Impact of Violence on Children

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Chapter 36 Impact of Violence on Children

Violence, whether as the victim, perpetrator, or witness, whether in person or through the media, is a major public health problem throughout the world (Chapter 1). The focus of pediatrics should not be limited to the traditional care of violence-related injury. Exposure to violence disrupts the healthy development of children; pediatricians need to be aware of this risk factor. Pediatric providers also have a wider responsibility to advocate on local, state, national, and international levels for safer environments in which all children can grow and thrive.

Witnessing violence is detrimental to children. Because their scars as bystanders are emotional and not physical, the pediatric clinician may not fully appreciate their distress and thereby miss an opportunity to provide needed interventions. For children not living in war zones, the source of 1st exposure to violence is often domestic violence. In a survey conducted by the World Health Organization in 2005 among over 24,000 women in 15 sites in 10 countries worldwide, between 11% and 21% of women in most sites reported having been physically abused by their intimate partner, with a range from 13% in Japan to 61% in provincial Peru. In a sample from among over 2,500 women in the Cameroon, 39% reported physical and 15% sexual abuse from their spouses at least once in their lifetime. According to data from the National Center for Posttraumatic Stress Disorder (PTSD), 20-30% of American women will be physically abused by a partner at least once in their lifetimes, and 1.3 million women and 834,732 men are physically assaulted by an intimate partner annually. Each year in the USA, as many as 324,000 pregnant women experience intimate partner violence; pregnancy is one of the highest risk times for domestic violence to a woman. Slightly more than half of female victims of intimate violence live in households with children <12 yr of age; family violence is most likely to be perpetrated by those between the ages of 18 and 30 yr (“the child-rearing years”). The majority of children in these homes have witnessed violence; by some estimates, up to 3 million children per year. In a national survey, 50% of the men who frequently assaulted their wives also frequently abused their children. Most of the children were injured when they intervened to protect their mother from her partner (Chapter 37).

Another source of witnessed violence is community violence. Community violence in the USA is a serious problem that disproportionately affects children from low-income areas. More than 70% of school-aged children from low-income communities have observed domestic violence, assaults, arrests, drug deals, gang violence, and shootings. Young children living in high crime and violence areas observe death more frequently and at younger ages than children growing up in more secure surroundings. Witnessing acts of violence may be a significant stressor in children’s lives. If children’s coping skills are not sufficient to deal with violent situations, stress may be manifested as psychologic, physical, or behavioral symptoms.

The most ubiquitous source of witnessing violence for children in the USA is media violence. The average child 2-5 yr of age watches 20-30 hr of television a week, hours that are increasingly filled with scenes of violence not only on commercial television but also on news outlets. In addition, the wider array of “screen time” children are exposed to, including computer and video games, increases the opportunities for violent events to enter the lives of children. Although exposure to media violence cannot be equated to exposure to real-life violence, many studies confirm that media violence desensitizes children to the meaning and impact of violent behavior. Not all children are equally affected by media violence. Children most at risk from viewing violence may be children who are also exposed regularly to real-life violence in their homes and communities. Interventions to reduce exposure to media violence are noted in Table 36-1.

Table 36-1 PUBLIC HEALTH RECOMMENDATIONS TO REDUCE EFFECTS OF MEDIA VIOLENCE ON CHILDREN AND ADOLESCENTS

Parents should:

• Be made aware of the risks associated with children viewing violent imagery, as it promotes aggressive attitudes, antisocial behavior, fear, and desensitization

• Review the nature, extent, and context of violence in media available to their children before children view

• Assist children’s understanding of violent imagery appropriate to their developmental level

Professionals should:

• Offer support and advice to parents who allow their children unsupervised access to extreme violent imagery as this could be seen as a form of emotional abuse and neglect

• Educate all young people in critical film appraisal, in terms of realism, justification, and consequences

• Exercise greater control over access to inappropriate violent media entertainment by young people in secure institutions

• Use violent film material in anger management programs under guidance

Media producers should:

• Reduce violent content and promote antiviolence themes and publicity campaigns

• Ensure that when violence is presented it is in context and associated with remorse, criticism, and penalty

• Ensure that violent action is not justified or its consequences understated

Policy makers should:

• Monitor the nature, extent, and context of violence in all forms of media and implement appropriate guidelines, standards, and penalties

• Ensure that education in media awareness is a priority and a part of school curricula

From Browne KD, Hamilton-Giachritsis C: The influence of violent media on children and adolescents: a public-health approach, Lancet 365:702–710, 2005.

Impacts of Violence

The violence children experience and witness also has a profound impact on health and development. In a cross-sectional analysis of a Head Start preschool age cohort, being abused, exposed to domestic violence, and having a mother using substances were associated with a higher number of health problems. Beyond injuries, violence affects children psychologically and behaviorally; it may influence how they view the world and their place in it. Children can come to see the world as a dangerous and unpredictable place. This fear may thwart their exploration of the environment, which is essential to learning in childhood. Children may experience overwhelming terror, helplessness, and fear even if they are not immediately in danger. Preschoolers are most vulnerable to threats that involve the safety (or perceived safety) of their caretakers. High exposure to violence in older children correlates with poorer performances in school, symptoms of anxiety and depression, and lower self-esteem. Violence, particularly domestic violence, can also teach children especially powerful early lessons about the role of violence in relationships. Violence may change the way that children view their future; they may believe that they could die at an early age and thus take more risks, such as drinking alcohol, abusing drugs, not wearing a seatbelt, and not taking prescribed medication.

Some children exposed to severe and/or chronic violence may suffer from post-traumatic stress disorder (PTSD), exhibiting constricted emotions, difficulty concentrating, autonomic disturbances, and re-enactment of the trauma through play or action (Chapters 1 and 23). Although young children may not fully meet these criteria, certain behavioral changes are commonly associated with exposure to trauma, such as sleep disturbances, aggressive behavior, new fears, and increased anxiety about separations (“clinginess”). A particula4r challenge in treating and diagnosing pediatric PTSD is that a child’s caregiver exposed to the same trauma may be suffering from it as well.