Polyvictimization Experiences and Depression Among Youth Living in Foster Care

Abstract

Current research indicates that violence against youth contributes to adverse psychological outcomes but has yet to focus on violence against youth while living in foster care and the associated psychosomatic changes over time. Multilevel modeling regression was used to analyze self-reported depression for a sample of 354 youth living in foster care from one Midwestern state. The present study found that changes in depression levels over time among the foster care youth who experienced polyvictimization, compared to the youth who experienced child maltreatment alone, were conditional upon gender and varied significantly by race. Policy implications are discussed.

Keywords

polyvictimization child maltreatment foster care mental health depression

Evidence suggests that each single type of victimization tends to increase the risk for youth to experience polyvictimization (Cuevas, Finkelhor, Ormrod, & Turner, 2010; Finkelhor, Turner, Hamby, & Ormrod, 2011; Finkelhor, Turner, Ormrod, & Hamby, 2009; McIntyre & Widom, 2011). Polyvictimization can be defined as multiple victimization experiences that are either simultaneous or sequential throughout an individual’s life span (Cuevas et al., 2010; Hahm, Lee, Ozonoff, & Van Wert, 2010; Hamby, Finkelhor, Turner, & Ormrod, 2010; Finkelhor, Ormrod, & Turner, 2007a; Finkelhor et al., 2011; McIntyre & Widom, 2011). Youth who have been placed into foster care due to substantiated child maltreatment experiences may be more vulnerable to experiencing polyvictimization. Specifically, research indicates that experiencing child maltreatment increases the risk for nonfamilial violent crime victimization during adulthood (McIntyre & Widom, 2011). Experiencing child maltreatment can also pose negative consequences for mental health status among youth (e.g., Cohen, Mannarino, Murray, & Igelman, 2006; Edleson, 2004; Finkelhor, Ormrod, & Turner, 2009b; Finkelhor, Ormrod, Turner, & Hamby, 2005: Kitzmann, Gaylord, Holt, & Kenny, 2003; Stapleton, Phillips, Moynihan, Wiesen-Martin, & Beaulieu, 2010). In addition, different types of violence against youth can independently contribute to negative effects on psychological wellness and functioning, including depression (Boxer & Terranova, 2008; Mrug & Windle, 2010; Turner, Finkelhor, & Ormrod, 2006).

In recent years, research dedicated to examining both child maltreatment and other forms of violence against youth (i.e., polyvictimization) has increased. To date, much of the child welfare literature has focused on examining polyvictimization among general populations of youth (Turner et al., 2006) and specific-associated traumatic outcomes (Bennett, Sullivan, & Lewis, 2010; Cuevas et al., 2010; Turner et al., 2006). There is limited research exploring polyvictimization experiences over time among youth living in foster care. Yet, the literature seems devoid of data on changes in depression levels over time within and among youth who experience polyvictimization while residing in foster care. To what extent are polyvictimization experiences associated with depression levels over time? Do depression levels vary from youth to youth living in foster care due to polyvictimization? The present study fills these gaps in the literature by assessing changes in youths’ depression levels due to experiencing polyvictimization while residing in foster care. The results of this study are expected to offer professionals working in or with the foster care system evidence-based data for developing specific services for youth transitioning out of the foster care system, particularly among youth most vulnerable for future victimization experiences.

Child Maltreatment and Depression

Estimates derived from population-based samples indicate that roughly 125 in 1,000 youth experience child maltreatment (Finkelhor et al., 2005). One of the most common effects of trauma from experiencing child maltreatment is emotional problems, including depressive symptoms (Carlson, 2000; Cohen, Mannarino, & Knudsen, 2005; Cohen et al., 2006; Van der Kolk & Courtois, 2005), and specifically increased depression levels (Edleson, 2004). Maltreatment types are often intertwined (Edwards, Holden, Felitti, & Anda, 2003; Martinez, Gudiño, & Lau, 2013; McGee, Wolfe, Yuen, Wilson, & Carnochan, 1995; Ney, Fung, & Wickett, 1994), and not all incidents of alleged maltreatment are substantiated. Some existing research uses samples of youth with unsubstantiated reports of child maltreatment, which do not generally have long-term official intervention for these youth. Therefore, the youth sampled in these studies were not studied over time to ascertain negative psychological outcomes. Comparatively, substantiated child welfare reports tend to involve more severe incidents of child maltreatment which can result in youth being placed in foster care homes (Crosson-Tower, 2010). Youth living in foster care then may have the most need for mental health services.

Foster Care and Mental Health

The most egregious of child maltreatment incidents may be the cases that are substantiated by the legal system and child welfare agencies. A large portion of the youth involved in substantiated child maltreatment cases require placement within the foster care system (Christian & Schwarz, 2011). Estimates place more than 500,000 children residing in foster care, and it is estimated that 70% of those youth were placed in foster care due to child maltreatment (Christian & Schwarz, 2011; Hahm et al., 2010). Studies using samples of youth reported to child protection suggest that many youth having involvement with the child welfare system have an associated mental health disorder (Garland, Landsverk, Hough, & Ellis-MacLeod, 1996; Landsverk, Garland, & Leslie, 2002; Taussig, 2002), including increased depression levels (Ayon & Marcenko, 2008). The few studies specifically focused on samples of youth living in foster care indicate that these youth exhibit more long-term negative psychological symptomatology, including an increased likelihood of experiencing some degree of depressive symptoms (McMillen et al., 2004; Pecora, Jensen, Romanelli, Jackson, & Ortiz, 2009; Pesonen et al., 2007; Van der Kolk & Courtois, 2005), as compared to the general population of youth (Landsverk, Burns, Stambaugh, & Rolls Reutz, 2006; Pilowsky & Wu, 2006). However, the current literature has a focus on the association between multiple foster care placement and greater risk of developing depressive symptoms (McMillen et al., 2005) and does not directly assess the association between victimization experiences and change in depression levels over time.

Polyvictimization and Depression

The emerging research on polyvictimization suggests that the cumulative exposure to multiple forms of victimization occurring over the course of a child’s development substantially increases mental health risk (Finkelhor, Ormrod, & Turner 2009a; Finkelhor, Turner, Ormrod, & Hamby, 2009; Hahm et al., 2010; Turner et al., 2006). For instance, trauma symptoms are more prevalent and severe for polyvictimization experiences compared to experiencing a singular type of victimization (Finkelhor et al., 2007a; Finkelhor, Ormrod, Turner, & Holt, 2009; Hahm et al., 2010; Turner, Finkelhor, & Ormrod, 2010). Specifically, exposure to various types of victimization increases the chances of developing and experiencing increased depressive symptomatology (Mrug & Windle, 2010; Turner et al., 2006) and other internalizing and externalizing problems (Mrug, Loosier, & Windle, 2008; Mrug & Windle, 2010). The current literature seems to offer a mispresented association between single forms of victimization and psychological symptoms, while disregarding the influence of polyvictimization (Finkelhor et al., 2007b). From a clinical perspective, these possible errors could have a significant impact on intervention modalities and subsequently the youth’s ability to cope with their victimizations.

Polyvictimization, Foster Care, and Depression

The negative impacts of polyvictimization tend to endure over time (Finkelhor, Ormrod, & Turner, 2007b). Youth living in foster care tend to already have increased psychiatric symptoms, and this symptomatology seems to be correlated with the trauma-based experiences (Heflinger, Simpkins, & Combs-Orme, 2000; McMillen et al., 2004; Van der Kolk & Courtois, 2005). Foster care is intended to serve as a ‘safe environment,’ and the natural assumption is that youth will be free from experiencing violence while residing in foster care. Yet, a substantive proportion of children who report experiencing child victimization have experienced more than one type of victimization (Cuevas et al., Turner, 2010; Finkelhor et al., 2011) possibly making youth living in foster care more vulnerable to other acts of violence.

For the child welfare system to ensure youth leaving foster care are fully prepared for independence upon exit from the system, it is vital to understand any underlying trauma from polyvictimization experiences. Research has examined the associations between initial child maltreatment and repeated abuse as well as the association between familial and nonfamilial victimization (McIntyre & Widom, 2011), and there is some emerging research that explores the associated mental health symptoms (Bruskas, 2008; Finkelhor et al., 2007a; Segura, Pereda, Guilera, & Abad, 2016) due to polyvictimization. When victimization occurs during foster care placement, youth may lack strong supports that would reduce their risk for victimization and the associated trauma. Research is needed to determine whether negative psychological outcomes, such as elevated depression levels over time, are associated with polyvictimization among youth living in foster care.

The Present Study

The present study explores changes in depression levels among a group of youth who experienced both child maltreatment and nonfamilial violent crime victimization (categorized here as polyvictimization) while in a foster care placement. Much of the existing research on this topic is retrospective in nature, limited to reports of memory recall rather than ‘real-time’ indicators of depression levels during foster care placement. The present study focuses on the changes over time in self-reported depression levels within and among youth living in foster care due to the cumulative effect of child maltreatment and nonfamilial violent crime victimization (e.g., robbery, sexual assault). Literature suggests that mental health services tend to be only utilized for manifest symptomatology (Leslie et al., 2000) and not all youth openly present depressive symptoms. The compounded effects of polyvictimization could possibly increase depressive symptoms among youth living in foster care as compared to the youth living in foster care who experienced child maltreatment only. Therefore, self-reported depression levels over time may provide increased insight into youth’s experiences while residing in foster care.

As noted above, existing literature suggests that each single act of victimization may increase the likelihood of future victimization experiences (i.e., polyvictimization) and that polyvictimization experiences are associated with depression and other negative psychosomatic symptoms. Therefore, we predict (H₁) that depression levels within the youth living in foster care who experienced child maltreatment only will decrease over time while (H₂) the youth who experience polyvictimization during their foster care placement will report increased depression levels. Child welfare literature has yet to make longitudinal comparisons among groups of foster care youth who experience maltreatment and nonfamilial violent crime victimization (i.e., polyvictimization). Victimization of youth is considered to be more serious when it involves children exposed to multiple dimensions of violence (Crosson-Tower, 2010), so it is critical to examine the impact of polyvictimization among youth residing in foster care.

Method

Our study used data from the Mental Health Service Use of Youth Leaving Foster Care (Voyages). ‘Voyages’ is a longitudinal, cohort design data set containing self-reported information of the youth placed in the foster care system from selected counties within one Midwestern state (Larrabee-Warner & McMillen, 2010). Data collection occurred between December 2001 and June 2003 with interviews occurring approximately every 3 months, producing nine waves of data over a period of about 18 months. While Voyages is dated, this data set provides unique indicators and methodology to assess longitudinal measures of depression among youth living in foster care. There are many methodological issues associated with data sets on foster care youth; for example, youth living in foster care are considered a ‘protected population’ for which confidentiality issues often arise (for a more robust discussion of these issues, see Newton, Litrownik, & Landsverk, 2000).

Subjects

The ‘Voyages’ data set contains a total of 404 youth living in foster care. In order for youth to be included in the Voyages data set, youth were required to be English speaking, to have been placed in the legal custody of the child protection agency for the state, to be living in or within 100 miles of the county Child Protection Agency offices selected for participation, and have an IQ level of at least 70 (Larrabee-Warner & McMillen, 2010). all youth in this sample ranged from 16 years-old, the youngest at the initial interview, to 19 years-old, the oldest at the exit interview. These youth were interviewed beginning at either age 16 or 17 and ending after aging out of foster care (no older than age 19). Despite all youth living in foster care at the initial interview (wave 1 of data collection), not all youth in this data set reported experiencing maltreatment. Some of the youth in this data set were placed into foster care due to involvement in the juvenile justice system (i.e., delinquency or status offense cases). Cases were filtered from this analysis to include only those youth who reported, at baseline, experiences with physical abuse, emotional abuse, sexual abuse and neglect within their families of origin. After filtering, the final sample size was 354 youth with substantiated child maltreatment cases.

Measures

All of the variables used in the present study derive from the Voyages data set. The data is self-reported directly from the youth living in foster care to the interviewer. Other than the youth’s experience with maltreatment, each variable was measured at each wave of data collection throughout the entirely of the study.

Maltreatment victimization

The Voyages study measured maltreatment victimization using the childhood trauma questionnaire (CTQ; Bernstein & Fink, 1998; Fink, Bernstein, Handelsman, Foote, & Lovejoy, 1995). The CTQ has demonstrated reliability (α: 0.80 to 0.97) and validity among adolescents, including specific use within adolescent psychiatric populations (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). In the present study, the questions from the CTQ were combined with three questions at baseline regarding ‘unwanted sexual experiences when you were touched or forced to have sex against your wishes’ to represent sexual abuse: (1) has anyone ever made you touch their private parts, against your wishes; (2) has anyone ever touched your private parts (breasts or genitals) against your wishes; and (3) has anyone ever had vaginal sex, oral sex, or anal sex with you against your wishes (McMillen, 2010). All of the questions on child maltreatment experiences were dichotomized to represent whether the youth had experienced maltreatment (1) for ‘sometimes true, often true, and very often true’ or no maltreatment experiences (0) for ‘never true’ and ‘rarely true’ responses. As described in the sample section, cases were then filtered to include only the youth in foster care who self-reported child maltreatment experiences at baseline. Of these cases, 81 percent of the youth had experienced a combination of different types of child maltreatment (see Table 1). Given this high proportion, the decision was made to collapse all types of child maltreatment together into a dichotomous variable rather than examine the effects of polyvictimization on depression level scores by specific type of child maltreatment, given that the research indicates child maltreatment is typically experienced as multiple dimensions rather that singular type of abuse (Crosson-Tower, 2010).

Table 1.

Demographic Variables.

Characteristic	n	Percentage	Min.	Max.	Mean	SD	α
Polyvictimization	97	27
Number of placements	354		1	21	5.07	3.71
Sex
Male (1)	161	45.5
Female (0)	193	54.5
Race
White (1)	160	45.2
Minority (0)	194	54.8
Age	354		16	19	17.33	0.47
Depression levels
Wave 1 (T ₁)	354		11	40	17.05	5.82	.840
Wave 2 (T ₂)	316		11	38	15.63	4.96	.787
Wave 3 (T ₃)	304		11	38	15.09	4.60	.773
Wave 4 (T ₄)	288		11	31	15.04	4.41	.731
Wave 5 (T ₅)	268		11	33	14.87	4.54	.768
Wave 6 (T ₆)	260		11	38	15.37	5.07	.797
Wave 7 (T ₇)	250		11	34	15.58	5.03	.791
Wave 8 (T ₈)	230		11	33	15.61	4.93	.763
Wave 9 (T ₉)	283		11	39	15.80	5.00	.798
Depression Scale	354		33	92	47.72	11.70	.845

Note. Adapted from McMillen, 2010.

Polyvictimization

Previous studies have used polyvictimization definitions including sexual assault (e.g., see Segura et al., 2016; Sterzing, Ratliff, Gartner, McGeough, & Johnson, 2017) and community violence (e.g., Cyr et al., 2012; Garrido, Culhane, Raviv, & Taussig, 2010). This study measured polyvictimization by identifying those youth who had both a maltreatment history and had also experienced nonfamilial violent crime victimization. Nonfamilial violent crime victimization was operationalized as the variable from the Voyages data set asking the youth about their self-reported experiences with being shot or stabbed, raped or sexually assaulted, threatened with a weapon, or experiencing a robbery during any point in the year and one-half of data collection, measured at each interview. The original variable was coded dichotomously to indicate if youth reported minimally one experience (yes = 1) with violent crime victimization during their placement in foster care. This variable was re-coded to (0) if youth reported experiencing child maltreatment with no other type of victimization and (1) if youth reported experiencing any of these types of nonfamilial violent crime victimizations, in addition to their child maltreatment experiences, during the nine waves of data collection. This is an abstracted variable derived at the end of data collection based on each youth’s history calendar information (McMillen, 2010) and is included here as one of the main predictors for depression levels. These victimization experiences occurred during any point in the data collection; therefore, the exact timing and causal order cannot be explicitly determined during foster care placement.

Foster care placement

The number of foster care placements was used as a control variable in the analysis. All youth were living in foster care homes at the initiation of the study, and the youth retained in the study were living in foster care at the exit interview. This variable was also abstracted at the end of data collection to measure the total number of foster care placements for each youth. The question asked, ‘Since the last interview, how many different places has the youth lived?’ This variable was grand-mean-centered in order to provide meaningful interpretation of true time values (Holden, Kelley, & Agarwal, 2008) for the dependent variable (Singer & Willett, 2003) at baseline (i.e., ‘initial status’). Centering is a common technique within multilevel modeling (MLM) for continuous variables (Luke, 2004). MLM is based on averages, such that the intercept is interpreted for values equal to zero and zero represents the average values for the centered variables.

Sociodemographic measures

Two socio-demographic variables were included as controls: (1) the sex of the youth, as either male or female, and (2) the race of the youth. Race was collapsed into two categories, white or minority, due to the inclusion of a small number (n = 19) of ethnic identities (e.g., ‘Middle Eastern,’ ‘Hispanic’) and other races (e.g., ‘American Indian,’ ‘mixed race’) for this variable.

Depression

Self-reported depression levels, the dependent variable in this study, were measured using the Depression Outcomes Module (Smith, Burnam, Burns, Cleary, & Rost, 2000). Specifically, eleven items from the Patient Baseline Assessment section of this instrument were used for each of the nine waves of data collection. The items ask about experiencing depressive symptoms during the four weeks prior to the interview at each wave of data collection and coincide with the Diagnostic and Statistical Manual. Responses for depression level scores, ranging in score from one to four for each of the 11 items, were summed into an additive scale at each wave of data collection to create a single variable to measure the extent to which youth reported experiencing depression through the course of data collection. Scores in this additive scale range from a low of 11 points to a high of 44 points. Higher scores represent higher levels of self-reported depression. Internal Consistency Reliability tests were run, and all the depression scales fell at or above the ‘respectable’ range of α = .70 (DeVellis, 2003, 95).

Data Analysis

MLM regression analysis was used to examine the two hypotheses posed in this study. We examined individual depression trajectories for each youth in this group of foster care youth, in order to determine their actual change in depression levels during the last one and one-half years each youth was living in foster care (Hypothesis 1). We used an unconditional model, a model that contains no predictors (Wang, 1998), similar to a one-way random effects analysis of variance (ANOVA; Schreiber & Griffin, 2004). At the same time, we examined variations in patterns of depression across this sample of youth that may be attributed to polyvictimization (Hypothesis 2). Using MLM for estimated growth trajectories in depression allows for analyses of both individual changes in depression over time and differences in depression changes across the entire sample (i.e., repeated measures of depression as a function of time) within the same statistical analysis (Holden et al., 2008; Singer & Willett, 2003). We were then able to ascertain the degree to which depression levels can be attributed to polyvictimization compared to how much depression varies among the youth with maltreatment experiences only.

Not all youth interviewed at baseline were interviewed at each wave of data collection (Larrabee-Warner & McMillen, 2010). Given the nature of foster care placement, with youth exiting the foster care system at different times over the course of data collection, attrition can occur with data sets using youth living in foster care. MLM was specifically designed to conduct analysis of individual growth trajectories (i.e., longitudinal data) containing variation in measurement occasions and the number of data collection points per person (Singer & Willett, 2003). Unlike repeated measures ANOVA, MLM makes statistical adjustments that allow for missing responses at any specific wave of data collection (i.e., attrition). These cases with missing points of data can still be included in the MLM regression analysis, rather than deleting cases and conducting the analysis with less data.

Results

Youth Characteristics

The sample includes slightly more female participants (54.5%) than male participants (45.5%). While all of these youth experienced some type of child maltreatment, the majority of these youth (73%) did not experience polyvictimization while in foster care. On average, the youth in this sample resided in five different foster care placements, with a minimum of 1 placement and a maximum of 21 placements. Table 1 lists these descriptive statistics for this sample, including the number of youth successfully interviewed at each wave of data collection.

Changes in Depression Levels Within Youth Living in Foster Care

Exploratory multilevel models were used to determine (1) the degree to which individual depression levels increased or decreased over time and (2) variance in depression levels among these youth. The results from this preliminary analysis indicate that minor depression symptoms presented within each youth when they were first interviewed, as shown in Table 2, Model 0. The estimated initial depression-level scores for each youth living in foster care was estimated at, on average, 15.8 points (p < .001) of a total of 44.0 possible points on the depression scale with significant variation among these youths’ initial depression-level scores ( $σ_{0}^{2}$ = 13.512, p < .001). Over time, these youth’s depression levels tended to decrease, with an estimated rate of change in depression level scores of about .06 points (Y ₁₀ = −.062, p < .10), on average. Hence, with each subsequent interview, these youth, on average, reported about .06 points less on the depression score scale but with significant variation ( $σ_{1}^{2}$ = .154, p < .001) among these youth (interindividual).

Table 2.

Results From Fitting the Taxonomy of Multilevel Models to the Mental Health Service Use of Youth Leaving Foster Care (Voyages), 2001–2003 Data.

Variable		Model 0	Model 1	Model 2
Fixed effects
Initial status
Intercept	Y ₀₀	15.810***	15.878***	16.946***
Polyvictim	Y ₀₁		−0.248	−0.468
Placement	Y ₀₂			0.331***
Male	Y ₀₃			−1.661***
White	Y ₀₄			−0.587
Rate of change
Intercept	Y ₁₀	−0.062†	−0.138***	−0.282***
Polyvictim	Y ₂₀		0.278***	0.275***
Placement	Y ₃₀			0.018*
Male	Y ₄₀			0.135*
White	Y ₅₀			0.163*
Pseudo-R ² statistic and goodness-of-fit
Level 1: within person	R ² _E		0	0
Level 2: initial status	R ² ₀		0	0.203
Rate of change	R ² ₁		0.10	0.195
Variance components
Level 1: within person	σ²	14.414***	14.414***	14. 188***
Level 2: initial status	σ² ₀	13.512***	13.500***	10.768***
Rate of change	σ² ₁	0.154***	0.138***	0.124***
Covariance	σ₀₁	−0.839***	−0.825***	−0.658***

Note. n = 354.

***p < .001. **p < .01. *p < .05. †p < .10.

Variation in Depression Level

The final model (Table 2, Model 2), including controls, shows there was significant variation among these youths’ levels of depression over time ( $σ_{1}^{2}$ = .124, p < .001). Additionally, the degree to which each individual youth personally experienced depression significantly varied (σ² = 14.188, p < .001) during the year and half of data collection. However, experiencing polyvictimization explained none of the variation in personal depression levels ( $R_{∊}^{2}$ = 0) among these youth. But, by including the control variables in the model, polyvictimization explains about 19.5% ( $R_{1}^{2}$ = 0.195) of ‘explainable’ variance for change in depression levels among these youth living in foster care.

Effects of Polyvictimization on Rate of Change in Depression Levels Among Youth Living in Foster Care

Among the youth who experienced polyvictimization while living in foster care, their depression levels tended to increase. As shown in Table 2, Model 2, depression-level scores for youth who experienced polyvictimization continued to significantly increase over time, by an estimated .28 points (Y ₂₀ = .275, p < .001) on average, once controlling for the effects of the number of foster care placements, sex, and race. By comparison, the youth who experienced maltreatment only had a significant decrease in depression level scores (Y ₁₀ = −.282, p < .001) over time, on average, net of controls. By including controls in the model, these variables alter the average depression-level scores over time, such that depression-level scores for the youth in this study varied depending on several factors. Youth who lived in multiple foster care placements tended to experience a significant increase in depression-level scores (Y ₃₀ = .018, p < .05). Male youth tended to have increase in their depression-level scores over time (Y ₄₀ = .135, p < .05). White youth tended to have significantly higher depressive symptoms over time (Y ₅₀ = .163, p < .05). Figures 1 and 2 display a graph of these variations in depression levels based on differences in personal attributes.

Figure 1.

Prototypical depression trajectories for White male and female foster youth with average number of placements.

Figure 2.

Prototypical depression trajectories for male and female foster youth of color with average number of placements.

Discussion

The main goal of the present study was to examine the association between foster care youths’ victimization experiences and depression levels, with a focus on the youth who experience polyvictimization while living in foster care. As predicted, depression levels within the youth living in foster care who experienced child maltreatment only were found to decrease over time. Some youth displayed higher levels of depression at the initial transition to foster care and the seriousness of these symptoms diminishes over time, possibly due to more stable living situations or removal from violent conditions. A decrease in average depression levels was found for all youth except for White males, whose depression levels tended to increase over time. It is possible that other factors, not included in this analysis, impacted depression among the White males in foster care; there is literature indicating that depression levels tend to increase over time for youth who experience maltreatment (Ayon & Marcenko, 2008; Bennett et al., 2010). Since MLM regression analyses are based on averages, it may be that those youth experiencing the most severe depression may have increased the average depression-level scores among the White male youth placed in foster care. Regardless, the present study found that depression levels tended to decrease over time among the youth living in foster care who experience child maltreatment only. These findings may indicate that the negative impact of child maltreatment may diminish over time among youth who did not experience other forms of victimization.

A second goal of the present study was to examine the extent to which polyvictimization contributes to changes in depression levels over time. We predicted that the youth who experienced polyvictimization during their foster care placement would report increased depression levels. Although the analysis reveals no significant differences in initial levels of depression between youth who experienced maltreatment only and those youth who had polyvictimization experiences, this finding was expected. Polyvictimization was measured as the combined effect of child maltreatment experiences and nonfamilial violent crime victimization while living in foster care. Hence, there should be no significant differences at baseline. Overall, the findings support our second hypothesis: Depressive symptoms not only differed over time for youth who experienced polyvictimization, compared to youth experiencing maltreatment only, but polyvictimization experiences were associated with an increase in depression levels for youth during their placement in foster care. This result is consistent with current mental health literature on child maltreatment, which suggests that violence exposure may manifest as depressive symptoms among adolescents (Carlson, 2000). This result also confirms the existing literature specific to polyvictimization (Mrug & Windle, 2010; Turner et al., 2006), which suggests that polyvictimization experiences may produce more severe levels of depression as compared to single-type victimization experiences.

Overall, the results of the present study seem to indicate that the longitudinal experiences for these youth living in foster care, including their experiences with polyvictimization, may contribute to increased depressive symptoms among some youth. However, these youths’ depression levels over time were somewhat variable, subject to the personal attributes of the youth. For example, there were significant differences in depression levels based on race. Among the youth living in foster care who experienced polyvictimization, youth of color experienced more pronounced levels of depression as compared to White youth. Yet, among the youth living in foster care who experienced child maltreatment only, there was a decline in depression levels among the youth of color as compared to White youth. This finding may be related to the timing of mental health services, displays of external symptomatology upon entry into foster care, or other factors that might impact depression outcomes (Gudiño, Lau, Yeh, McCabe, & Hough, 2009; Gudiño, Martinez, & Lau, 2012; Martinez et al., 2013). But overall, the youth of color living in foster care reported slightly lower levels of depression compared to the White youth living in foster care.

Previous research suggests that the association between violent victimization and depression levels is, in part, contingent on gender (Vaske, Makarios, Boisvert, Beaver, & Wright, 2009). In the present study, female youth living in foster care who experienced child maltreatment only reported the highest levels of depression initially and those with polyvictimization experiences tended to have the highest levels of depression compared to any of the males. This moderation effect was unexpected but supported in the current literature. Female youth tend to have more pronounced depression levels compared to male youth, and that these differences tend to hold true over time (Castelao & Kröner Herwig, 2013). Similarly, previous studies of youth in foster care have found that female youth tend to have higher rates of depression than male youth, particularly over time (Keller, Salazar, & Courtney, 2010). Worth noting here are the more intense levels of depression male youth who experienced polyvictimization reported over time while living in foster care. It is possible that the impact of polyvictimization among males may be more intractable over time. The hegemonic ideal of masculinity may interfere with these youths’ ability to effectively cope with polyvictimization in part due to the development of self-identity surrounding cultural ideals of masculinity (e.g., being ‘tough’ and ‘self-reliant’).

The results of the present study found that polyvictimization alone explains about a 10th of the variation in depression levels for this group of foster care youth. Further, there is significant variation in the rate of change in depression levels among the youth who experienced polyvictimization. This may indicate that different youth experience different levels of depression, situated to experiences with multiple types of victimization. Such negative psychological outcomes may be more intense among those youth who are about to age out of the foster care system, particularly if mental health services are being terminated or reduced upon exit from the foster care system. It should also be noted that these results give some support that youth who experience the most foster care placements may have higher levels of initial depression. Existing literature indicates that youth who experience multiple different foster placements tend to experience a higher prevalence of psychiatric symptoms (Pilowsky & Wu, 2006), but these studies have not examined longitudinal outcomes. These findings suggest that living in a number of different out of home placements may be associated with depression while youth are in care, but that this effect may be less pronounced over time. The present study accounted for long-term displacement and the effects of the often transitory nature of foster care placements on depression levels.

These findings suggest implications for child welfare agencies working with youth in foster care. Data from the present study may provide information regarding reasons for elevated depression levels among youth living in foster care. Services in treating these youth may need to be concentrated toward more specific populations of youth and utilized throughout placement in the foster care system. As one possibility, child welfare workers could consider whether adolescent male youth may engage in higher levels of risk behavior, exposing them to a greater potential for experiencing polyvictimization. It is possible that if the appropriate services are implemented to prevent certain high-risk behaviors, polyvictimization may be more preventable (Cabrera, Auslander, & Polger, 2009). Second, it is possible that interventions during foster care involvement may include services that directly address depressive symptomology that might lead to heightened youths’ awareness of their depressive symptoms. By providing these youth with the ability to engage in active reflection of their victimization experiences, foster care youth may be empowered to positively influence a reduction in depressive symptomatology.

The results of the present study may be used, cautiously, to better inform service providers of the conditions that may face youth about to exit the foster care system. With more than half of youth in the U.S. population experiencing some form of family violence (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009), a significant number of youth are exposed to risk for a myriad of psychological issues. Services provided to these youth may mitigate depressive symptomatology (Landsverk et al., 2006) and hence depression levels. This is a critical consideration among youth who are facing termination from the foster care system. These youth need to receive effective services in order to support their efforts at productivity during adulthood, as research has shown that violent experiences during childhood can predict violent revictimization during adulthood (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009 ). Further, current research indicates that youth’s decision-making processes are negatively impacted when exiting from the foster care system, and this is particularly salient among youth during late adolescence (Landsverk et al., 2006). The present study contributes to this growing literature by offering preliminary information about how polyvictimization experiences may contribute to depression among youth living in foster care.

Limitations

Several limitations of this study deserve note. First, these results may not be generalizable to all youth in foster care, as these data were collected in one Midwestern state. The data collected here were self-reported, which may also impact the results. Future research should seek to replicate these findings among youth living in foster care within other states and could examine mental health issues beyond depression as well as other behavioral health indicators. It may be that additional longitudinal analysis is needed to assess the persistent effect of childhood victimization and placement history. Finally, the experiences reported by the youth in this study could have occurred during any point in the data collection. Therefore, the exact timing and causal order cannot be explicitly determined.

Implications for Future Research and Practice

It is important for future research to examine the specific effects of different types of child maltreatment at entry to the foster care system to assess whether differences in depression levels vary across the various manifestations of child maltreatment. The results of our study support child welfare system efforts to provide inclusive mental health services that focus on the effects of multiple and different types of victimization experiences throughout foster care placement rather than focusing solely on the initial child maltreatment that led to placement within the foster care system. However, more research is needed to determine the extent to which associated psychological outcomes are associated with these victimization experiences. Information on the effects of polyvictimization among youth living in foster care remains limited. Future studies will need to examine other types of victimization (e.g., bullying, exposure to community violence, peer violence) that may be associated with negative mental health outcomes among youth living in foster care and include a myriad of mental health issues (e.g., suicidal ideation). Such data are critical to best inform the child welfare system of the need for definitive services.

Conclusion

Research has shown that child maltreatment increases risk for violence against children in the future (Capaldi, Pears, Kerr, & Owen, 2008; Pears, Capaldi, & Owen, 2007), school-related problems (Stapleton et al., 2010), and future criminal behavior (Knutson, DeGarmo, Koeppl, & Reid, 2005; Leve, Kim, & Pears, 2005). Youth living in foster care display specific trauma-based symptomatology that requires special mental health services (Landsverk et al., 2006), and based on the results from the present study, there may be variance across different populations of (e.g., race) and trajectories for (i.e., throughout placement) youth living in foster care. Treatment services need to take a more pluralistic approach among these youth in order to offer more effective coping strategies for when these youth leave the foster care system and no longer have supports from child welfare. Given this research and the findings from the present study, more comprehensive specialized care may be needed to address the complexity of youth’s psychological trauma, and especially depressive symptoms, while in foster care. Treatment strategies need to consider the possibility of revictimization while living in foster care. Such services are vital not only to ensuring healthy development of psychological outcomes for the youth but also to prevent future violence toward, and subsequent trauma of, youth living in foster care.

Footnotes

Authors’ Note

The Carsey Institute did not play a role in study design, data collection, data analysis and interpretation of data, writing this article, or in the decision to submit this article for publication. An earlier version of this article was presented at the 2012 annual meeting of the International Family Violence and Child Victimization Research, Portsmouth NH (July 9, 2012). 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 Mental Health Service Use of Youth Leaving Foster Care (Voyages) 2001–2003 were originally collected by Curtis McMillen, Lionel D. Scott, and Wendy Fran Auslander. 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.

Acknowledgments

The authors wish to thank former UNH Sociology student Kai Ji and former UNH Social Work student Jonathan Hutchings for research assistance on this project. The authors would like to thank the Carsey Institute for their generous funding.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors were able to carry out this study, in part, with a Summer Research Fellowship awarded through the Carsey Institute at the University of New Hampshire. Funding for the project was provided by the National Institute of Mental Health (Award Number: 1R01 MH 61404).

References

Ayon

Marcenko

M. O.

(2008). Depression among Latino children in the public child welfare system. Children & Youth Services Review, 30, 1366–1375. doi:10.1016/j.childyouth.2008.04.005

Bennett

D. S.

Sullivan

M. W.

Lewis

(2010). Neglected children, shame-proneness, and depressive symptoms. Child Maltreatment, 15, 305–314. doi:10.1177/1077559510379634

Bernstein

D. P.

Ahluvalia

Pogge

Handelsman

(1997). Validity of the childhood trauma questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 340–348. doi:10.1097/00004583-199703000-00012

Bernstein

D. P.

Fink

(1998). The childhood trauma questionnaire manual. San Antonio, TX: The Psychological Corporation.

Boxer

Terranova

A. M.

(2008). Effects of multiple maltreatment experiences among psychiatrically hospitalized youth. Child Abuse & Neglect, 32, 637–647. doi:10.1016/j.chiabu.2008.02.003

Bruskas

(2008). Children in foster care: A vulnerable population at risk. Journal of Child and Adolescent Psychiatric Nursing, 21, 70–77. doi:10.1111/j.1744-6171.2008.00134.x

Cabrera

Auslander

Polgar

(2009). Future orientation of adolescents in foster care: Relationship to trauma, mental health, and HIV risk behaviors. Journal of Child & Adolescent Trauma, 2, 271–286. doi:10.1080/19361520903317311

Capaldi

D. M.

Pears

K. C.

Kerr

D. C. R.

Owen

L. D.

(2008). Intergenerational and partner influences on fathers’ negative discipline. Journal of Abnormal Child Psychology, 36, 347–358.

Carlson

B. E.

(2000). Children exposed to intimate partner violence. Trauma, Violence & Abuse, 1, 321–342. doi:10.1177/1524838000001004002

10.

Castelao

Kröner-Herwig

(2013). Different trajectories of depressive symptoms in children and adolescents: Predictors and differences in girls and boys. Journal of Youth & Adolescence, 42, 1169–1182. doi:10.1007/s10964-012-9858-4

11.

Christian

C. W.

Schwarz

D. F.

(2011). Child maltreatment and the transition to adult-based medical and mental health care. Pediatrics, 127, 139–145. doi:10.1542/peds.2010-2297

12.

Cohen

J. A.

Mannarino

A. P.

Knudsen

(2005). Treating sexually abused children: One year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29, 135–145.

13.

Cohen

J. A.

Mannarino

A. P.

Murray

L. K.

Igelman

(2006). Psychosocial interventions for maltreated and violence-exposed children. Journal of Social Issues, 62, 737–766. doi:10.1111/j.1540-4560.2006.00485.x

14.

Crosson-Tower

(2010). Understanding child abuse and neglect (8th ed.). Upper Saddle River, NJ: Prentice Hall, Inc.

15.

Cuevas

C. A.

Finkelhor

Clifford

Ormrod

R. K.

Turner

H. A.

(2010). Psychological distress as a risk factor for re-victimization in children. Child Abuse & Neglect, 34, 235–243. doi:10.1016/j.chiabu.2009.07.004

16.

Cyr

Chamberland

Lessard

Clément

Wemmers

Collin-Vézina

… Damant

. (2012). Polyvictimization in a child welfare sample of children and youths. Psychology of Violence, 2, 385–400.

17.

DeVellis

R. F.

(2003). Scale development: Theory and applications (2nd ed.). Newbury Park, CA: Sage.

18.

Edleson

J. L.

(2004). Should childhood exposure to adult domestic violence be defined as child maltreatment under the law? In Jaffe

P. G.

Baker

L. L.

Cunningham

A. J.

(Eds.), Protecting children from domestic violence: Strategies for community intervention (pp. 8–29). New York, NY: Guilford Press.

19.

Edwards

V. J.

Holden

G. W.

Felitti

V. J.

Anda

R. F.

(2003). Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study. American Journal of Psychiatry, 160, 1453–1460.

20.

Fink

L. A.

Bernstein

Handelsman

Foote

Lovejoy

(1995). Initial reliability and validity of the childhood trauma inteview: A new multidimensional measure of childhood interpersonal trauma. American Journal of Psychiatry, 152, 1329–1335.

21.

Finkelhor

Ormrod

R. K.

Turner

. (2007a). Polyvictimization and trauma in a national longitudinal cohort. Development & Psychopathology, 19, 149–166. doi:10.1017/S0954579407070083

22.

Finkelhor

Ormrod

R. K.

Turner

H. A.

(2007b). Polyvictimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7–26. doi:10.1016/j.chiabu.2006.06.008

23.

Finkelhor

Ormrod

R. K.

Turner

H. A.

(2009a). The developmental epidemiology of childhood victimization. Journal of Interpersonal Violence, 24, 711–731. doi:10.1177/0886260508317185

24.

Finkelhor

Ormrod

R. K.

Turner

H. A.

(2009b). Lifetime assessment of polyvictimization in a national sample of children and youth. Child Abuse & Neglect, 33, 403–411. doi:10.1016/j.chiabu.2008.09.012

25.

Finkelhor

Ormrod

Turner

Hamby

S. L.

(2005). The victimization of children and youth: A comprehensive, national survey. Child Maltreatment, 10, 5–25. doi:10.1177/1077559504271287

26.

Finkelhor

Ormrod

Turner

Holt

(2009). Pathways to polyvictimization. Child Maltreatment, 14, 316–329. doi:10.1177/1077559509347012

27.

Finkelhor

Turner

H. A.

Hamby

S. L.

Ormrod

(2011). Polyvictimization: Children’s exposure to multiple types of violence, crime, and abuse. Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention.

28.

Finkelhor

Turner

H. A.

Ormrod

Hamby

S. L.

(2009). Violence, abuse and crime exposure in a national sample of children and youth. Pediatrics, 124, 1–14. doi:10.1542/peds.2009-0467

29.

Finkelhor

Turner

H. A.

Ormrod

Hamby

S. L.

Kracke

(2009). Children’s exposure to violence: A comprehensive national survey. Washington, DC: U.S. Government Printing Office.

30.

Garrido

E. F.

Culhane

S. E.

Raviv

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.

31.

Garland

A. F.

Landsverk

J. L.

Hough

R. L.

Ellis-MacLeod

(1996). Type of maltreatment as a predictor of mental health service use for children in foster care. Child Abuse & Neglect, 20, 675–688.

32.

Gudiño

O. G.

Lau

A. S.

Yeh

McCabe

K. M.

Hough

R. L.

(2009). Understanding racial/ethnic disparities in youth mental health services: Do disparities vary by problem type? Journal of Emotional and Behavioral Disorders, 17, 3–16.

33.

Gudiño

O. G.

Martinez

J. I.

Lau

A. S.

(2012). Mental health service use for children in contact with Child Welfare: Racial disparities depend on problem type. Psychiatric Services, 63, 1–12. doi:10.1176/ appi.ps.201100427AQ6

34.

Hahm

H. C.

Lee

Ozonoff

Van Wert

M. J.

(2010). The impact of multiple types of child maltreatment on subsequent risk behaviors among women during the transition from adolescence to young adulthood. Journal of Youth and Adolescence, 39, 528–540. doi:10.1007/s10964-009-9490-0

35.

Hamby

Finkelhor

Turner

Ormrod

(2010). The overlap of witnessing partner violence with child maltreatment and other forms of victimizations in a nationally representative survey of youth. Child Abuse & Neglect, 34, 734–741. doi:10.1016/j.chiabu.2010.03.001

36.

Heflinger

C. A.

Simpkins

C. G.

Combs-Orme

(2000). Using the CBCL to determine the clinical status of children in state custody. Children and Youth Services Review, 22, 55–73.

37.

Holden

J. E.

Kelley

Agarwal

(2008). Analyzing change: A primer on multilevel models with applications to nephrology. American Journal of Nephrology, 28, 792–801. doi:10.1159/000131102

38.

Keller

T. E.

Salazar

A. M.

Courtney

M. E.

(2010). Prevalence and timing of diagnosable mental health, alcohol, and substance use problems among older adolescents in the child welfare system. Children & Youth Services Review, 32, 626–634. doi:10.1016/j.childyouth.2009.12.010

39.

Kitzmann

K. M.

Gaylord

N. K.

Holt

A. R.

Kenny

E. D.

(2003). Child witnesses to domestic violence: A Meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 339–352. doi:10.1037/0022-006X.71.2.339

40.

Knutson

J. F.

DeGarmo

D. S.

Koeppl

Reid

J. B.

(2005). Care neglect, supervisory neglect, and harsh parenting in the development of children’s aggression: A replication and extension. Child Maltreatment, 10, 92–107.

41.

Landsverk

J. A.

Burns

B. J.

Stambaugh

L. F.

Rolls-Reutz

J. A

. (2006). Mental health care for children and adolescents in foster care: Review of research literature. Seattle, WA: Casey Family Programs. Retrieved from http://www.casey.org/Resources/Publications/pdf/MentalHealthCareChildren.pdf

42.

Landsverk

J. A.

Garland

A. F.

Leslie

L. K.

(2002). Mental health services for children reported to child protective services. In Meyers

Briere

(Eds.), APSAC handbook on child maltreatment (2nd ed.). Thousand Oaks, CA: Sage.

43.

Larrabee-Warner

McMillen

J. C.

(2010). Mental health service use of youth leaving foster care (Voyages) 2001-2003: User’s guide and codebook. Ithaca, NY: National Data Archive on Child Abuse and Neglect.

44.

Leslie

L. K.

Landsverk

Ezzet-Lofstrom

Tschann

J. M.

Slymen

D. J.

Garland

A. F.

(2000). Children in foster care: Factors influencing outpatient mental health service use. Child Abuse and Neglect, 24, 465–476.

45.

Leve

L. D.

Kim

H. K.

Pears

K. C.

(2005). Childhood temperament and family environment as predictors of internalizing and externalizing trajectories from ages 5 to 17. Journal of Abnormal Child Psychology, 33, 505–520.

46.

Luke

A. D.

(2004). Multilevel modeling. Thousand Oaks, CA: Sage.

47.

Martinez

J. I.

Gudiño

O. G.

Lau

A. S.

(2013). Problem-specific racial/ethnic disparities in pathways from maltreatment exposure to specialty mental health service use for youth in child welfare. Child Maltreatment, 18, 98–107. doi:10.1177/1077559513483549

48.

McGee

R. A.

Wolfe

D. A.

Yuen

S. A.

Wilson

S. k.

Carnochan

(1995). The measurement of maltreatment: A comparison of approaches. Child Abuse & Neglect, 19, 233–249.

49.

McIntyre

J. K.

Widom

C. S.

(2011). Childhood victimization and crime victimization. Journal of Interpersonal Violence, 26, 640–663.

50.

McMillen

J. C.

(2010). Mental health service use of youth leaving foster care (Voyages) 2001-2003. Ithaca, NY: National Data Archive on Child Abuse and Neglect.

51.

McMillen

J. C.

Scott

L. D.

Zima

B. T.

Ollie

M. T.

Munson

M. R.

Spitznagel

(2004). Use of mental health services among older youths in foster care. Psychiatric Services, 55, 811–817.

52.

McMillen

J. C.

Zima

B. T.

Scott

L. D.

Auslander

W. F.

Munson

M. R.

Ollie

M. T.

Spitznagel

(2005). Prevalence of psychiatric disorders among older youths in the foster care system. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 88–94.

53.

Mrug

Loosier

P. S.

Windle

(2008). Violence exposure across multiple contexts: Individual and joint effects on adjustment. American Journal of Orthopsychiatry, 78, 70–84. doi:10.1037/0002-9432.78.1.70

54.

Mrug

Windle

(2010). Prospective effects of violence exposure across multiple contexts on early adolescents’ internalizing and externalizing problems. Journal of Child Psychology and Psychiatry, 51, 953–961. doi:10.1111/j.1469-7610.2010.02222.x

55.

Newton

R. R.

Litrownik

A. J.

Landsverk

J. A.

(2000). Children and youth in foster care: Disentangling the relationship between problem behaviors and number of placements. Child Abuse & Neglect, 24, 1363–1374.

56.

Ney

Fung

Wickett

A. R.

(1994). The worst combinations of child abuse and neglect. Child Abuse & Neglect, 18, 705–714.

57.

Pears

K. C.

Capaldi

D. M.

Owen

L. D.

(2007). Substance use risk across three generations: The roles of parent discipline practices and inhibitory control. Psychology of Addictive Behaviors, 21, 373–386.

58.

Pecora

P. J.

Jensen

P. S.

Romanelli

L. H.

Jackson

L. J.

Ortiz

(2009). Mental health services for children placed in foster care: An overview of current challenges. Child Welfare, 88, 5–26.

59.

Pesonen

A. K.

Raikkonen

Heinonen

Kajantie

Forsen

Eriksson

J. G.

(2007). Depressive symptoms in adults separated from their parents as children: A natural experiment during World War II. American Journal of Epidemiology, 166, 1126–1133. doi:10.1093/aje/kwm254

60.

Pilowsky

D. J.

(2006). Psychiatric symptoms and substance use disorders in a nationally representative sample of American adolescents involved with foster care. Journal of Adolescent Health, 38, 351–358. doi:10.1016/j.jadohealth.2005.06.014

61.

Schreiber

J. B.

Griffin

B. W.

(2004). Review of multilevel modeling and multilevel studies in “The Journal of Educational Research” (1992-2002). The Journal of Educational Research, 98, 24–33.

62.

Segura

Pereda

Guilera

Abad

(2016). Poly-victimization and psychopathology among Spanish adolescents in residential care. Child Abuse & Neglect, 55, 40–51. doi:10.1016/j.chiabu.2016.03.009

63.

Singer

J. D.

Willett

J. B.

(2003). Applied longitudinal data analysis: Modeling change and event occurrence. New York, NY: Oxford University Press.

64.

Smith

G. R.

Burnam

Burns

B. J.

Cleary

Rost

K. M.

(2000). Depression outcomes module (DOM). In American Psychiatric Association (Ed.), Handbook of psychiatric measures (pp. 213–215). Washington, DC: American Psychiatric Association

65.

Stapleton

J. G.

Phillips

K. G.

Moynihan

M. M.

Wiesen-Martin

D. R.

Beaulieu

A. L.

(2010). New Hampshire endowment for health planning grant final report: The mental health needs of children exposed to violence in their homes. Concord, NH: New Hampshire Coalition Against Domestic and Sexual Violence.

66.

Sterzing

P. R.

Ratliff

G. A.

Gartner

R. E.

McGeough

B. L.

Johnson

K. C.

(2017). Social ecological correlates of polyvictimization among a national sample of transgender, genderqueer, and cisgender sexual minority adolescents. Child Abuse & Neglect, 67, 1–12. doi:10.1016/j.chiabu.2017.02.017

67.

Taussig

H. N.

(2002). Risk behaviors in maltreated youth placed in foster care: A longitudinal study of protective and vulnerability factors. Child Abuse and Neglect: The International Journal, 26, 1179–1199.

68.

Turner

H. A.

Finkelhor

Ormrod

(2006). The effect of lifetime victimization on the mental health of children and adolescents. Social Science & Medicine, 62, 13–27. doi:10.1016/j.socscimed.2005.05.030

69.

Turner

H. A.

Finkelhor

Ormrod

(2010). The effects of adolescent victimization on self-concept and depressive symptoms. Child Maltreatment, 15, 76–90. doi:10.1177/1077559509349444

70.

Van der Kolk

B. A.

Courtois

C. A.

(2005). Editorial comments: Complex developmental trauma. Journal of Traumatic Stress, 18, 385–388. doi:10.1002/jts.20046

71.

Vaske

Makarios

Boisvert

Beaver

K. M.

Wright

J. P.

(2009). The interaction of DRD2 and violent victimization on depression: An analysis by gender and race. Journal of Affective Disorders, 112, 1–3. doi:10.1016/j.jad.2008.03.027

72.

Wang

(1998). Opportunity to learn: The impacts and policy implications. Educational Evaluation and Policy Analysis, 20, 137–156. doi:10.3102/01623737020003137