Studies related to the cycle of youth violence are important given the serious impact on affected individuals, communities, and society as a whole. Childhood abuse and repeated exposure to violence has a pervasive effect on a child's psychological and biological regulatory processes that can cause a complex set of reactions and lead to multiple psychiatric and functional impairments. In clinical settings, the link between violence exposure and depression,33 anxiety, posttraumatic stress disorder (PTSD),34 drug and alcohol(Drug information on alcohol) abuse,35 and aggression and delinquency36 are frequently observed. Numerous other problems are associated with violence exposure, including a higher suicide risk,37,38 poor academic performance,39 and high-risk sexual behavior.40 Economically, direct and indirect costs of youth violence exceed $158 billion annually.41
Another important issue in understanding the impact of children's exposure to violence relates to neurological maturation and neurobiological processes in response to traumatic stress. The neurobiological sequelae of violence exposure and childhood abuse are well documented.42 Much of the work in this area has focused on altered catecholamine activity within the hypothalamic-pituitary-adrenal axis following exposure to traumatic events. Central catecholamine neurons play a critical role in the level of alertness, vigilance, attention, memory, fear conditioning, and cardiovascular response to life-threatening situations.43 Recurrent exposure to violence can lead to frequent flooding or dysregulation of noradrenergic and corticosteroid systems and contribute to heightened responsiveness and increased levels of aggression in persons with PTSD.44,45
It is believed that these chronically dysregulated systems have an eventual impact on structural and functional brain development. Research using functional MRI and positron emission tomography points toward dysfunction of the hippocampus in patients with PTSD.46 The hippocampus is believed to mediate emotional processing of complex visual stimuli and the integration of different aspects of memory, as well as the ability to locate a memory in time, place, and context. Prolonged periods of stress have been shown to correlate with elevated cortisol levels in the brain, which can damage the hippocampus in humans,47 thus potentially affecting a person's ability to accurately process and respond to incoming information.
Accordingly, brain development, stress regulation, and exposure to early traumatic experience are seen as interactive and cumulative in their influence on the development of impulsive violence and aggression.48Psychopathology of trauma and impulsive violence
Aggressive behaviors can be classified into 2 general categories: premeditated aggression and impulsive aggression. While traumatized youth who perpetuate the cycle of violence may do so for a multitude of reasons—such as a means to express anger and resentment, revenge, distrust, as a self-protective need to attack before being attacked, to escape stressful circumstances, or to reenact previously abusive relationships—youth referred for psychiatric care typically exhibit reactive, impulsive forms of aggressive behavior. Increasingly, impulsivity, affective dysregulation, hyperarousal, and cognitive disorganization are seen as key concepts in understanding the determinants of violence and aggression among traumatized youth; consideration of these elements holds promise for the implementation of effective psychiatric interventions for those referred for outpatient or inpatient psychiatric treatment.CASE VIGNETTE
Jackie is a 13-year-old African American girl referred to the emergency department with suicidal ideation after assaulting a peer at school. She has a long history of oppositional behavior, impulsivity, aggression, family dysfunction, school difficulties, and le- gal involvement, including 2 charges for assault.
Her mother reports that Jackie is surrounded by violence. As a child, Jackie witnessed domestic violence between her parents and engaged in frequent physical fighting with her siblings. She lives in a violent neighborhood, where she witnessed 2 neighborhood shootings and the death of a friend. In school, she frequently fights with peers and has developed a defiant, belligerent attitude toward school personnel.
A family assessment revealed a history of physical abuse, emotional abuse, and emotional neglect. Parental support and modeling have been problematic—her father has been in and out of jail for involvement with drugs, and her mother, also the victim of childhood abuse, is hostile and rigidly opinionated. Several immediate and extended family members have histories of aggressive behavior, including one who is in jail for murder.
Previous in-home and outpatient treatment efforts have been unsuccessful because Jackie often misses appointments, inconsistently takes prescribed medications, and refuses to follow rules at home. On admission to the hospital, she presents as loud, hostile, hypersensitive, intolerant, and threatening. She makes frequent verbal threats to explode, run away, or to commit suicide. She complains that people get on her nerves.
Cases such as Jackie's are all too common and illustrate the challenges faced by mental health professionals. For many adolescents treated within community-based clinics or hospital-based programs, violent and aggressive behavior is a frequent reason for referral and is often a central component of treatment planning. However, the psychopathological processes that underlie impulsive and aggressive behavior are complex. Diagnostically, patients with a history of trauma who exhibit high levels of affective instability, anger, and impulsivity may exhibit signs of an unstable mood disorder, eg, bipolar disorder or a mood disorder not otherwise specified, disruptive behavior disorder (attention-deficit hyperactivity disorder [ADHD], oppositional-defiant disorder, or conduct disorder), or PTSD. Often a core constellation of psychological deficits is present for traumatized and impulsively aggressive adolescents. Namely, impulsively aggressive adolescents typically have difficulty in recognizing, identifying, and verbalizing underlying emotions so that emotional flooding easily occurs and leads to rapid shifts in affect and behavior.
Deficient problem-solving skills are a common cognitive feature in that impulsive adolescents often have difficulty in drawing on intellectual resources to generate alterative options to resolve conflicts, resulting in rigid or negative thought processes. Traumatized adolescents are also likely to view their world as hostile and unsafe and see others as untrustworthy. Children who have been maltreated are hypervigilant to aggressive stimuli and prone to misinterpret verbal and nonverbal cues, making them more likely to perceive threats even when threats do not exist.
Perhaps as a consequence of neurodevelopment and neurocognitive function, impulsive adolescents who have been traumatized are also prone to have an exaggerated fight-flight response, whereby aggression can serve both as a means to protect the self as well as a means to destroy the other. Deep-seated feelings of shame and poor or disrupted interpersonal attachments make impulsive, traumatized adolescents hard to reach, guarded, prone to externalize and project blame, and resistant to sharing feelings openly with adults.
The Figure illustrates the cycle of violent behavior in adolescents.