Domestic Violence and Child Development

1. John Stirling, MD Center for Child Protection Santa Clara Valley Medical Center San Jose CA Domestic Violence and Child Development

2. Objective: To better understand the influences of a violent home environment on child development

3. Kids and DV: questions What does DV look like? What constitutes exposure? What effect does DV have on kids? What are the significant relationships within a violent home? How can we help?

4. Take Home Messages: • Home violence is common, and • Often witnessed by children, who • Learn to accept and “normalize” it. • Incidents of DV are best considered symptoms of wider disorder • Interventions have to consider many factors

5. Domestic Violence: Definition Intimate partner violence is a pattern of purposeful coercive behaviors … perpetrated by someone who is, was or wishes to be involved in an intimate or dating relationship with an adult or adolescent victim …aimed at establishing control of one partner over the other. • Family Violence Prevention Fund, 2004

6. Domestic Violence: Dimensions • Physical • Mutual combat versus direct terrorism • Sexual • Unwanted or painful, unsafe • Psychological • Threats, degradation, alienation • Isolation • Stalking • 81% assaulted by exes

7. Domestic Violence: US • >3 women are murdered each day by husbands or boyfriends • 1 of every 4 women has experienced violence by a current or former boyfriend or spouse Hamby, et al., Juv. Justice Bull. 2011

8. Domestic Violence: World • 15 sites, 10 countries, industrialized and not • Lifetime prevalence: 15% - 71% • 86% reported “severe” incident • Overlap, physical/sexual: 30% - 56% • ~ 80% of all violence by partner - WHO study, Lancet, 2006

9. Domestic Violence: Kids • Up to 70% of abused children report DV • 40% of violent adolescents recall DV • Many batterers and rapists recall childhood DV • Many victims reenter violent relationships

10. Domestic Violence: Kids • 70% of women in DV shelters are moms • Children were present in 41% of NYPD DV calls • Younger children more at risk

11. Domestic Violence: Kids • Police call cohort study, Alberquerque, 2004 • 2038 homes, 2617 children, 4-12yr of age • 76% witnessed violence • 27% physically, 1.2% sexually abused • 27% PTSD sx before intervention • 80% of perpetrators had been witnesses or victims - Ernst, Acad Emer Med, 2006

12. Domestic Violence: Kids • 15.5 M kids live in violent homes • 7 M describe severe violence (beating, kicking, choking) • On a given day in 2008, 16,458 children lived in a DV shelter Hamby, et al., Juv. Justice Bull. 2011

13. Domestic Violence: Kids In the past year: • 1/15 kids (6.6%) exposed to physical IPV • 1.3% experienced severe violence • 1/9 (11%) were exposed to domestic violence involving at least one adult Hamby, et al., Juv. Justice Bull. 2011

14. Domestic Violence: Kids Lifetime exposures: • 17.9% were exposed to physical IPV • 25.6% were exposed to domestic violence involving at least one adult Hamby, et al., Juv. Justice Bull. 2011

15. What does “exposure” mean? • hearing/seeing assault • hearing threats of physical harm • feeling tension building in home prior to assault • being hit/threatened • being denied care • being forced to participate in violence • seeing aftermath of violent incident • having their relationship with their non-violent parent undermined • being forced to choose between parents • being taken hostage • experiencing the loss of a parent due to murder/suicide

16. Sequelae of Exposure to Violence: for survivors • 80% more likely to suffer stroke • 70% more likely to have heart disease • 60% more likely to have asthma • 70% more likely to drink heavily MMWR, Feb 2008

17. Sequelae of Exposure to Violence: for Children • Increased aggression and externalizing problems • Increased levels of depression and poor self- esteem/self-concept • Impaired social interactions and peer relationships • Delayed cognitive development and poor academic functioning Margolin & Gordis,2000

18. Sequelae of Exposure to Violence: for Children • meta-analysis of 60 studies • Strongly associated with boys’ use of externalizing behaviors • Strongly associated with trauma symptoms Evans et al. (2008)

19. Sequelae of Exposure to Violence: (Thanks to Jeffrey Edleson) • Yates et al. (2003): 155 children over 25 years • Preschool exposure linked to externalized problems for boys and internalized problems for girls in adolescence and teen years • Ehrensaft et al. (2003): 543 children, prospective over 20 years • Exposure to DV in childhood was a key predictor of both perpetrating and receiving as adult. • Whitehead et al. (2003) ACE study: 8,629 adults, retrospective • Exposure doubled likelihood of perpetration and victimization as adult • Paradis et al. (2009): 346 children, prospective over 25 years • Family arguments and violence exposure during childhood correlated to poorer health, mental health and occupational achievement at age 30.

20. Domestic Violence Child Abuse 20 – 40% Family dysfunction?

21. Domestic Violence: Kids’ injuries Edleson et al. (2003)

22. Domestic Violence: Kids’ injuries Many types of injury: • physical • behavioral (social/emotional) • cognitive

23. “There is no such thing as a baby; there is a baby and someone.” - D.W. Winnicott

24. High Risk Parents ? Victimized Children

25. Male Parent Female Parent Child

26. Male Parent Female Parent Child

27. Community Family Male Parent Female Parent Child Society School

28. Ecological Theory of Causation No single cause Multiple, interacting influences Belsky, J. Child Maltreatment, 1980

29. Parent Studies • Fathers • Mothers

30. Warning! A few words about: • Generalizations • “Profiling” • Resiliency

31. Parent Studies • Fathers • rigid, authoritarian • social isolation • lack social skills • ?SES • ?alcohol/drugs Power and Control

32. Power and Control Wheel Slide # 32

33. Parent Studies • Mothers • depression • anxiety • psychosomatic illness • sense of helplessness • ?SES • ?alcohol/drugs

34. Kids are moving targets! • Temperament • Growth • Development • Plasticity

35. Erickson’s Stages of Personality Development Stage Age Characteristics I 0-2 basic trust vs mistrust II 2-4 autonomy vs shame/doubt III 4-8 initiative vs guilt IV 9-12 industry vs inferiority V 13-30 identity vs diffusion VI 20-30 intimacy vs isolation

36. The Developmental ARC(after Van Horn) • Attachment • Regulation • Cognition

37. Attachment needs Caregiver needs to be: • Present when needed • Consistent (enough) • Prompt (enough) So child can feel: • Valuable • Optomistic

38. Types of Attachment Child • Secure • Avoidant • Ambivalent • Disorganized Parent • Nurturing • Dismissive • Preoccupied • Disorganized

39. Erikson’s Stages of Personality Development Stage Age Characteristics I 0-2 basic trust vs mistrust - attachment to parent II 2-4 autonomy vs shame/doubt - exploration - self-esteem

40. Trauma bonding Bonding is not the same as attachment Trauma may result in dysfunctional bonding Can lead to confusion in foster care, assessment

41. The Brain: Targets of Stress Cerebral cortex EEG changes smaller callosum Limbic system neuronal changes decreased size Brainstem/Cerebellum altered transmitters

42. Stick or snake?

43. Cycles homeostasis . (home’ eo STA sis): n., the process of maintaining a steady state

44. Cycles POSITIVE & NEGATIVE feedback

45. Cycles Feedback can be: POSITIVE - perpetuates change or NEGATIVE - discourages change

46. One Positive Feedback Cycle Parent Stress behavioralchallenges child maltreatment Insecure attachment

47. What we see… • Complex PTSD • Attention-Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Major Depression or Bipolar Disorder • Autism Spectrum Disorders • Reactive Attachment Disorder

48. Erikson’s Stages of Personality Development Stage Age Characteristics III 4-8 initiative vs guilt - must reward independence IV 9-12 industry vs inferiority - fear of failure - peer identification

49. Accommodation Assimilation Fish-Murray et al, 1987

50. Erikson’s Stages of Personality Development Stage Age Characteristics V 13-30 identity vs diffusion - independence from family VI 20-30 intimacy vs isolation - domestic relationships - childbearing - parenting