Journal of Urban Health

, Volume 93, Issue 3, pp 479–492 | Cite as

Role of Direct and Indirect Violence Exposure on Externalizing Behavior in Children

  • Julia M. Fleckman
  • Stacy S. Drury
  • Catherine A. Taylor
  • Katherine P. Theall


The objective of this study was to examine the association between externalizing behaviors and indirect violence exposure, assessed both within the household and at the community level, as well as the interaction effect of indirect and direct violence exposure. A sample of parents of children ages 4–15 who have not been referred or enrolled in child welfare (n = 82) were recruited from the greater New Orleans community. Externalizing behavior was assessed with the Child Behavior Checklist (CBCL). The child’s indirect exposure to violence included witnessing community violence, witnessing physical assault, and witnessing fighting or domestic violence at home. Direct exposure to violence included the child experiencing physical aggression from a caregiver. All assessments were based on caregiver reports. To decrease potential for confounding, children were matched for analysis based on age, Hurricane Katrina exposure, and their propensity to be exposed to high indirect violence. Cumulative indirect exposure to violence was significantly positively correlated with CBCL scores. After controlling for key covariates, CBCL externalizing T score increased significantly by approximately 1.25 points for each level increase in indirect violence exposure (β = 1.25, SE = 0.57, p = 0.027). There also was a significant interaction between indirect and direct exposure to violence in the association with CBCL score (β = −0.08, SE = 0.03, p = 0.002). These findings extend previous research by demonstrating that exposure to both direct and cross-contextual indirect violence influences externalizing behaviors in children. Additionally, the findings suggest that community and household social environments are both important targets for interventions designed to decrease externalizing behaviors and improve long-term outcomes for youth at risk of exposure to violence.


Childhood exposure to violence Cumulative exposure to violence Indirect exposure to violence Direct exposure to violence Community violence Household violence Child physical aggression Child externalizing behaviors 



This study was supported by grants from the National Institutes of Health (NIH; R01ES020447 and P60AA009803-RC5 to Dr. Theall, and R21MH094688 and R01MH101533 to Dr. Drury) and Centers for Disease Control and Prevention (CDC, R01CE002327 to Dr. Taylor).

Compliance with Ethical Standards

This study was approved by the Tulane University Health Sciences Center Institutional Review Board.


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Copyright information

© The New York Academy of Medicine 2016

Authors and Affiliations

  • Julia M. Fleckman
    • 1
  • Stacy S. Drury
    • 2
  • Catherine A. Taylor
    • 1
  • Katherine P. Theall
    • 1
  1. 1.Department of Global Community Health and Behavioral SciencesTulane School of Public Health and Tropical MedicineNew OrleansUSA
  2. 2.Department of Psychiatry and Behavioral SciencesTulane School of MedicineNew OrleansUSA

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