Fawn McNeil-Haber, PhD

1. Child Abuse Professional Training Series #4 How does child sexual abuse and witnessing domestic violence alter and affect the course of development? Fawn McNeil-Haber, PhD

2. Childhood Trauma “Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms the personality. The child trapped in an abusive environment is faced with formidable tasks of adaptation. She must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness. Unable to care for or protect herself, she must compensate for the failures of adult care and protection with the only means at her disposal, an immature system of psychological defenses.” - Judith Herman, 1992

3. Childhood • Rapid brain development • most rapid between birth and 5 years old • by 3 years old ~ 85% of adult volume • Primed to learn from our experiences • Early development and experiences provides a foundation for later development. The following slides are provided courtesy of The National Child and Traumatic Stress Network's Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (2010)

12. Normative Developmental Tasks Infants and toddlers • Attachment • Security • Trust • Emotion regulation • Autonomy • Recognition of and response to emotional cues Preschoolers • Autonomy • Agency • Initiative • Emotion regulation • Self control

13. Developmental tasks School-aged • Sustain attention for learning and problem solving • Control Impulses • Becoming Industrious • Emotional Awareness • Complex reasoning • Friendships • Manage anxieties Adolescence • Independence • Relationships • Achievement • Identity (Values) • Abstract thought • Anticipate and consider consequences of behavior • Control behaviors for long term goals • Accurately judge danger and safety

14. In what ways does trauma impact these normative developmental tasks?

15. Complex Trauma Children’s experiences of multiple traumatic events that occur within the caregiving system • Neglect • Emotional abuse • Physical abuse • Sexual abuse • Witnessing Domestic Violence (Cook et. al, 2003)

16. Child Sexual Abuse A sexual act imposed on a child who lacks emotional, maturational, and cognitive development to understand and consent to such acts. • 1 in 5 girls • 1 in 10 boys • 70% of sexual assaults occur before age 18 • > 90% of offenders are known to and trusted by victims • Crime of control, betrayal, secrecy, isolation, intimidation and helplessness • A crime that is misunderstood by most adults including non-offending parents (Finklerhor & Jones, 2012; Snyder, 2000)

17. Domestic Violence Exposure Commonly defined as a behavior, or pattern of behaviors, that occurs between intimate partners with the aim of one partner exerting control over the other through aggression, coercion, abuse and/or violence. • 43% of female victims and 25% of male victims of DV live in households with children (Bureau of Justice Statistics) • Occurs disproportionately in home with children under 5 (Taylor et. al, 1994) • 45%-70% also physically abused1 • 15 times more likely to be physically abused or neglected1 • Evidence for a raised cooccurrence of DV and CSA1 • The ability to parent is compromised1 1.(Holt et al, 2008)

18. Simple vs. Complex Trauma Simple • Non-interpersonal • Limited exposure (single event) • Shorter duration • Occurrence at later developmental stage • Support of caretaker/family • Secure attachment with with primary caretaker(s) Complex • Interpersonal • Multiple exposures/types • Longer duration • Occurrence at an earlier developmental stage • Limited or no support • Insecure attachment with primary caretakers (Lanktree & Briere, 2008)

19. Complex Trauma Mental, Emotional, Biological and Behavioral effects of experiencing recurrent childhood abuse. Seven domains of impairment • Attachment • Biology • Affect Regulation • Dissociation • Behavioral Control • Cognition • Self Concept (Cook et. al, 2003)

20. Attachment The emotional bond between an infant and caregiver serves to create safety and security for that child. • Secure attachment • Insecure attachments (avoidant and resistant) • Disorganized attachments Attachment continues to evolve throughout childhood and adulthood.

21. Disorganized attachments “For some infants the caregiving environment so bizarre, threatening, unpredictable, violent or frightening that not only are the infants insecure, but they also cannot organize a strategy for ensuring protective access to their caregivers.” When in need of comfort, these infants demonstrate undirected, odd, and contradictory behaviors. (Cassidy & Mohr, 2001)

22. Attachment • Uncertainty about the reliability and predictability of the world • Problems with boundaries • Distrust and suspiciousness • Inappropriate help seeking (e.g.social isolation; undiscriminating affection) • Interpersonal difficulties • Difficulty attuning to other people’s emotional states • Difficulty with perspective taking • Difficulty enlisting other people as allies (Cook et. al, 2003)

23. Biology • Brain development • Hypersensitivity to physical contact • Somatization • Increased medical problems across a wide span, e.g., pelvic pain, asthma, skin problems,autoimmune disorders, pseudoseizures (Cook et. al, 2003)

24. Affect Regulation • Involves the ability to identify emotion and regulate the experience of emotion • Begins at a very young age and continues throughout childhood

25. Affect Regulation • Difficulty with emotional self-regulation • Depression, Anger, Anxiety • Difficulty describing feelings and internal experience • Problems knowing and describing internal states • Difficulty communicating wishes and desires (Cook et. al, 2003)

26. Dissociation Three primary functions of dissociation: • Automatization of behavior in the face of psychologically overwhelming circumstances • Compartmentalization of painful memories and feelings • The detachment from one’s self when confronting extreme trauma (Putnam, 1997)

27. Dissociation • Distinct alterations in states of consciousness • Amnesia • Two or more distinct states of consciousness, with impaired memory for state-based events (Cook et. al, 2003)

28. Behavioral Control Refers to a person's ability to control their impulsive and manage and direct their behavior in a responsible manner. When attachment, affect regulation, biological functioning and perceptual integration has been compromised behaviors become dysregulated.

29. Behavioral Control • Poor modulation of impulses • Self-destructive behavior • Aggression against others • Pathological self-soothing behaviors • Communication of traumatic past by reenactment in day-to-day behavior or play (sexual,aggressive, etc.) • Difficulty understanding and complying with rules • Sleep disturbances • Eating disorders • Substance abuse • Excessive compliance • Oppositional behavior (Cook et. al, 2003)

30. Cognition Refers to higher brain functioning needed for • Executive Function • Academic Advancement • Abstract Reasoning • Sustained Attention • Flexibility • Creativity

31. Cognition • Difficulties in attention regulation and executive functioning • Lack of sustained curiosity • Problems with processing novel information • Problems focusing on and completing tasks • Difficulty planning and anticipating • Problems understanding own contribution to what happens to them • Learning difficulties • Problems with language development • Problems with orientation in time and space (Cook et. al, 2003)

32. Self Concept The mental image or perception that an individual has of his/herself and his/her abilities

33. Self Concept • Lack of a continuous, predictable sense of self • Poor sense of separateness • Disturbances of body image • Low self-esteem • Shame and guilt • Feeling stigmatized

34. Post Traumatic Stress Disorder Exposed to a traumatic event that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others resulting in: • Recurrent intrusive recollections • nightmares, intrusive thoughts, physical/emotional distress • Avoidance of reminders • of thoughts, of feelings, feeling distant, difficulty feeling positive feelings • Increased physical arousal • sleep difficulties, concentration difficulties, anger, hypervigilance

35. Trauma Symptoms for CSA (birth to age 8) • Eating disorders • Fear of sleeping alone • Nightmares/Night terrors • Separation anxiety • Thumb- or object-sucking • Enuresis (wetting accidents) • Encopresis (soiling) • Language regression • Sexual talk • Excessive masturbation • Sexual acting out, posturing • Crying spells • Hyperactivity • Change in school behavior • Regular tantrums • Excessive fear (including of men or women) • Sadness or depression • Suicidal thoughts • Extreme nervousness

36. Trauma Symptoms for CSA (age 9 through adolescence) • Fear of being alone • Nightmares/Night terrors • Peer problems • Fights with family • Poor self esteem • Memory problems • Intrusive recurrent thoughts or flashbacks • Excessive guilt/shame • Mood swings • Sexual acting out • Overly compliant • Self mutilation • Hypervigilance • Substance abuse • Avoidant, phobic behaviors including sexual topics • Sadness or depression • Suicidal thoughts or gestures • Excessive nervousness • Violent fantasies

37. Trauma Symptoms for DVE Birth to 5 • Sleep disruption • Eating disruptions • Withdrawal • Separation anxiety • Inconsolable crying • Regression • Anxiety, fears • Increased aggression • Impulsive behavior 6 to 11 • Sleep disruptions • School Difficulties • Aggression/Difficulty with peer relationships • Concentration problems • Withdrawal and/or emotional numbing • School avoidance and/or truancy

38. Trauma Symptoms for DVE 12-18 • Antisocial behavior • School failure • Impulsive/reckless behavior • School truancy • Substance abuse • Running away • Abusive dating relationships • Depression • Anxiety • Withdrawal Adulthood • Depression • Child Maltreatment • Substance Abuse • Intimate Partner Violence

39. Adverse Childhood Experiences (ACE) Study Ace Score 0-10 • emotional abuse • physical abuse • sexual abuse • neglect • lack of emotional support • domestic violence exposure • separated/divorced parents • mentally ill household member • alcoholic household member • household member who went to prison • ~ 2/3 experienced 1+ ACEs • 1 in 5 reported 3+ http://www.cdc.gov/ace/prevalence.htm http://acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf

40. Adverse Childhood Experiences (ACE) Study

41. Adverse Childhood Experiences (ACE) Study • Alcoholism and alcohol abuse • Chronic obstructive pulmonary disease (COPD) • Depression • Fetal death • Health-related quality of life • Illicit drug use • Ischemic heart disease • Liver disease • Risk for intimate partner violence • Multiple sexual partners • Sexually transmitted diseases (STDs) • Smoking • Suicide attempts • Unintended pregnancies • Early initiation of smoking • Early initiation of sexual activity • Adolescent pregnancy http://www.cdc.gov/ace/findings.htm

42. Do all children who witness domestic violence grow up to become domestic violence perpetrators?

43. Do all children who witness DV grow up to become DV perpetrators? • Family of Origin Violence is one of risk factors in Intimate Partner Violence (Franklin et. al, 2011) • Several studies to suggest that many children show resilience in the face of interparental violence. • 54% of 2-4 yr. olds showed positive adaptation. (Martinez-Toreya, 2009) • 31% of 8-14 yr. olds in a DV shelter didn't exhibit any signs of maladjustment. (Gyrch et. al, 2000) • 67% of 8-16 yr. olds in a community sample score below clinical cutoffs on internalizing and externalizing. (Spilsbury et. al, 2008) • 118 studies were analyzed. Results 37% of DV exposed children were doing similarly or better than non-witnesses. (Kitzmann, 2003)

44. Why do people respond differently to the "same" traumatic event? Risk and Protective factors • Pre-trauma factors • Factors specific to the trauma • Post-trauma factors

45. Resiliency factors Having a supportive parent who can: • Believe and validate their child’s experience • Tolerate the child’s affect • Manage their own emotional response (Cook, et. al, 2003)

46. Resiliency factors • Easy disposition • Positive beliefs about self • Positive Temperment • Internal locus of control • external attribution of blame • High degree of mastery • Spirituality • High self esteem in one area • Positive attachment to emotionally supportive and competent adults • Motivation to act effectively • Development of cognitive and self regulation abilities

47. Risk Factors • Poverty, which is related to poor educational achievement (a protective factor) • Parental unemployment • Alcohol use • Poor social supports • Violence with a weapon • Witnessing sexual abuse against the mother • Co Occurrence of Physical Abuse • Self blame appraisals

48. Do all children who exposed to domestic violence grow up to have violent relationships? Nope

49. References Bureau of Justice Statistics, Intimate Partner Violence in the U.S. 1993-2004, 2006. Cassidy, J., & Mohr, J.J. (2001). Unsolvable fear, trauma, and psychopathology: Theory, research, and clinical considerations related to disorganized attachment across the life span. Clinical Psychology: Science and Practice, 8, 275-298. Cook, A., Blaustein, M., Spinazzola, J., & van derKolk, B. (2003). Complex Trauma in Children: White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. [White Paper] Retrieved from http://www.nctsn.org/sites/default/files/assets/pdfs/ComplexTrauma_All.pdf Finklerhor, D. & Jones, L. (2012). Have sexual abuse and physical abuse declined since the 1990s? Crimes Against Children Research Center, C267. Franklin, C.A., Menaker, T.A., & Kercher, G.A. (2011). The effects of Family-of-Origin Violence on Intimate Partner Violence. Retrieved from http://dev.cjcenter.org/_files/cvi/7935%20Family%20of%20Origin%20Violence.pdf Grych, J.H., Jouriles, E.N., Swank, P.R., McDonald, R., & Norwood, W.D. (2000). Patterns of adjustment among children of battered women. Journal of Consulting and Clinical Psychology, 68, 84-94. Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books Holt, S., Buckley, H., & Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse and Neglect, 32, 797-810. Kitzmann, K.M., Gaylord, N. K., Holt, A. R., & Kenny, E. D. (2003). Childwitness to domestic violence: Ameta-analytic review. Journal of Consulting and Clinical Psychology, 71(2), 339–352. Lanktree, C. & Briere, J. (2008). Integrative Treatment of Complex Trauma for Children (ITCT-C): A guide for the treatment of multiply-traumatized children aged eight to twelve years. Retrieved from http://www.johnbriere.com/Child%20Trauma%20Tx%20Manual%20(LC%20PDF).pdf Martinez-Torteya, C., Bogat, A., von Eye, A., & Levendonsky, A.A., (2009). Resilience among children exposed to domestic violence: The role of risk and protective factors. Child Development, 80 562-577. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press. Spilsbury, J.C., Kahana, S., Drotar, D., Creeden, R., Flannery, D.J., & Friedman, S. (2008). Profiles of behavioral problems in children who witness domestic violence. Violence and Victims, 23, 3-17. Snyder, H N. (2000). Sexual assault of young children as reported to law enforcement: Victim, incident, and offender characteristics. National Center for Juvenile Justice, U.S. Department of Justice. Retrieved December 31st, 2008, from http://www.ojp.usdoj.gov/bjs/abstract/saycrle.htm Taylor, L., Zuckerman, B., Harik, V. & Groves, B. (1994).Witnessing violence by young children and their mothers.  Journal of Developmental and Behavioral Pediatrics. 15, 120–123.