Domestic Violence Column: The Impact of Violence on Children
By Betty Borghesani, RNC/MSN

Jesse arrived at the clinic late at the end of a long and busy day. The six-year old had received sutures for a laceration at the emergency room the day before but had never had his kindergarten DPT booster. I checked the stitches and got the immunization ready. His mother and I tried to prepare him for the “quick pinch” of the shot by explaining what I needed to do. Jesse panicked. Overcome by anxiety, he bolted for the waiting room and was grabbed by his mother just as he was about to run out the clinic door. Brought back to the pediatric area, Jesse cowered in a corner of the corridor like a caged animal. Neither I nor his mother could reason with him nor give him any physical contact or comfort.

Jesse’s mother had recently separated from his father because of an abusive relationship. Jesse had witnessed violence in his home repeatedly and had seen his father beat his mother and drag her across the driveway by her hair. Months later and in spite of being engaged in profession counseling, Jesse was still very much suffering the effects of that exposure to violence. He exhibited some of the symptoms of Post-Traumatic Stress Disorder characteristic of children who witness violence.

Recent news has been staggering and depressing. Children kill other children. There are guns and mass murder in our grade and high schools, date rape and murders on college campuses. Children are shot at in a day-care center. The American public reacts to these happenings with bewilderment. We are stunned and search for reasons for this violence. We, as nurses, need to explore the reasons for violence in society and then work to find ways of primary prevention

Studies have shown that children’s exposure to violence can increase the risk of later delinquent and criminal behavior. Many inter-related factors can increase the child’s exposure to violent situations early in life. Among these are socio-economic, cultural and environmental influences as premature birth, adolescent parenting, single parent families and absent fathers, working (and therefore absent) parents, drug and alcohol abuse, ineffective, non-consistent, or severe discipline, poverty, homelessness, and living in high crime neighborhoods.

Frequent exposure to violence in the media is also cited as increasing aggressive behavior in children. By age 12, the average child has witnessed 8000 murders on TV and many more acts of violence. The violence is often accompanied by a smile, the pain of the victims is ignored. Children are unable to differentiate fact from fantasy or evaluate the credibility of the action and lifestyles portrayed. Behavior seen in the media becomes acceptable behavior for the child. Because of this risk, The American Academy of Pediatrics recently recommended no TV for children under two years, no TV in children’s bedrooms, and a maximum of two hours of TV watching a day for children of any age.

Domestic violence puts children directly and indirectly at risk for later violent behavior. Approximately 3.3 million children less than seventeen years old are affected by domestic violence yearly. Exposure to violence in the home either through witnessing domestic violence or being the child victim of verbal, physical, or sexual abuse has long-lasting detrimental effects on the child’s development. Children who witness abuse are often also being abused. Mothers who abuse their children are often in an abusive relationship themselves. Fifty percent of men who abuse partners abuse their children.

Even if the children are not direct victims of physical or sexual abuse, but just witness to it, they are affected psychologically and exhibit similar physical, emotional or behavioral symptoms. One study found that children in abusive families suffer some of the same effects as children growing up amid war and social upheaval like that in Somalia and Bosnia. They may complain of physical symptoms as headache, stomachache, or chronic fatigue and have frequent visits to health care providers. Often they exhibit anxiety, depression, sleep disturbances, appetite changes, aggressive, acting-out behavior, school phobias and adjustment problems, and developmental problems.

These children learn to see the world as a dangerous and unpredictable place where violence is expected. There is no security in their world if one parent is a victim and the other an offender. They may have actual fears for their own or their mother’s safety based on past real experience (as what will happen if Daddy comes home drunk tonight) or fears of abandonment or of other people’s anger. Also, if others in their world see violence as permitted behavior, they learn violence as a form of conflict resolution as a result of their childhood experiences.

Children respond to exposure to violence in various ways. Some studies indicate that girls will more often internalize their responses to violence or identify with the victim and become anxious, depressed or clinging, or have a need to be perfect. They are at risk for suicide attempts, promiscuous sexual behavior as teens, drug and alcohol use. As adults, they may have more trouble protecting themselves and their own children from danger.

Boys run the risk of identifying with the perpetrator in an effort to maintain some control over their lives. As children, they may have temper tantrums, decreased attention span, become a bully and exhibit coercive behavior. They may develop symptoms of Post- Traumatic Stress Disorder and set fires, show cruelty to animals, or relive the experienced violence in other ways. Statistics indicate that male victims of child abuse are forty per cent more likely to become delinquent or criminal, three times more likely to use drugs or alcohol. Seventy-eight per cent of prisoners and ninety per cent of domestic batterers were abused as children. However, many children growing up in homes with abuse and domestic violence do not suffer from PTSD and, although exposure to violence puts a child at serious risk, eighty per cent of the boys do not become adult abusers.

The child’s response to the violence is dependent on many factors including the intrinsic strengths of the individual, the degree and frequency of exposure to the violence, the presence of other stable, supportive people in the child’s life, and community supports. Some children exhibit more resiliency in their personality. Their communication skills, temperament, self-esteem, inter-personal relationships all help them to cope. It is very important that the child’s fears, needs, and questions are heard and responded to by a competent adult. This can help him to feel some control of the situation and allay feelings of guilt.

A strong, supportive extended family that can step in and assist the mother can be most helpful to children exposed to domestic violence. Grandparents, aunts or uncles can provide family cohesion, warmth, physical protection, financial assistance, and stability. Others in the community – as teachers, church members, daycare providers, big sister and brother programs – can also intervene in the child’s life. By listening to the child, helping him to express and understand his feelings, they can help the child see the situation of abuse from another perspective. By creating opportunities for role playing and problem solving, they can help the child understand the effects of one’s actions, develop negotiating skills, and find non-violent solutions to conflicts.

Nurses and nurse practitioners working in primary health clinics, as well as schools and other community settings, have the unique opportunity and responsibility to address the issues of potential violence in a child’s life. In primary care, we see the child and parent together and can observe their interactions. Often we are the only adults, other than the child’s parent or guardian, who know the child over a period of time and during different developmental stages. We can be a role model for the parent and a mentor for the child. We can help the child and parent to recognize problems and begin to make changes. And it takes time to effect change. The nurse must have an open, trusting, mutually respecting relationship with both child and parent. This can develop in the context of well child exams and episodic care for childhood illnesses. Without this trust, we cannot expect parents to come to us with their problems or to be compliant with recommendations.

To effect change, we must begin with a holistic assessment of child and family for risk of exposure to violence at home or in the community, guns and knives, and media violence at every encounter. And in this day of managed care, it must be integrated into the visit along with immunizations and management of minor illness. What is the pattern of TV and video watching? Is there a TV in the child’s bedroom? What are the methods the family uses for settling conflicts at home and for limit-setting? Does the child get along with siblings and other children in school? Is he a bully or being victimized by a bully?

We must be especially alert to symptoms of abuse and domestic violence. Routine screening questions need to be incorporated into every health history. Mothers should be asked about their relationships with their partners and risks for violence identified. Is their conflict in her relationship with her partner? Has she ever been physically hurt or feared for her safety? Is their drug and alcohol use? Is there a gun in the house? Has the mother considered a safety plan? Supportive counseling should be offered to mother and children.

Nurses have always been vocal advocates for the needs of their patients. We must continue to speak out for the right of children to grow up in a safe, non-violent environment. We must treasure our children and nurture their self-esteem; the alternative is costly. The child who grows up amid violence and does not learn to value his own life, finds life is cheap and then violent actions have no consequences.