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Family Violence and Child mental health

Mitigating the Impact

Sue Penfold

Surveys have shown that 14 percent of children aged 4 to 17 years (over 800,000 in Canada) suffer from mental disorders that cause significant distress and impairment at home, at school, and in the community. (Waddell, McEwan, Shepherd, Offord, and Hua, 2005) For many of these children, family violence either causes the disorder or exacerbates pre-existing problems. Family violence directed toward or involving children includes physical, sexual, or emotional abuse or neglect of the child by parents, parent figures, or older siblings, and exposure to partner violence. The term ‘child maltreatment’ encompasses both abuse and neglect.

While some resilient children are apparently unscathed by family violence, it is likely that the violence and related family difficulties may cause longstanding problems with trust, distorted expectations about relationships, and unusual beliefs about male and female roles. The impact of violence is influenced by the child’s age and developmental level, temperament, intelligence, gender, preexisting health or mental-health issues, sibling relationships, the availability of other support systems and friendships, relationships with parents, the type, severity, and chronicity of the violence, other family stresses, parental substance abuse, and the parents’ mental health and ability to parent.

In addition to the direct physical effects of physical or sexual abuse, children in violent homes may suffer a variety of physical, emotional, behavioural, social, and cognitive effects. (Johnson, Kotch, Catellier, Winsor, Dufort, Hunter, et al, 2002) Physical effects include failure to thrive, eating and sleeping difficulties, poor motor skills, headaches and stomach aches, bedwetting, and eczema. Frequent emotional dif.culties are anxiety, depression, low self-esteem, shame, withdrawal, and anger. Behaviour problems include temper tantrums, defiance, aggression, disruptive behaviour, truancy, having unprotected sex, running away from home, and delinquency. Poor social skills, lack of empathy, and rejection by peers are common problems. Cognitive dif.culties include language delays, information gaps, and impaired concentration, causing poor academic performance.

Some researchers have postulated that exposure to a violent environment, particularly in infants or young children, can influence neurodevelopment and cause a lifelong state of hyper-arousal and extreme sensitivity to perceived threat. (Perry, 1997) Children who are exposed to a parent being abused suffer as much distress as those who are maltreated. Children feel terrified and helpless when a parent is assaulted and are more likely to develop Post- Traumatic Stress Disorder (PTSD) than children who suffer other traumas. Witnessing parental homicide is almost certain to cause PTSD.

Given this array of possible problems, it is obvious that children affected by family violence may be identified in many settings including schools, preschools, daycares, hospitals and other medical facilities, community agencies, mental-health centres, police, and probation services. Moreover, the family may have many needs including financial relief, accommodation, clothing, food, medical and mentalhealth care, educational planning, employment counselling, legal services, and temporary foster care or respite care for children. Rarely do children and their families have needs that are limited to one area alone, so a coordinated and collaborative approach is crucial, with community agencies working together. For instance, working in isolation, a busy family doctor could misdiagnose PTSD,and instead, medicate a child for Attention Deficit Hyperactivity Disorders.

To restore their sense of well-being, children may need counselling. Their parents or caregivers may need help to create a stable home where children feel safe, cared for, and nurtured, and where parents provide them with age-appropriate limits. Children who have been exposed to partner violence will bene.t from referral to a Children Who Witness Abuse counselling program.

The 56 CWWA programs in BC offer psycho-educational groups and individual counselling for children, as well as information and support for non-offending parents and caregivers. Children with more serious mental disorders, who may be a threat to themselves or others, and whose mental-health needs are beyond the scope of a community or school counsellor, will need to be referred to child and youth mental-health services in the community or in medical settings. In BC, Child and Youth Mental Health services are offered in 71 communities, with more specialized services in larger communities.

BC CHILDREN’S HOSPITAL RESOURCE MANUAL PROJECT

From 1987-2001, I worked on the Child Psychiatry Inpatient Unit at BC Children’s Hospital, a 10-bed assessment and short-term treatment setting for children from 5 to 12 years, which receives referrals of seriously disturbed children from all over mainland BC and the Yukon. Many of these children have suffered maltreatment in the home or have been exposed to partner violence. During my time there, maltreated children had usually been identified, and attempts made to meet their mental health needs in the local community.

But a second group—those children who had been, or were currently, exposed to partner violence—often remained hidden. The child might be thought to be suffering from anxiety, depression, psychotic illness, or severe behaviour problems, with treatment approaches in the community ignoring the violence in the home. We were particularly concerned about children from isolated rural areas. Parents could not access resources and had little or no information about how to support traumatised children.

In 2002, the Vancouver Foundation gave Mental Health Programs at BC Children’s Hospital funding for three years for the Child and Family Resource Manual Project for Children Who Have Witnessed or Experienced Abuse or Violence. The objectives of this project include conducting a literature review, assessing the needs of children and families within these areas, consulting with BC/Yukon Society of Transition Houses, the Ministry of Children and Family, and other interested parties, and coordinating all this information into a resource manual for use by children and families. I was asked to coordinate this project.

Initially the aims of the project appeared very broad, and the amount of literature and other information available was overwhelming. We decided to focus on violence in the home and not community violence. The main focus would be on children exposed to partner violence. Studies have shown that 45 to 70 percent of these children are also abused themselves, (Margolin, 1998) and therefore, to a great extent, we would be ful.lling the project goal of creating resources for children who had both witnessed and experienced abuse or violence. An advisory committee was formed representing a variety of organizations, backgrounds, and areas of the province.

The main concerns emerging from this committee were that:

• Children exposed to domestic violence had vastly unmet needs.

• Needs were sometimes missed or misdiagnosed by mental-health professionals.

• Many professionals lacked knowledge and skills regarding children exposed to domestic violence.

• There was a lack of collaboration between CWWA counsellors and mental-health professionals in some areas of the province. (This was later con.rmed by a survey, done with BC/ Yukon Society of Transition Houses, of CWWA workers and child mentalhealth professionals.)

• Government cutbacks had had devastating impacts.

• Abused women feared that their disclosure of problems would lead to apprehension of their children by child-welfare authorities.

After some heated discussions, the committee endorsed the production of a manual in three sections. The main emphasis has been on producing a resource for mothers that provides information about how children are affected by domestic violence, how mothers can support their children, and how to gain access to needed resources.

A section for children—a self-help guide about coping with domestic violence—is based on children’s ideas and illustrated with children’s art work. A guide for professionals provides information about children exposed to domestic violence, and basic principles about intervention. The committee hopes that publication of these three guides will increase public and professional understanding and facilitate communication and collaboration.

Each section of the manual went through a number of drafts that were reviewed by members of the advisory committee and their coworkers. During this time I made presentations about the mental-health needs of children exposed to domestic violence to colleagues and at conferences, had an article published in the Canadian Psychiatric Association Bulletin, (Penfold, 2004) and participated in several community projects concerned with prevention or intervention for children exposed to domestic violence. The three guides, “Helping my child: a guide to supporting children exposed to domestic violence,” “Kids helping kids: a guide for children exposed to domestic violence,” and “Interventions with children exposed to domestic violence: a guide for professionals,” are currently in the design process and will soon be ready. They will be available on the BC/Yukon Society of Transition Houses website, and some printed copies will also be available.

Sue Penfold is a child and adolescent psychiatrist and a Professor Emeritus in the Department of Psychiatry, UBC. A feminist perspective and personal experience of abuse have informed her work and led to the publication of Women and the Psychiatric Paradox (1983) and Sexual Abuse by Health Professionals: A Personal Search for Meaning and Healing (1998). She is currently enjoying a ‘semi-retirement’ of multiple part-time jobs that probably amount to a career change. These include working with Delta, Nelson, and Surrey Child and Youth Mental Health Services, and with the Infant Psychiatry Clinic and Oak Tree Clinic at BC Children’s Hospital. She is also a member of the Board of Directors of BCIFV. Her passions include kayaking, skiing, snowshoeing, hiking and climbing, and other outdoor activities. She has three children and three grandchildren, and was recently widowed.

REFERENCES

Johnson, RM, Kotch, JB, Catellier, DJ, Winsor, JR, Dufort, V, Hunter, et al. (2002) “Adverse behavioural and emotional outcomes from child abuse and witnessed violence,” in Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 7: 179-186.

Margolin, G (1998) “Effects of domestic violence on children,” in PK Trickett and CJ Stellenbach (Ed’s) in Violence Against Children in the Family and the Community, 57-101, Washington DC: American Psychological Association.

Penfold, PS, “Children living with partner violence,” in CPA Bulletin 36(4): 10-12.

Perry, BD (1997) “Incubated in terror: Neurodevelopmental factors in the ‘cycle of violence,’” in Osofsky, J (Ed) Children, Youth and Violence: The Search for Solutions, 124-8, New York NY: Guilford Press.

Waddell, C, McEwan K, Shepherd, CA, Offord, DR, and Hua, JM (2005) “A public health strategy to improve the mental health of Canadian children,” in Canadian Journal of Psychiatry, 50: 226-33.