of Child Psychology and Psychiatry, http://dx.doi.org/10.1111/jcpp.12213 Cohen, J. A., & Mannarino, A. P. (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health, 13, 158–162. http://dx.doi.org/10.1111/j.1475-3588.2008.00502.x Fairchild, A. J., & MacKinnon, D. P. (2009). A general model for testing mediation and moderation effects. Prevention Science, 10, 87–99. http://dx.doi.org/10.1007/s11121-008-0109-6 Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2009). Lifetime assessment of poly-victimization in a national sample of children and youth. Child Abuse & Neglect, 33, 403–411. http://dx.doi.org/10.1016/j.chiabu.2008.09.012 Finkelhor, D., Turner, H., Ormrod, S., & Hamby, S. L. (2009). Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics, 124, 1411–1423. http://dx.doi.org/10.1542/peds.2009-0467 Fowler, P. J., Tompsett, C. J., Braciszewski, J. M., Jacques-Tiura, A. J., & Baltes, B. B. (2009). Community violence: A meta-analysis on the effect of exposure and mental health outcomes of children and adolescents. Development and Psychopathology, 21, 227–259. http://dx.doi.org/10.1017/S095479409000145 Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology, 51, 115–134. http://dx.doi.org/10.1037/0022-0167.51.1.115 Garrido, E. F., Culhane, S. E., Raviv, T., & Taussig, H. N. (2010). Does community violence exposure predict trauma symptoms in a sample of maltreated youth in foster care? Violence and Victims, 25, 755–769. http://dx.doi.org/10.1891/0886-6708.25.6.755 Grych, J., & Swan, S. (2012). Toward a more comprehensive understanding of interpersonal violence: Introduction to the special issue on interconnections among different types of violence. Psychology of Violence, 2, 105–110. http://dx.doi.org/10.1037/a0027616 Hankin, B. L. (2005). Childhood maltreatment and psychopathology: Prospective tests of attachment, cognitive vulnerability, and stress as mediating processes. Cognitive Therapy and Research, 29, 645–671. http://dx.doi.org/10.1007/s10608-005-9631-z Hanson, R. F., Self-Brown, S., Fricker-Elhai, A. E., Kilpatrick, D. G., Saunders, B. E., & Resnick, H. S. (2006). The relations between family environment and violence exposure among youth: Findings from the National Survey of Adolescents. Child Maltreatment, 11, 3–15. http://dx.doi.org/10.1177/1077559505279295 Haskett, M. E., Nears, K., Sabourin-Ward, C., & McPherson, A. V. (2006). Diversity in adjustment of maltreated children: Factors associated with resilient functioning. Clinical Psychology Review, 26, 796–812. http://dx.doi.org/10.1016/j.cpr.2006.03.005 Hawkins, S. S., & Radcliffe, J. (2006). Current measures of PTSD for children and adolescents. Journal of Pediatric Psychology, 31, 420–430. http://dx.doi.org/10.1093/jpepsy/jsj039 Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. [White paper]. Retrieved from: http://www.afhayes.com/public/process2012.pdf Hayes, A. F. (2013). An introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press. Hayes, A. F. (in press). An index and test of linear moderated mediation. Multivariate Behavioural Research. Kliewer, W., Cunningham, J. N., Diehl, R., Parrish, K. A., Walker, J. M., Atiyeh, C., & Mejia, R. (2004). Violence exposure and adjustment in inner-city youth: Child and caregiver emotion regulation skill, caregiver–child relationship quality, and neighborhood cohesion as protective factors. Journal of Clinical Child and Adolescent Psychology, 33, 477–487. http://dx.doi.org/10.1207/s15374424jccp3303 5 Lansford, J. E., Dodge, K. A., Pettit, G. S., Bates, J. E., Crozier, J., & Kaplow, J. (2002). A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Archives of Pediatrics and Adolescent Medicine, 156, 824–830. http://dx.doi.org/10.1001/archpedi.156.8.824 Lynch, M. (2003). Consequences of children’s exposure to community violence. Clinical Child and Family Psychology Review, 6, 265–274. http://dx.doi.org/10.1023/B:CCFP.0000006293.77143.e1 Lynch, M., & Cicchetti, D. (1998). An ecological–transactional analysis of children and contexts: The longitudinal interplay among child maltreatment, community violence, and children’s symptomatology. Development and Psychopathology, 10, 235–257. http://dx.doi.org/10.1017/S095457949800159X Lynch, M., & Cicchetti, D. (2002). Links between community violence and the family system: Evidence from children’s feelings of relatedness and perceptions of parent behavior. Family Process, 41, 519–532. http://dx.doi.org/10.1111/j.1545-5300.2002.41314.x Mallinckrodt, B., Abraham, W. T., Wei, M., & Russell, D. W. (2006). Advances in testing the statistical significance of mediation effects. Journal of Counseling Psychology, 53, 372–378. http://dx.doi.org/10.1037/0022-0167.53.3.372 Margolin, G., & Gordis, E. B. (2000). The effects of family and community violence on children. Annual Review of Psychology, 51, 445–479. http://dx.doi.org/10.1146/annurev.psych.51.1.445 Margolin, G., & Vickerman, K. A. (2007). Posttraumatic stress in children and adolescents exposed to family violence: 1. Overview and issues. Professional Psychology: Research and Practice, 38, 613–619. http://dx.doi.org/10.1037/0735-7028.38.6.613 Muller, R. T., Sicoli, L. A., & Lemieux, K. E. (2000). Relationship between attachment style and posttraumatic stress symptomatology among adults who report the experience of childhood abuse. Journal of Traumatic Stress, 13, 321–332. http://dx.doi.org/10.1023/A:1007752719557 Muller, R. T., Thornback, K., & Bedi, R. (2012). Attachment as a mediator between childhood maltreatment and adult symptomatology. Journal of Family Violence, 27, 243–255. http://dx.doi.org/10.1007/s10896-012-9417-5 Pearlman, L. A., & Courtois, C. A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18, 449–459. http://dx.doi.org/10.1002/jts.20052 Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891. http://dx.doi.org/10.3758/BRM.40.3.879 Preacher, K. J., & Kelly, K. (2011). Effect size measures for mediation models: Quantitative strategies for communicating indirect effects. Psychological Methods, 16, 93–115. http://dx.doi.org/10.1036/a0022658 Reich, W., Welner, Z., & Herjanic, B. (1995). Posttraumatic stress disorder section. Diagnostic interview for children and adolescents (DICA) [software for computer aided assessment, version 8.0]. Newbury, Berkshire, UK: Multi-Health Systems Inc. Richters, J. E., & Saltzman, W. (1990). Survey of children’s exposure to community violence: Self report. Rockville, MD: National Institute of Mental Health. Roche, D. N., Runtz, M. G., & Hunter, M. A. (1999). Adult attachment: A mediator between child sexual abuse and later psychological adjustment. Journal of Interpersonal Violence, 14, 184–207. http://dx.doi.org/10.1177/0886260990 Salzinger, S., Feldman, R. S., Ng-Mak, D. S., Mojica, E., & Stockhammer, T. (2001). The effect of physical abuse on children’s social and affective status: A model of cognitive and behavioral processes explaining the association. Development and Psychopathology, 13, 805–825. Salzinger, S., Feldman, R. S., Ng-Mak, D. S., Mojica, E., Stockhammer, T., & Rosario, M. (2002). Effects of partner violence and physical child abuse on child behavior: A study of abused and comparison children. Journal of Family Violence, 17, 23–52. http://dx.doi.org/10.1023/A:1013656906303 Salzinger, S., Feldman, R., & Ng-Mak, D. (2008). Adolescent outcome of physically abused schoolchildren [dataset]. Available from National Data Archive on Child Abuse and Neglect Web site, http://www.ndacan.cornell.edu Salzinger, S., Rosario, M., Feldman, R. S., & Ng-Mak, D. S. (2011). Role of parent and peer relationships and individual characteristics in middle school children’s behavioral outcomes in the face of community violence. Journal of Research on Adolescence, 21, 395–407. http://dx.doi.org/10. 1111/j.1532-7795.2010.00677.x Sandberg, D. A., Suess, E. A., & Heaton, J. L. (2010). Attachment anxiety as a mediator of the relationship between interpersonal trauma and posttraumatic symptomatology among college women. Journal of Interpersonal Violence, 25, 33–49. http://dx.doi.org/10.1177/0886260508329126 Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychological Methods, 7, 422–445. http://dx.doi.org/10.1037/1082-989X.7.4.422 Vranceanu, A., Hobfoll, S. E., & Johnson, R. J. (2007). Child multi-type maltreatment and associated depression and PTSD symptoms: The role of social support and stress. Child Abuse & Neglect, 31, 71–84. http://dx.doi.org/10.1016/j.chiabu.2006.04.010

M.J. London et al. / Child Abuse & Neglect 42 (2015) 1–9

9

Welner, Z., Reich, W., Herjanic, B., Jung, K., & Amado, H. (1987). Reliability, validity, and parent–child agreement studies of the diagnostic interview for children and adolescents (DICA). Journal of the American Academy of Child & Adolescent Psychiatry, 26, 649–653. http://dx.doi.org/10. 1097/00004583-198709000-00007 Zinzow, H. M., Ruggiero, K. J., Resnick, H., Hanson, R., Smith, D., Saunders, B., & Kilpatrick, D. (2009). Prevalence and mental health correlates of witnessed parental violence and community violence in a national sample of adolescents. Journal of Child Psychology and Psychiatry, 50, 441–450. http://dx.doi.org/10.1111/j.1469-7610.2008.02004x