Post-traumatic stress disorder in children witnessing domestic violence

Family Violence and PTSD

Children are subject to a number of stressors that may contribute to the onset of post-traumatic stress disorder (PTSD). One of the stressors given particular attention is domestic violence, not necessarily against the child, but violence that the child witnesses. Such events in the home have an effect on the child who is privy to them, creating a sense of guilt, adding to the child's stress, and distorting many aspects of the bonding process with one or both parents while also putting a strain on other relationships the child may have at home, at school, and elsewhere. Studies have examined this issue and found a link between violence in the home and subsequent problems played out in children who have witnessed this violence without being the target of it. Abused children suffer from many of the same problems, and that seems to be understood and accepted in diagnosis. The idea that the same sort of problem will result in children who have only witnessed violence in the home has required stronger proof. These children may display the effects of PTSD soon after witnessing this violence, or they may develop the problem later. Some act out similar behaviors in their own lives in relations with others or in overtly criminal behavior that otherwise seems to have no clear cause. Much of this research will be discussed below.

PTSD

In describing the etiology and treatment of PTSD, research adds to the knowledge of how family dynamics might contribute to the onset of PTSD for some individuals or how a different family structure might prevent its onset for others. Not everyone experiencing a traumatic event suffers from PTSD, raising the question of what differences might be found between those who do and those who do not in terms of family structure in this case and in terms of other differences of importance for other studies. Knowing what elements in family dynamics contribute to the onset of PTSD should suggest what changes need to be made as a form of treatment, with changes in the family dynamic helping add to the support the sufferer needs and helping remove adverse influences coming from the family.

Post-traumatic stress disorder (PTSD) affects not only those returning from battle but also victims of rape, burglary, car accidents, and natural disasters-along with the health professionals who must care for them. According to one estimate, nearly half of all patients treated at urban trauma centers have severe PTSD, and another 31% are moderately affected. The hallmark of the disorder is repeatedly reliving the ordeal in frightening detail. To blunt the pain generated by such recollections, many patients turn to alcohol and other drugs and may go to great lengths to avoid activities or situations that arouse memories of the occurrence. These people experience consequences in terms of memory -- a selective memory that keeps some memories vivid while blunting others -- that may one day show researchers another aspect of the relationship between stress and learning and memory (Petit, 1991).

The child who witnesses domestic violence may relive this event, adding to any stress they may experience and creating the setting for PTSD and all of the problems that go with it. Children experience degrees of stress in any case, and this will certainly increase if they are suffering from having witnessed a violent act. They may experience degrees of guilt over the incident, as if they had perpetrated it themselves. They may also feel guilty because they were not able to protect their mother from their father, and they will have increased resentment toward the father conflicting with their natural love for both parents. The damage that can be done is considerable, involving not only the mental suffering of the children but further damage when they are unable to learn effectively, do not get along with others as they should, and act out in ways that are antisocial and even violent. In later life, such a child may engage in criminal behavior that creates a pattern for a lifetime. Intervention is therefore needed, which begins with recognition of the source of the problem so that help can be offered and can be effective. The problem of child abuse has been more readily recognized than the issue of psychological damage to children who witness family violence, though both were long avoided as topics because people did not want to believe such things were possible. The abused child shows other signs that make identification more likely, while the child who acts up in class or who withdraws from the society of others could be suffering form any one of a number of problems.

Family Violence

Family violence includes violence against wives, physical and sexual abuse of children, and marital rape. Violence against wives has been analyzed and found to develop because of individual factors, situational factors, and societal factors. Some aggressors have character traits that contribute to their behavior. The victims may also show certain characteristics, such as "learned helplessness." Stressful situations may contribute to the onset of wife beating. Some see the nature of society itself as contributing to the problem, such as social norms that encourage or tolerate male violence.

Violence against wives has been analyzed and found to develop because of individual factors, situational factors, and societal factors. Some aggressors have character traits that contribute to their behavior. The victims may also show certain characteristics, such as "learned helplessness." Stressful situations may contribute to the onset of wife beating. Some see the nature of society itself as contributing to the problem, such as social norms that encourage or tolerate male violence.

The view that women and children are property make them more likely to be subject to violence, as if they were animals that could be owned rather than human beings with some freedom of choice. The role of women in American society was conditioned by religious attitudes and by the conditions of life that prevailed through much of American history. The culture of Europe and America was based for centuries on a patriarchal system in which exclusive ownership of the female by a given male was considered important, with the result that women were relegated to the role of property with no voice in their own fate. The girl-child was trained from birth to fit the role awaiting her.

Clearly, circumstances of family life have changed in the modern era. Industry has been taken out of the home, and large families are no longer economically possible or socially desired. The home is no longer the center of the husband's life, and for the traditional wife there is only a narrowing of interests and possibilities for development. Changes in both family structure and sex roles over the last century have produced the ferment we still see today, and one of the problems with the changing role of women is the degree to which society perceives this as causing unwanted changes in the family, though it is just as true that changes in the family have altered the roles of women. Children today are seen as rightly under the control of their parents, and this contributes, however inadvertently, to the idea that children are like property, not old enough to make their own decisions or even to have certain rights.

The view that women and children are property is probably linked to the male role as provider, as if his work were not only purchasing food and lodging but in some way purchasing the wife and child as well. This may be changing as more and more women are accepted in the workplace and as the male role is no longer that of the single breadwinner in the family. Women encounter problems in finding jobs, and they encounter problems in coping with their family situation when they do. If they are married, they may find that they have two jobs -- one at home and one at work. Mothers will always have two jobs, for raising their children is a full-time job in itself. Affordable child care is a major issue for women today. The traditional social structure is based on the assumption of a stable family structure, but with more and more single and divorced women with children in the workplace, the need for affordable and dependable child care is evident. The trends that have brought about this crisis in child care are likely to continue, and women in the 1990s will call for more governmental and business innovation to provide solutions.

Still, more and more women will enter the workforce, many of them having no choice in the matter because they are the head of their household. The image of self-indulgent feminists as the majority in the workplace, an image fostered by enemies of the woman's movement, is simply false. The image of women and children as property is also false, an image held over from the patriarchal society that is clearly being undermined economically but persists psychologically and in some ways in law.

Not all physical force can be characterized as violence, and not all violence is created equal. There are numerous controversies regarding definitions of violence and abuse and no clear consensus among researchers on how to characterize acts as one or the other. Presumably, there should be commonalities among different types of violence so that all can be characterized first as violence, and yet some violence is socially approved and so would be placed in a separate category. Even the issue of whether it should be assumed that there are many different kinds of violence is controversial, with some holding that violence is violence in any setting and at any time. At the same time, while there are important differences among the different forms of family violence, all may be caused by similar social and psychological factors. Research has shown that the some forms of violence are more damaging than others but that all may be linked in terms of etiological factors. Society has responded to these issues by passing laws against child abuse and spouse abuse, but at times mixed signals are sent by laws and legal actions. Women who are abused are seen to be victims, but at some point, many of these women turn on their attackers and commit violence against them. The legal system has responded to this trend in an ambiguous way. Often, these women are prosecuted for killing their abusers on the theory that no one has the right to take the law into their own hands. Juries, however, often acquit these women, seeing them as victims who had little choice except to fight back, even if they did so with excessive violence. Here, again, is evidence that society insists on making distinctions between different forms and instances of violence and creating a gradation or hierarchy of violence, with violence allowed at some times even though violence in general is seen as a social evil.

Inherent in abusive relations is a disparity in terms of power, with the abuser asserting his power over those in the family who lack power. As noted, we see violence as a clear use of power, but power can also be expressed verbally and have just as devastating an effect. In an article on the abuse of nurses, Cameron (1998) notes,

Verbal abuse is the most common form of aggression; its consequences in terms of emotional upset?

anger, low self-esteem, embarrassment, and fear?

may be as damaging as a physical attack (Cameron, 1998, 34).

Cameron further notes that verbal abuse often follows a moment of stress or a stressful event, and verbal are then used as a coping mechanism to deal with stress. Nurses responding to a questionnaire on the subject noted that following an incident of verbal abuse, they most often felt "unappreciated" (54%) and "anxious/upset" (42%), followed by "concerned" (4%). Those reporting also indicated that verbal abuse influenced job performance by causing increased errors (52%), decreased morale (51%), decreased productivity (40%), and increased workload for peers (29%)(Cameron, 1998, 34).

It is widely accepted that a great deal of violence occurs in the family setting. Findings from research on family violence may serve as a point of departure (Fleming, 1979; Kincaid, 1985; Pagelow, 1984; Schechter, 1982; Straus et al., 1980; Walker, 1984). There are disagreements about the nature of the impact of family violence on the behavior of children, but it is not necessary to resolve the minor debates in order to pursue the logic presented here. Nor will much time be spent debating the link between financially troubled families and the likelihood of family violence. Currie (1985) and others show quite effectively that economically disadvantaged families are more likely to produce violent offspring. An argument can be posed in response to these findings. The economic factors are frequently treated as minor problems which do not require urgent response. We can appreciate the long-range implications of decreased social support for families (Currie, 1987, pp. 11-12), but those in policy making positions feel the need to respond immediately to the more dramatic forms of adult violence.

To date, the most frequently used instrument to measure violence between dating and marital partners has been the Conflict Tactics Scale. Although the CTS has been shown to be a relatively sound device (Barling et al., 1987), several problems exist. First, violent acts are ordered in terms of severity as perceived by the investigators without regard to the sex of the persons exhibiting or receiving the behavior. Whether research participants would order the acts in the same way is not known. Further, people may be more tolerant of female-to-male violence than that carried out by males against females. This suggests that the recipients of violence may be differentially affected and perceive the acts disparately depending on their gender (Arias and Johnson, 1986, 1989; Makepeace, 1986). For example, being slapped has been considered mild or ordinary violence. It may be that a man who is slapped by a woman would consider that mild; however, a woman slapped by a man might view the act as moderate or serious violence. The severity of Violence Against Men Scales (SVAMS; Marshall, in press) was designed to assess female to male violence.

A common criticism of the CTS has been that the effects of violent acts on the recipient are not considered (Arias and Johnson, 1989; Finkelhor et al., 1988; Gondolf, 1987). Another instrument, the Index of Spouse Abuse (Hudson and McIntosh, 1981) allows the severity, but not necessarily the consequences, of behavior to be scored. It also meets another identified need (Weis, 1989) by including threats (and other nonphysical acts) which may be harmful to women; the nonphysical subscale includes some direct physical acts.

According to Mcwhirter, Mcwhirter, Micwhirter, & McWhirter (2004), antisocial behavior leads to delinquency and gang activity, with its accompanying violence and drug involvement, and one of the sources for such problems is family violence, along with problems in school and peer pressure. The authors consider some of the prevention and intervention strategies they see as useful and effective, including the application of reality therapy to turn these young people around before they commit crimes or become victims of violence themselves.

Treatment

Treatment is given due consideration by many researchers. Groves (1999) examines research on the topic in order to offer recommendations as to how to work with child witnesses of family violence. Among the effects seen on such children are aggressive behavior, depression, anxiety, sleep disturbance, and learning problems. The author then stresses the importance of proper identification and assessment of children exposed to domestic violence, noting that often children who have witnessed domestic violence are "hidden," meaning that their mothers do not seek assistance from a shelter. Also, the families keep their violent histories cloaked in secrecy. Assessment then must rely on a clinical interview supplemented by sources like parents and teachers. Groves (1999) finds that there are four goals of intervention with children: reduce the child's sense of isolation, help the child understand his or her emotional responses to violence, reduce the symptoms that children experience (e.g. nightmares), and work with the family to develop a safe and nurturing environment for the child. The author also cites therapeutic approaches such as group therapy. The advantage of group work is that it breaks the child's sense of isolation and allows children to identify with one another. Individual therapy is also possible, but Groves (1999) finds that little has been written about that specific approach. Groves (1999) also notes the many challenges facing practitioners in this area. The first is addressing the possibility of concurrent child abuse or neglect. The second is meeting the complex emotional needs of the child client and his/her family. Groves (1999) recommends that agencies and schools increase efforts to identify children who are exposed to domestic violence.

The author also note that there are four goals to be cosnidered when intervening with a child suffering in this way, and these are: reducing the child's sense of isolation, helping children understand their emotional responses to violence, reducing the symptoms that children experience (e.g. nightmares), and working with the family to develop a safe and nurturing environment for the child. He then cites the potential for therapeutic approaches such as group therapy, stating that an advantage of group work is that it breaks the child's sense of isolation and allows children to identify with other children. Individual therapy is also possible, although little has been written about that specific approach. Finally, Groves summarizes the challenges facing practitioners in this area. He notes first the challenge of addressing the possibility of concurrent child abuse or neglect. Second is meeting the complex emotional needs of the child client and his/her family. To combat the problem, agencies and schools should increase efforts to identify children who are exposed to domestic violence.

Ducharme, Atkinson, and Poulton (2000) recommend noncoercive treatment methods for these children, emphasizing the importance of compliance training, which can give parents a way to get children to comply with request without resorting to physical punishment. Ther researchers studied this method and found it to be very effective, as determined by statistical analysis, and they also state that the mothers' subjective reports indicate significant improvement in their children's behavior.

Group work is given attention by Tutty and Wagar (1994), who describe a therapy group for children between the ages of five to seven years old. The authors claim that this therapy group is innovative because of the young age of the participants, since most group programs are for children between the ages of eight and twelve. The authors note that over the years, groups have evolved from loosely structured gatherings to those containing more adult-directed, structured activities. The authors present their group model, which is called "storybook club" and uses stories as metaphors for children to express their feelings and build problem solving skills. The group also uses a variety of activities to help children process their feelings. These activities include the use of a "mood chart" for the children to classify how they are feeling at a particular time. Furthermore, group leaders read short stories with a specific theme (such as divorce or sadness). The children often identify themselves as the focus of these stories, which generates discussion. Finally, the children act out plays or "dramas" to further help them express their feelings. These techniques are used because traditional verbal discussion is usually difficult for children this young. The authors conclude that one of the main problems they encountered was the lack of engagement from the parents, leading at times to poor attendance. In addition, the researchers found that positive changes in children are often not met with corresponding positive changes in the parents.

Wilson, Jaffe, and Wolfe (1989) examine an intervention model specifically for children who have witnessed family violence, and they find first that these children learn six "lessons" from their violent families: "(1) violence is an appropriate form of conflict resolution; (2) violence has a place within the family interaction; (3) if violence is reported to others in the community... there are few consequences; (4) sexism... As defined by roles within the family... is to be encouraged; (5) violence is an appropriate means of stress management; and (6) victims of violence are... To tolerate this behavior" (p.180). The goals of the group are to learn new problem solving techniques, examine the use of violence to resolve conflict, adjust attitudes toward relationships and responsibility, and build self-esteem. The group is designed for children from nine to thirteen years old, with specific activities and objectives for each of the ten sessions. A condensed list of topics follows: Session 1: introduction; Session 2: labeling feelings; Session 3: dealing with anger; Session 4: safety skills; Session 5: building social support; Session 6: improving self-concept; Session 7: understanding responsibility for parents' violence; Session 8: understanding family violence; Session 9: wishes about the family; Session 10: review and termination.

Silvern and Kaersvang (1989) considers the way the children who witness violence in the family are traumatized, hypothesizing that "traumatization underlies the difficulties these children experience... interventions should be designed to counteract post-traumatic disorders" (p. 422). The authors begin by defining the emotions experienced during the traumatic event of witnessing parental violence, feelings that include fear, helplessness, and overstimulation. They then explain the "traumatic process" (p. 424), and an important element of this process is mental repetition of the event. Signs of repetition include nightmares and flashbacks. Trauma resolution, they find, must be discussed by direct disclosure in order for them to resolve their issues. Simple play therapy, these authors believe, is not adequate to do this. To further illustrate, the researchers then present a detailed case report of an eight-year-old boy named Jon who exhibited violent behavior at school. Jon's fantasy play involved viewing himself as a superhero, with four snakes that helped him fight "bad guys." Jon drew a picture of these snakes that resembled human fingers. When this was pointed out by the therapist, Jon was eventually able to talk about (and therefore process and resolve) the time he witnessed his father choke his mother. This therapeutic process for Jon lasted over 14 months, and eventually his violent behavior vanished. The authors recommend that practitioners balance symbolic expression play therapy with direct talking so the children can master the experience of witnessing family violence.

Lehmann, Rabenstein, Duff, and Van Meyel (1994) offer a multi-dimensional model for treating families where the mother has been assaulted, using a Family Systems model and citing three areas of research that may help family therapists. The first is the documentation of the negative effects of violence on child witnesses, including anger, withdrawal, and peer relation problems. The second area of research is the increasing body of knowledge that child witnesses to mother assault may develop PTSD. Finally, the authors present feminist family therapy, which addresses the social and political elements of family violence. The authors then describe their guidelines for practitioners to consider: To focus on the assault, deal with accountability, engage in open family discussion, and adopt a personal and political position on violence. Three intervention approaches that develop from these guidelines are explored. The first is working with the larger system, including the economic system. The second is addressing the traumatic after-effects of witnessing violence. The third is to rebuild relational imbalances among family members. The authors then cite nine issues that could be important for clinical consideration for both mother and child, these being: Basic safety skills; responsibility for behavior; building social support systems; understanding departure from the abusive relationships; learning flexible, non-gender stereotyped behaviors; learning differences between conflict and abuse; disclosure of family secrets; conflicting feelings of loyalty to both parents; and accepting the permanent loss of the previous family unit.

Schol counselors can also be of help in treatment, as Fontes (2000) notes. Private practitioners frequently consult with school counselors about their client's school behavior and academic achievement, and familiarity with the ways a school counselor can help could prove very valuable. Certain theoretical frameworks to understand the effects of violence are offered and include Social Learning Theory, the PTSD theory. And Attachment Theory. Techniques to identify children from violent homes are noted, including looking for a child who acts out scenes of marital violence in play. It is recommended that the child be asked direct questions about family violence. The issue of mandated reporting of domestic violence must be considered as well. Ways to help the child in school are discussed, and these include the goals of individual counseling and suggestions on how to aid the child in improving classroom performance. The school counselor should also be aware of important cultural considerations if they are to be effective.

Conclusion

PTSD is often one of the consequences of a child witnessing family violence, unfortunately an increasing problem in society. Numerous treatment methods have been developed and tested, and all begin with the need to recognize the nature of the problem and to intervene appropriately in order to restore the child to normal functioning. There also appears to be a consensus that eliciting an overt memory of the incident from the child is a necessary component of effective treatment, though some practitioners make use of various dramatic play methods of bringing the events back to mind without overtly discussing them. Research in this area continues and can help refine treatment and make it more effective at eliminating not just the symptoms but the underlying psychological damage as much as possible.