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Transcript: NICHD Research Perspectives—December 16, 2013

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Announcer: From the Eunice Kennedy Shriver National Institute of Child Health and Human Development, part of the National Institutes of Health, welcome to another installment of NICHD Research Perspectives.

Ms. Kerri Childress: Hi, my name is Kerri Childress. I’m the Director of Communications for the Eunice Kennedy Shriver National Institute of Child Health and Human Development. And we’re here today with three experts to discuss a problem that is nationwide. And although the statistics are showing that there’s less and less of it, it is still a major problem in the United States, and that is youth violence.

Today, I have three experts to help shed some light on the topic: Dr. Valerie Maholmes, who is the Chief of the National Institute on Child Health and Human Development’s Pediatric Trauma and Critical Illness Branch, whose expertise covers the physical and psychological aspects of youth violence, the type of violence and injuries, implications for child behavior and emotional development, and the role pediatricians can play as a resource to families.

Also with us today is Dr. Layla Esposito, a Program Director at the National Institute of Child Health and Human Development’s Child Development and Behavior Branch, who has done research in such areas as the psychosocial aspects of youth violence, the relational aspects of bullying, and some of the more basic facts about youth violence, such as risk factors and consequences, etc.

And our third expert is Dr. James Blair, Chief of the Unit on Affective Cognitive Neuroscience at the National Institute of Mental Health, who can speak about neurological differences seen in youth with violent tendencies. He has focused specifically on youth with conduct disorders and on those with callous emotional and antisocial traits—not all of whom are violent, however. Dr. Blair hopes to find a biological marker that could ultimately help in finding personalized interventions.

Dr. Maholmes, let’s start with you. Youth violence is a big category: let’s get a little more specific. What are some of the forms that youth violence can take?

Dr. Valerie Maholmes: Thank you. That’s an important question. Youth violence can take the form of interpersonal violence, the one-on-one types of violence, the kinds of relational violence that Dr. Esposito has expertise in and will share about, community violence, gang violence, homicide, as well as self-injurious behavior. And when we talk about youth violence, we’re really talking about an age band of adolescents through earlier emerging adulthood, and it’s really important to think about that violence in the context of understanding adolescent development and what the kinds of developmental tasks are that they are struggling with at this particular point in their development.

Ms. Childress: Well, I know along those same lines that NIH as a whole has done some research on cyberbullying as well, and I think you can speak to that, which I think is an issue that is very, very prevalent in today’s youth.

Dr. Maholmes: Yes, the data are still coming in on cyberbullying, and I’ll defer to Dr. Esposito to share her insights in that regard, but the issue and challenge with any kind of electronic aggression is who aggresses against whom and what media they use, and it is pervasive. We’re just now getting a handle on how these children and young people aggress against each other and the consequences and the impact of it, and we’re learning that the trauma experienced from being exposed to electronic aggression does have implications and far-reaching effects in the lives of children in terms of their ability to function academically and to engage in other social tasks, and it does lead to often—in some cases, I should say—self-injurious behavior. And we are looking more for the community to do more research and sharing with us how that new phenomenon—relatively new phenomenon—is gaining traction and hold within the youth culture.

Ms. Childress: Would you like to add anything to that, Dr. Esposito? 

Dr. Layla Esposito: Thank you. I agree that we don’t really have a handle on statistics with cyberbullying yet and cyber aggression because it is a new, a relatively new form, of aggression, but we know it’s becoming more and more prevalent. It’s often anonymous, so it’s hard to know who’s committing those acts, and it’s very prevalent, and it can affect children on multiple mediums, including things like Facebook, text messages, emails—a variety of mediums—so we know that it’s a problem. We’re looking to increase the research in that area and hoping to come up with some strategies to help parents keep children safe and give them tools to prevent them from being exposed to those types of aggression.

Ms. Childress: Good. Good. What makes some youth more likely to commit violence? And are there specific risk factors? And I throw that open to any of the three of you, if you’d like to address that.

Dr. Esposito: I’ll take a first stab at it. I think there are a variety of risk factors that occur at multiple levels, so we have individual risk factors, family risk factors, societal risk factors. Some of the main risk factors that have been identified include things like prior aggression or prior violent acts especially in childhood, drug and alcohol use, exposure to a deviant peer group or involvement in gangs, poor family functioning—we also know that these children often don’t perform well in school—and poverty in the community, and lack of resources or access to opportunity, I think are some of the main risk factors. But we can dive deeper in to any of those categories in terms of individual level or community level, if you’re interested in that.

Ms. Childress: Well, I also know that there are some misconceptions on who the people are that are the recipients of this violence, and I know that I’ve heard Dr. Maholmes address that before, that we tend to always think it’s a small person or it’s a weak person that is the recipient in this violence, but that’s not always the case, I understand.

Dr. Maholmes: Yeah, it’s not necessarily the case, and I do want to just extend some of Dr. Esposito’s comments as well to underscore the importance of looking at all those multiple levels of risks for children and families. But many of these children have multiple risks, so you don’t just see a child who has been exposed to violence or a child who is just poor or a child who uses or abuses alcohol or substances that might be engaging in this violent behavior, but often they have multiple risks, and the interaction of these risks in the way that they are manifested in a life of a child, depending on where those vulnerabilities are, may place the child at greater risk of either perpetrating or being a victim of violence, and we know that some children who have been exposed to violence—let’s say, for example, in the home, child abuse and domestic violence—may themselves be victims of violence. We know that sometimes we see more internalizing behaviors among girls, meaning that they might be depressed, or they might be more susceptible to victimization, although that’s not, as Layla will point out, that’s not always the case, but there are many, many factors to consider and when we talk about aggression—peer-to-peer aggression—it may not always be that the young, the unpopular child, the bully of our parent’s childhood is the one who is being aggressed against. It’s a social network phenomenon, and often these young people are popular and they are not marginalized, but they may aggress against someone who might not be your typical youth that you’d expect to be aggressed against.

Ms. Childress: Thank you. Thank you very much. Dr. Blair, what about the biological risk factors?

Dr. James Blair: So again, it’s a complicated picture, I mean, so you see, with respect to issues of trauma. There are definitely individuals who are more predisposed to have stronger access to trauma, and the importance of this is that we actually know the impact of trauma on the brain. There’s a basic threat circuitry that runs from the amygdala down into more basic brain architecture that allows you to have a threat response, and your really basic threat response is as the threat comes by, you freeze, you flee, and if it’s really there in front of you, you fight. And the problem that some individuals face—particularly individuals who (a) are a bit predisposed, and (b) may be suffering a lot of traumatic exposure, whether it’s abuse, or exposure to violence in the community, or any of these variables—is that the individual is bombarded by threat cues leading to a really strong threat response. And whereas a healthy individual not exposed to those things might just freeze or move themselves out of a something that irritates them or frustrates them or frightens them, this individual is much more likely to explode and have a reactive—what’s called a reactive aggressive response. It’s a response to frustration or threat with very limited thought beforehand, just a lashing out.

So, you have that group of individuals who are the emotionally labeled when you say talking about comorbidity with emotional disorders, that group is highly comorbid with anxiety and mood, very high increased risk for potentially PTSD or at least some clinical forms of PTSD. And then you’ve got another group who have a rather different form of neurobiological risk factor, where instead of the emotional systems being overly responsive, they’re actually reduced responsiveness. And the reason why this is particularly problematic is that one of the reasons why we don’t like harming other individuals is because it’s so upsetting to imagine how sad they actually are after the action has been done. We may do, you know, something that’s not very nice to somebody else, but we often feel guilty about it afterwards. And a lot of that is to do with the fact that we have good strong emotional responses when we either see the person upset or we imagine what we’ve actually might have done to that other person. Some people don’t have such good responses in that type of system, and so they don’t get the good empathic response to the other individual that is the basis of how we socialize kids, children, into not liking harming other individuals.

So those, really these two rather different classifications, in fact, it’s even possible, it looks like it’s actually quite probable that that second group is actually protected from the really pernicious impacts of trauma even if it’s protected in a way that clearly is not healthy for the individual. It’s not just that the individual does not feel empathy and caring for others, but there’s also a lot of positive emotions that also seem to be for the whole basis of attachment and love for another individual also potentially is disrupted as well.

Ms. Childress: Fascinating, I mean, really interesting. Would either of you ladies like to comment on that?

Dr. Maholmes: Well, I wanted to say we talked about the risk factors, but they accompany protective factors. And to the extent that they accompany protective factors, you may see behaviorally the things that were just described, so that you may see a child that comes from, that may be in the community where there’s lots of blighted buildings and low resources and the kinds of things that Dr. Esposito described, but if they have a strong family, if they have good relationships internally, or even if their family might have some vulnerabilities, maybe there’s an extended family, maybe there’s a teacher, a pastor, a friend, an afterschool club, but that there’s some opportunities for that child to learn those kinds of behaviors of empathy and caring and support and valuing of life and resources of others. Those kinds of protective factors really have the power, if you will, to help buffer a child from these constant assaults and threats to them and to behave in ways that certainly would get them into lots of trouble.

Ms. Childress: Well, to you, Dr. Esposito, tell me some of the more common myths that you’ve heard regarding youth violence.

Dr. Esposito: Well, I think that one common myth that is being debunked by current literature is that boys are always physically aggressive and girls are always relationally aggressive. By relationally aggressive, I mean things like spreading rumors, backstabbing, gossip, things like that. And what we’re finding is that although it’s true that boys tend to be more physically aggressive, girls are physically aggressive as well. And when we look at relational aggression, we’re finding that boys are actually just as relationally or indirectly aggressive as girls are. So I think there have been perpetuated myths about the role of gender and aggression that we’re coming to learn aren’t actually true.

There are other myths about the relationship between violence and psychopathology. So often you think that everybody who commits a crime has some kind of a clinical disorder, and we know that that’s not always the case. And there are also myths about children who have been abused or neglected that they might go down a path of being violent individuals, and we know for the majority of children who experience some kind of abuse or neglect do not turn out necessarily to become perpetrators later on, so there are several myths that the research that we’re conducting here and that we’re supporting at the NIH has been able to show isn’t true.

Ms. Childress: Interesting. And speaking of women and men, Dr. Blair—I mean, of girls and boys—have you seen any differences?

Dr. Blair: I completely agree with respect to the issues about the level of psychopathology in aggressive individuals. I mean, even within the population who meet the diagnostic criteria for conduct disorder, you’re finding individuals who have these problems I’ve just been describing, but you have individuals who look like the typically developing individuals. And one of the reasons that I, you know, I’m interested in what I do—obviously I’m always interested in what I do, but I’m interested in what I do—because the hope is that we can, by having the markers identify this type of problem from that type of problem, and then also see that it’s not present in a third group of children, we can direct interventions, because there are likely to be very clear differences in the interventions that are going to be most successful in those three different groups.

Ms. Childress: Understand, yeah. And I think that’s very admirable what you are studying to do where we can more specifically focus the interventions, but until we really find those markers, can you speak to what kind of interventions if, one, if you’re a parent of a child who is being bullied or who has had an act of violence against them in the school by another youth, or on the other side of the fence, you’re a parent whose child is actually the perpetrator of that violence. Do you have some recommendations for those parents?

Dr. Esposito: Well, there are several programs that have been shown to be effective if we’re going to talk about bullying. Because I think there, the intervention is going to be to some extent specific on the type of violence that you are talking about, and we are investing in evaluating a lot of those programs right now through our extramural research program. I think a lot of the programs help teach children about social problem-solving, help teach them how to manage their emotions, and how to think about the consequences of their actions before they act when we’re talking about these kind of social development programs. There also are programs that help parents and help parents listen to their children, bond with their children, be a resource to their children. They help parents understand how to be positive role models for their children because we know that parents are very, very powerful role models, and so if their own behavior is influencing the child’s development, then we can intervene on that level and help them be a better support for their child.

Ms. Childress: And I would like to, at this point, especially reference bullying to let folks know that there is an excellent website, it’s called, has a lot of the resources that you’re talking about on it, and so if you’re either experiencing bullying or at least know other people who might be, I really recommend that you take a look at this website because I think it can at least lead you in the right directions. Anything else either of you would like to add to that topic?

Dr. Blair: Actually, we do now have the biomarker tasks. So it’s not the situation we were at 5 years ago. We do actually, or at least we think we have, we can’t be sure, but we think we have the task. And indeed I think that certainly I’m working in collaboration with extramural individuals who are indeed running the sort of Coping Power from John Lochman’s group—I think he’s actually received funding from NICHD in the past or certainly from NIH generally—and other researchers out there so that we can actually indeed see both with behavioral indices of these biological mechanisms as well as FMRI, functional magnetic resonance images, of these mechanisms to see whether we can actually see both whether we can predict who’s going to really benefit from interventions, but also whether we see a successful intervention in a child, whether it’s accompanied by brain-level changes. I mean one of the exciting, it’s quite a few that are based around reducing the impact of trauma as a treatment, an indirect treatment, for aggression or it reduces stress levels, you sort of we’re alluding to it, and we certainly know that successful interventions with patients with post-traumatic stress disorder are accompanied directly by this reduction in those basic systems that respond to threat, and so if that’s the case with patients with PTSD, it should be the case as well with children who were benefiting most from these programs designed to reduce the responsiveness to stress, although we haven’t documented, but we do have the tools to document it, and we hope we can, so that, indeed, we can then best guide interventions to the children who will best benefit.

Ms. Childress: Interesting. And do we see in the world where this is more from the clinical to the bedside type of research that you’re talking about, do you see a way that that could happen fairly easily, or do you see that taking some years ahead before we actually get that information to the key people we need to help treat the youth?

Dr. Blair: I’m ludicrously optimistic. So, I believe we’ll have the information relatively rapidly, but unfortunately I am ludicrously optimistic. But the fact is we won’t be using—or at least I don’t think we’ll be using—FMRI to index treatment response, and that’s why we have this parallel arm of behavioral tests to index the most, because those should be, won’t take too much training to be able to use them, assuming they actually prove to be useful. And so under those circumstances, if the studies do show that we are able to detect who will benefit most and we do see the impact from the interventions, then we could see it relatively rapidly. 

Dr. Maholmes: Well, I’m all for optimism. What’s so exciting about this conversation, it goes back to Dr. Esposito’s point about the multiple levels of risks, and where you have multiple levels of risk, you really have to look at this problem for multiple solutions. This is a public health problem, and if we look at youth violence like a public health problem, then we will solve it in that way, we will address it in that way, we will draw on the research from multiple disciplines to help us get down to the root of some of these challenges. And if we look at how we interrupt other kinds of diseases, we participated in a workshop with the Institute of Medicine, looking at the contagion of violence, and we looked at it like an infectious disease model where you have interrupters that come in to stop the cycle of violence. That’s what we need to be able to do. The parents are not going to be able to do it alone. The schools can’t do it alone. The neurobiologists can’t do it alone. But we all have to work together to make sure that we’re looking at this problem in the way that it presents itself, with lots of tentacles and complexities and issues that we all have to figure out how to solve together.

Ms. Childress: Wonderful. Thank you, that’s really good to know, and I think you summed up the effort that all of us in a lot of different organizations have to make together, and I think you did that very beautifully. I was wondering, Dr. Esposito, if you’d like to finish with any lasting messages that you would like to say or anything that you think is really key or something that we might have missed so far.

Dr. Esposito: I guess I will give some tips to parents who might be listening. If I had to come up with three key messages to parents, I would say it’s really important for you to be a positive role model for your child and to be very involved in your child’s life. This includes things like helping them problem solve, discussing alternatives when they do come up against a problem that they’re having a hard time against, and also monitoring your own behavior as you are a very powerful figure for your child and they will model how you act.

I think it’s also important to monitor your child and to provide as much supervision as possible, so know who your child’s peer group is.

And lastly, we haven’t spoken about this but I think it’s actually really important that parents need to try as best as they can to limit their child’s exposure to violent media. We know that children are exposed to violent TV shows, violence in movies, and violent video games, and I think that’s a really important way that parents can contribute to helping guide their children is to try to steer them away from those types of exposures because we are seeing that exposure to violence in those forms actually can normalize violence and normalize aggression for children, and so if they’re able to do it and see it all around them, it doesn’t become such a big deal. And I think that’s something that parents really need to think about.

Ms. Childress: Thank you very much. Dr. Blair, do you have anything that you would like to add or any messages you haven’t given yet that you think any be it researchers, parents, anyone?

Dr. Blair: The fact is that we are in a situation where there is enormous growth in understanding of the various problems indeed from a social point of view, from a neurobiological point of view, from a family point of view, and we are looking like we have the possibilities for traction for really making enormous differences over the next 10 years.

Ms. Childress: And I can’t think of a better note to end on. So thank you all very, very much. I think this is an issue and something that’s important to our entire nation—no, actually important to the entire world. So thank you all very, very much for your time, and thank you for what you do every day, and I mean this sincerely from the bottom of my heart. Thank you for what you do every day to help both youth and the country at large. Thank you.

Guests: Thank you. Thank you. Thank you.

Announcer: This has been NICHD Research Perspectives. To listen to previous installments, visit If you have any questions or comments, please email ​

Last Reviewed: 01/21/2014
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