Table 1 Maladaptive Responses in Children Exposed to IPV
Emotional
Cognitive
Shock Terror Guilt Horror Irritability Anxiety Hostility Depression
Concentration impairment Confusion Self-blame Intrusive thoughts Flashbacks Decreased self-efficacy Fears of losing control Fear of recurrence of trauma
Biologically Based Insomnia Nightmares Exaggerated startle response Psychosomatic symptoms
allergies, asthma attacks, gastrointestinal problems or the flu due to the stress on their immune systems.5, 6, 10, 11 Grade school kids tend to lose respect for the victim and identify with the aggressor, equating anger with violence and justifying the violence; some however, will become very dependent or protective. Male roles are identified as dominant, female roles as subordinate.10 Pre-adolescent youngsters are more verbal about the events of IPV, but they too may display symptoms of anxiety and avoid social activities and peer relationships.Traditionally, male children display aggressive externalized behaviors, becoming abusers or victimizers, having tantrums, bullying, fighting, threatening, treating pets cruelly, destroying property, or exhibiting violent attention-getting maneuvers. Female children exhibit internalized effects of depression or withdrawal; self-destructing to become victims themselves. Sadly, a quiet withdrawn child may not be noticed as a child in need of significant help.5 Risks for adolescents are failing academically, dropping out of school, falling into delinquency or substance abuse. These kids may run away, develop food addictions, or be victims of sexual assault/date rape/ teen pregnancy. Depressed teens may attempt or succeed at suicide. Approximately 20-33% of teenagers abuse or are abused by their dating partners; 30-50% of these abusive relationships may re-create the same escalating violence as their adult role models. Thus, a new generation of violent families begins. 5
Behavioral Avoidance Social withdrawal Decreased intimacy in relationships Decreased trust Substance abuse
of IPV are reluctant to disclose abuse, and so too, are the children that witness IPV. They may have been threatened or warned about talking to strangers about the events that occur at home. At risk children should be referred to counselors or social workers. Other resources are relatives and teachers. Certainly children should be encouraged to verbalize their feelings and concerns, but if they are not comfortable with that level of personal emotional exposure, there are other therapies like art or journaling to facilitate expression. Older pre-adolescents and teens may feel more open about talking. Give them permission to share their experiences. In that case, warm, non-judgmental, genuine listening and unconditional acceptance will be most effective.5, 10 If real abuse, neglect or abandonment is identified, by Florida law the standard for reporting for all doctors, dentists, nurses, mental health and social workers is “knowledge of reasonable cause to suspect abuse, abandonment or neglect”. The mechanism is an oral report to the Florida Department of Children and Family Services (DCFS).12
What Children Need
Practice Implications
Children need a safe, secure home environment where adults will listen, believe and shelter them in a home that provides routine and normalcy. They also need child-focused support services that teach IPV is wrong and then guide them to learn non-violent conflict resolution by role-modeling. One place where these services are offered is at Hubbard House in Jacksonville, FL. (see www.hubbardhouse.org) There are other local domestic violence shelters in other locations. Doing an online search will provide contact information.
First, physicians must identify the problem. Just as all adult patients must be screened for IPV by utilizing the RADAR (Table 2, p.5) method and Partner Violence Screen, (Table 3, p.5) so too must parents and children be screened for evidence that children are witnesses to violence in the home.1, 2, 3 Victims
In order for the necessary role-modeling and teaching to occur, children need courageous adults and healthcare providers to break the silence and speak out, to create laws and policies that protect children and to raise the social awareness of the impact of IPV on children.13, 14, 15
4 Vol. 60, No. 4 2009
Northeast Florida Medicine
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