Chapter 4
Child Exposure to Parental Violence
CASE OF AMANDA, AGE 4
Maxine Weinreb
Betsy McAlister Groves
This chapter describes the course of treatment for a young child who witnessed her father’s physical abuse of her mother. The episodes of actual physical abuse were interspersed with loud arguments and threats of abuse, which had occurred with regularity since the child’s birth. This family was seen at the Child Witness to Violence Project at Boston Medical Center, a program that provides develop-mentally informed trauma-focused counseling for young children and their par-ents who are exposed to violence. The chapter prespar-ents an overview of research and clinical findings about the impact of domestic violence on children, and then focuses on assessment and intervention strategies as demonstrated in the detailed case example.
PREVALENCE OF DOMESTIC VIOLENCE
Although the term, “domestic violence” technically includes any act of interper-sonal violence between or among family members, our program defines “domes-tic violence” as threats of intimidation or violence, or actual acts of sexual or physical violence, between intimate partners. The large majority of victims are women. A national survey (Tjaden & Thoennes, 2000) reveals that 22.1% of women and 7.4% of men experience some form of intimate partner violence in their lifetime. Children are often the hidden victims of domestic violence (Groves, Zuckerman, & Marans, 1993). While the U.S. Department of Justice and state law enforcement officials maintain extensive statistics on adult victims 73
of domestic violence, there are no reliable data on the number of children who are bystanders to this violence. One recent study estimates that as many as 15.5 million children live in dual-parent families in which some form of intimate part-ner violence occurred at least once in the past year (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006). Young children (age 6 and youn-ger) are disproportionately represented in this population (Fantuzzo & Mohr, 1999).
THE IMPACT OF DOMESTIC VIOLENCE ON CHILDREN
As the epidemic of domestic violence has become more publicly recognized, there has been a dramatic increase in research on its effects on family members.
Hundreds of studies have focused on the consequences of domestic violence on children. These studies indicate that domestic violence may affect children’s emotional and cognitive development, their social functioning, their ability to learn and function in school, their moral development, and their ability to nego-tiate intimate relationships in adolescence and adulthood (Edelson, 1999; Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003). It is associated with greater rates of juvenile delinquency, antisocial behavior, substance abuse, and mental illness. A large study of adult patients in California (Felitti et al., 1998) revealed an associa-tion between adverse health outcomes and exposure to domestic violence as chil-dren.
Young children appear to be particularly vulnerable to the effects of domes-tic violence. Davidson and Connor (1999) found that if an adult and a child were exposed to the same traumatic event, a child under the age of 11 was three times more likely to develop symptoms associated with posttraumatic stress disorder (PTSD). In a study of children under the age of 4, Scheeringa and Zeanah (1995) found that a child’s perceptions of the danger toward his or her caretaker was a strong risk factor for the development of PTSD. Young children’s perception of their own safety is closely linked to the perceived safety of their caregivers, and if a caregiver is not safe, the effects on a child may be overwhelming.
A number of studies have documented the overlap between witnessing domestic violence and being a direct victim of child abuse. One study shows a 40% median co-occurrence of domestic violence and child maltreatment in the same family (Appel & Holden, 1998). As domestic violence becomes more chronic in families, the risk that a child will be directly abused grows accordingly.
It is not uncommon for older children and adolescents to intervene directly in an attempt to protect their mothers, thereby increasing the risk of direct injury.
Infants and toddlers, who may be unable to anticipate danger or get out of harm’s way, are also vulnerable to injury.
Children who grow up with domestic violence learn powerful lessons about the use of intimidation and force in relationships. In violent homes, children learn that aggression is a part of intimate relationships, or that it is acceptable to relieve stress by yelling at or threatening another family member. These lessons
do not work well for children in other social contexts; they may misinterpret other children’s behavior or behave in distrustful and aggressive ways.
Perhaps the greatest distinguishing feature of domestic violence for young children is that it psychologically robs them of both parents. One parent is the terrifying aggressor; the other is the terrified victim. For young children, who depend exclusively on their parents to protect them, there is no refuge. They cannot trust that their caretaking environment will reliably protect them, and this increases their psychological vulnerability (Groves, 2002; Osofsky, 1999).
Although research enumerates many adverse effects of domestic violence on children, several variables may mediate the intensity and severity of a child’s response (Pynoos & Eth, 1985). These variables include the chronicity and sever-ity of the domestic violence, the proximsever-ity of the child to the violence, and the existence of other risk factors in the child’s and family’s life (e.g., substance abuse, poverty, mental illness). Children are affected in different ways, and not all chil-dren are equally affected. Some chilchil-dren appear to withstand the stresses of domestic violence. Protective factors may include the child’s temperament, his or her achievement in school, parental attunement, and a child’s relationship with other caring adults. The fact that children are affected in such a range of ways has implications both for practice and policy. Services for children and families affected by domestic violence should offer a range of supports that build on strengths and encourage growth.
CLINICAL FINDINGS ON CHILDREN EXPOSED TO DOMESTIC VIOLENCE
The Child Witness to Violence Project at Boston Medical Center, a clinical mental health intervention program for children age 8 and younger who have been exposed to violence, was founded in direct response to the high prevalence of young children exposed to violence in Boston (Taylor, Harik, Zuckerman, &
Groves, 1994). The majority of children referred to the program are exposed to domestic violence.
A retrospective analysis of clinical information from 149 children under the age of 7 seen in the Child Witness to Violence Project gives an interesting profile of young children whose parents decide to seek help for exposure to domestic violence. The majority (73%) of referred children were boys. Nearly two-thirds of the children had been exposed to violence chronically since birth, according to parent report. The most common symptoms mentioned by parents were increased aggression, impulsivity, temper tantrums, sleep dysregulation, and sepa-ration anxiety. In addition, parents mentioned preoccupation with the violent event, as seen in play, verbalizations, and avoidance/withdrawal.
In our clinical work with young children, we have learned about the impor-tance of understanding the violence from the child’s perspective. Children make unique meanings out of events in their lives, which are in part based on age, developmental stage, and prior life experiences. Furthermore, children’s
under-standings of events may differ significantly from the adults’ appraisals of the same event. An essential component of successful therapeutic intervention with trau-matized children requires understanding their subjective experiences of trauma, assisting them with distortions they may have, and helping the caretaking adults better understand the children’s perspective.
Our model of intervention draws heavily from a treatment model developed by Alicia Lieberman and Patricia Van Horn (Lieberman & Van Horn, 2005) at the Child Trauma Research Project at the San Francisco General Hospital. The intervention model, called “child–parent psychotherapy” (CPP), has demon-strated its effectiveness in reducing symptoms and improving functioning of both children and their mothers who are involved with the treatment. This interven-tion has been recognized as an effective and evidence-based interveninterven-tion by the National Child Traumatic Stress Network and is being disseminated to sites across the country.
CPP recognizes the centrality of the child’s relationship with a parent in the early years; it targets the parent–child relationship, rather than only the individual child or only the parent. CPP builds on the premise that the attachment system is the main organizer of the child’s response to safety and danger in the first 5 years of life, and that emotional or behavioral problems can best be addressed within the context of the attachment relationship. The intervention seeks to strengthen the parent–child relationship, recognizing that this relationship is the most important protection a child can have.
CPP focuses on the development of both the parent and the child. Infants, toddlers, preschoolers, and school-age children are in a rapidly developing pro-cess of growth and learning. The impact of trauma on their lives will be depen-dent on their ages and developmental stages. CPP allows developmental issues to guide the treatment. This model enables parents and children to increase their understanding of the other’s perspective and to build stronger mutual relation-ships.
PRINCIPLES OF INTERVENTION WITH CHILDREN AFFECTED BY DOMESTIC VIOLENCE
The Child Witness to Violence Project treats children and mothers affected by domestic violence in flexible combinations of individual and parent–child meet-ings. The specific arrangement of sessions may depend on the age of the child, the presentation of the mother, the topics to be discussed, and the preferences of the child and mother. Regardless of the configuration of the sessions, the parent is essential to the treatment and is actively involved.
The initial phase of the assessment includes an evaluation of each family’s safety and immediate needs. In this phase, families may need referrals for legal assistance, housing, or other concrete services. This case management/advocacy is an essential component of the intervention. If families are not safe, or if the violence is ongoing, trauma-focused work cannot begin. Once these initial issues
have been dealt with, the assessment focuses on the child’s symptoms that are interfering with daily functioning, the parent’s concerns about the child, the child’s experience with the violent event, the child’s understanding of these events, the parent’s emotional strengths and vulnerabilities, and the child’s strengths.
The goals of treatment include relieving symptoms that interfere with func-tioning; increasing skills of parents and children at recognizing and regulating affective states; creating a trauma narrative and shared understanding of the meaning of the trauma; increasing the child’s and parent’s ability to understand the perspective of the other; and strengthening the child–parent relationship.
Obviously, when treating a young child exposed to violence, the clinician needs to consider these principles and issues. The following case example, which was formulated from a composite of several families with whom we worked, strives to translate those principles and issues into therapeutic practice.
CASE EXAMPLE AND APPLICATIONS OF THE PRINCIPLES AND METHODS Family Information
Amanda (age 4 years, 3 months) was referred by a battered-women’s advocate from a nearby health center, where her mother had sought help for the increas-ing tension, violence, and fear in the household. She lived with her mother, Mir-iam, and her 2-year-old sister, Stephanie. Amanda’s father, Yosef, had moved out of their house 3 months ago after being arrested for domestic violence.
Both of Amanda’s parents were professionals who were trained as engineers.
Miriam was born in the United States. Yosef was Israeli, but had lived in the United States for 6 years. When Miriam met Yosef, she was astounded by his history of multiple violent and politically related deaths of family members. The marriage appeared to be one of political sympathy on her part, and it deteriorated quickly. Miriam and Yosef were both Jewish, but Miriam did not practice the religion. However, she did identify with some of the cultural values of Judaism, including a commitment to altruism. Yosef adhered much more closely to the dictates of the religion. He believed that it is a mother’s responsibility to keep the family together and to do as her husband commands. Miriam did not embrace that piece of the culture and felt that Yosef distorted the meaning of such cultural beliefs. Yosef was reported to be very controlling. He made all family decisions unilaterally, withheld his share of financial resources, screamed insults at his wife during unprovoked rageful outbursts, coerced sexual activity, and even unabash-edly brought home a mistress to live with them for a while.
On the day of Amanda’s fourth birthday, the family rode down in the small elevator from the ninth floor of their apartment building, headed for Amanda’s birthday party at a children’s restaurant. They were loaded down with presents, balloons, and other party paraphernalia. Even before the elevator door closed, Yosef and Miriam began to argue, and the quarrel immediately escalated to
phys-ical assault when Yosef shoved Miriam against the back of the elevator and held her head there. The attack startled Amanda and caused her to let go of the bal-loon she had been holding. The balbal-loon popped, and, given the small space in which this all occurred, the reverberation from it was thunderous. Amanda began to tremble and sob uncontrollably. Her mother tried to soothe her when they reached the lobby, but Amanda could not be comforted and pleaded for another balloon.
In a subsequent incident, Yosef shoved Miriam’s head against the refrigera-tor, and she momentarily lost consciousness. She then called the police, who arrested Yosef, and he spent the weekend in jail. After Miriam procured a restraining order, Yosef moved out. Neither child was in the house at the time of the second incident, and therefore neither witnessed it. However, when the chil-dren arrived home, they noticed the bruise on Miriam’s forehead. Miriam explained, “Daddy hurt my head. I made Daddy leave because he hit me.”
Stephanie went off to play after the explanation, but Amanda began to cry. Mir-iam comforted her and reported that Amanda recovered fairly quickly.
Miriam decided to file for divorce. Yosef retained a lawyer and was granted visitation with the children that included an 8-hour daytime visit every other week. Miriam was unhappy about the visitation arrangement, but decided to wait and deal with the question of visitation at the time of divorce. There was also a pending assault charge against Yosef, resulting in Miriam’s involvement in two different courts.
Presenting Problem
Miriam sought treatment for Amanda approximately 3 months after Yosef left their home. She was desperately worried about her daughter, stating that she
“would not stop talking about the balloon that popped.” She noted that Amanda was extremely frightened, and that after the balloon incident she developed sleep difficulties, including nightmares and problems falling asleep. Miriam added that Amanda was having difficulty making the transition to day care and whined con-tinually when any family routines were altered. She also described her as occa-sionally “pushy” when playing with Stephanie. Finally, Amanda talked regularly about the departure of her father.
Parent Interview
Given that young children’s development occurs in relationship to their care-givers (Lieberman & Van Horn, 2005) working with the child in the context of the family is critical. In fact, caregivers are often the central therapeutic agents for change. However, when caregivers are themselves traumatized as a result of domestic violence (as was Miriam), it is not uncommon for them to have diffi-culty being emotionally available, sensitive, and responsive to their children.
Therefore, when a clinician is interviewing a battered mother, it is important to consider her symptoms, her ability to maintain an empathic relationship with her
child (which may become ruptured as a result of the trauma), her skill in recog-nizing danger or stress, and her capacity to support the child. This extremely sen-sitive assessment requires the clinician not only to be familiar with the effects of violence on children and their parents, but to be highly responsive to the mother from the very first contact.
Goals of Parent Interview
• Assess safety and stabilization of Miriam and her children.
• Obtain Amanda’s developmental history.
• Obtain a detailed history of the traumatic exposure.
• Identify current symptoms in Miriam, Amanda, and the family system.
• Learn about Miriam’s reactions to Amanda’s symptoms.
• Understand the quality of the attachment relationship between Miriam and Amanda, as well as Miriam’s ability to support Amanda.
• Obtain a history of Miriam’s psychological functioning.
• Identify Amanda’s and the family’s strengths.
• Provide psychoeducation, including information about symptoms of trau-ma, children’s ambivalent feelings about their abusing parent, the way young children think and understand events, and normalizing of child and parent reactions.
• Offer hope that things will improve.
In the initial two interviews with Miriam, the clinician (Maxine Weinreb, the “I” in what follows) gathered the family information presented above. Mir-iam presented as a woman with intense anxiety and symptoms of hyperarousal.
She stated that she had been “a worrier” since childhood, but she had never pre-viously felt so overwhelmed. She expressed fear of her husband and was terrified that each time he called, he would try to persuade her to take him back. Miriam reported that Yosef was calling the house to speak with the children, and that she couldn’t help trembling and crying when these calls occurred. She was especially worried that he would try to kidnap the children, but she felt helpless to prevent it.
It was clear that Miriam was very concerned about and sensitive to the reac-tions of her children. She talked in great length about the guilt and shame she was experiencing, due to her belief that she was unable to protect her children from the rages of her husband. She worried that her children, especially Amanda, would be damaged forever, and that Amanda would never forgive Miriam. As she talked about it, she began to quiver and cry. Miriam and I went on to explore her feelings at length: She felt ashamed that she had stayed with Yosef for as long as she had, experienced herself as a failure in the relationship, and doubted her skill as a parent. I acknowledged and validated Miriam’s strong feel-ings, and added that such feelings are commonly held when there has been a traumatic experience such as that which she and her children had endured. We agreed to talk more about her feelings in subsequent sessions. I also offered
con-crete information about the effects of trauma on children and explained that Amanda’s symptoms were “normal responses to abnormal events.” I reassured Miriam that her thoughtful decision to seek therapy for Amanda was a significant way to help her; I added that I expected that, like most children who get thera-peutic assistance after such events, Amanda would progress well.
Preliminary Treatment Goals for Miriam
• Create an alliance/partnership with Miriam to help Amanda begin to heal from her experiences.
• Continue psychoeducation about trauma and the role of therapy.
• Help lessen Miriam’s guilt, shame, and anxiety about her daughter’s diffi-culties.
• Restore Miriam’s self-esteem and confidence as a parent.
• Refer Miriam for individual trauma-focused therapy and for assessment of anxiety.
• Support Miriam’s relationship with her domestic violence advocate to assist with safety planning.
Process of Play Therapy First Session
Amanda came into the playroom with her mother, but separated from her shortly after the session began. She presented as a meticulous, well-organized, verbal, and even precocious child who moved carefully from one toy to the other as she explored the room. She talked spontaneously to me about what appealed to her in the room and invited me to draw some rainbow pictures with her. When I asked, “Do you know why your mommy has brought you here to talk to me?”, she replied vehemently, “Because my mommy and daddy were fighting, and my dad doesn’t live at our house any more.” When I asked if she knew why her dad couldn’t live with them any more, she said, “Because he hit my mommy, and that is wrong.” She added, “My daddy scares me. He makes monster noises.” When asked if she might care to draw a picture about what she was telling me, she drew a tidy picture of her family standing in a line holding hands. She said about it sadly, “I miss Daddy.” This sort of ambivalent feeling about a perpetrating parent is common among children exposed to marital violence. However, since children at Amanda’s developmental level find it cognitively difficult to integrate two conflicting feelings at one time, I felt it especially important to clarify and reflect those feelings. It also gave me an oppor-tunity to explain my role in a context that was concrete:
THERAPIST: Sometimes you feel afraid of Daddy. Sometimes you miss seeing him.
Sometimes you feel both things all together.
AMANDA: Yes, I do.