Witness/Child Exposure to Community or Domestic Violence
Betsy McAlister Groves
I. Description of the problem. Children who are exposed to violence in their communities or in the home are often hidden victims. Although it has been well established that children who are the victims of violence (e.g., child abuse and sexual abuse) suffer severe and long-lasting consequences, there is now ample evidence that witnessing violence is also damaging to children, and in some cases, may be more psychologically toxic than being a victim. Because their scars are emotional and not physical, the primary care clinician may not fully appreciate their distress and miss an opportunity to provide needed interventions for these children.
A. Epidemiology.
1. Community violence.
In one study, more than a third of school-aged children in New Orleans had witnessed severe violence; 40% had seen a dead body.
In a study of urban middle school students, the majority (76%) of young adolescents reported witnessing or being victimized by at least 1 violent event in the prior 6 months.
In a survey of parents of children aged 0 to 6 in an outpatient pediatric setting, one in ten children had witnessed a knifing or shooting; half the reported violence occurred in the home.
Nearly two-thirds of young children attending a Head Start program had either witnessed or been victimized by community violence, according to parent reports.
2. Domestic violence.
In a survey of parents in three SAMHSA-funded community mental health partnerships, 23% of parents reported that their children had seen or heard a family member being threatened with physical harm.
A recent survey of American households revealed that 15 to 17 million, or nearly 30%, of children in this country live in homes where there is some form of intimate partner violence.
A July 2009 analysis of more than 10,000 children served by the National Child Traumatic Stress Network found that 44.3% of the children reported exposure to domestic violence.
Children aged 5 and younger are disproportionately represented in households with domestic violence.
Although exposure to community or domestic violence is the most prevalent type of child exposure to violence, a complete listing would include child exposure to war and terrorism. With the growing number of immigrant and refugee families served in most pediatric practices, it is likely that the clinician will see children who have been exposed to these types of traumas.
B. Etiology. Research in the past two decades has shown that children of all ages may be adversely affected by violence in their environments. Short-term symptoms include sleep difficulties, avoidance of reminders of the event, somatic symptoms, hyperarousal, helplessness, and fear, even if the child is not immediately in danger. Longer term effects include an increased risk of substance abuse, juvenile delinquency, anxiety or depression, and adverse health outcomes. Studies suggest that young children are particularly vulnerable to the impact of violence in the environment, and that chronic exposure may affect brain development and self-regulatory processes. In addition, children under the age of four may be particularly vulnerable to threats that involve the safety (or perceived safety) of their caregivers.
II. Making the diagnosis.
A. Symptoms. Children may develop a range of post-traumatic symptoms, and in some cases will meet criteria for the diagnosis of post-traumatic stress disorder (PTSD) (Table 88-1). Although young children may not fully meet these criteria, certain behavioral changes are uniquely associated with their exposure to trauma: sleep disturbances, aggressive
behavior, new fears, developmental regression, and increased anxiety about separations from caretakers.
Table 88-1. Symptoms of post-traumatic stress disorder (DSM IV)
Re-experiencing
1. Intrusive and distressing recollections, thoughts
2. Distressing dreams of the trauma
3. Acting or feeling as if the trauma were recurring (“flashbacks”)
4. Psychological distress at exposure to cues that symbolize the trauma
5. Physiological reactivity at exposure to cues that symbolize the trauma
Avoidance and numbing
1. Efforts to avoid thoughts, feelings associated with the trauma
2. Efforts to avoid activities, places, people that arouse recollections of the trauma
3. Diminished interest in activities
4. Feeling of detachment from others
5. Restricted affect
6. Sense of foreshortened future
Arousal
1. Sleep problems
2. Irritability, outbursts of anger
3. Concentration problems
4. Hypervigilance
5. Exaggerated startle response
Symptoms that are unique to children aged 6 or younger:
1. Aggressive behavior
2. Increased separation anxiety
3. Development of new fears
4. Developmental regression
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