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“SILENT victims” was the headline on a recent perspective article published in the New England Journal of Medicine discussing the epidemic of children exposed to domestic violence or intimate partner violence.
The article highlighted recent changes in US health care provisions which now require private insurance companies to cover routine screening for intimate partner violence (IPV) and counselling for women at no additional cost to the patient.
What are the implications of this development for Australia?
A number of Australian states have routine screening for IPV, particularly as a part of perinatal psychosocial assessment in public practice, although less so in private. Pregnancy is a time of increased risk of violence for women.
About half of the children who witness IPV witness severe violence, such as a parent using a weapon to assault the other parent.
In recent years a range of terms including “being exposed to violence” or “living with violence” have been used to describe the experience of children from violent homes. This can include hearing the violence, being forced to participate in or watch assaults, being blamed for violence, intervening to stop the violence and phoning for emergency assistance, “patching up” a parent, dealing with a parent who alternates between a violent and a caring role, seeing a parent arrested and having to leave home to be safe.
While screening women is important in its own right, parents commonly underestimate the extent of children’s exposure to domestic violence.
Exposure may co-occur with other types of violence and abuse. In clinical practice the adverse impacts of trauma are poorly recognised. In infancy these include sleep disturbance, regulatory problems and developmental delays, and in toddlers and preschoolers poor socialisation, aggression and tantrums are more common.
It will surprise many that post-traumatic stress disorder can be reliably diagnosed in young children. As a generalisation, young children are inside the psychological envelope of their parents and vicariously experience psychological aspects of parental trauma.
Early childhood represents the greatest period of vulnerability particularly to stress-related changes in the brain. Learning problems, hyperactivity, aggression, anxiety and mood disorders occur more frequently and may continue into adolescence with deliberate self-harm, substance abuse, homelessness and depression increasing. IPV exposure is linked to higher rates of physical health problems in children, such as increased incidence and severity of childhood asthma.
Even so, about one-third of children who experience domestic violence don’t show obvious signs of trauma. Children’s ability to cope in violent homes is linked to their mothers’ ability to maintain consistent care, model assertive and non-violent responses to abuse, maintain high levels of extended familial and social support, and sustain their wellbeing.
Nevertheless, one of the ways in which parental domestic violence affects children indirectly is through maternal depression. This links children exposed to domestic violence to another group of silent victims — the one million Australian children living in families where a parent experiences a mental illness. Sometimes there is the “triple whammy” of parental domestic violence, mental illness and substance abuse affecting children’s wellbeing.
During clinical assessment, when IPV is identified or children disclose domestic violence, safety issues are paramount and appropriate reporting is required. Sound management plans that highlight protection should be implemented. There are a range of evidence-based interventions, such as trauma-focused cognitive behaviour therapy, and others that are effective and actively involve parents. The problem is that they are not readily accessible in the community.
The expansion of Access to Allied Psychological Services for 0-11-year-olds in Medicare Locals has the potential to begin to address this. Continued advocacy to expand availability of these programs is essential.
Screening for domestic violence and childhood exposure to domestic violence requires appropriate pathways to care, not only for early intervention and measures that secure personal safety but also for a comprehensive range of clinical interventions that are accessible in the community, combined with access to child protection, welfare, accommodation, police and legal services.
The epidemic of childhood exposure to domestic violence is a major public health challenge, but there is real promise that we can prevent the effects of such exposure on children’s mental health, and reduce the threat of intergenerational violence.
The welfare, legal, community and policy fields have made some progress, and it is up to clinicians and our service systems to take the next steps.
Maybe you’re wearing a white ribbon so your patients can see your intentions.
Dr Nick Kowalenko is a child and adolescent psychiatrist, and head of infancy and early childhood studies at the NSW Institute of Psychiatry.
And thus I clothe my naked villany and seem the saint, when most I play the devil.
I was held captive by my abusive parents, both of whom were severely mentally ill, from birth until the age of 30, that is, when my extremely aggressive father died. And yet, since the complex trauma with which I live does not count as a mental illness in DSM-V terms, the quote often horrendously disabling legacy of the child abuse to which I was subjected remains unrecognised in Australia. For example, after I was clinically assessed by a psychiatrist in 2012 and declared not to be mentally ill, the GP who had for several months prior observed and documented the profound impact that workplace bullying was having on me at the time, an impact made exponentially worse for me because of my child abuse background, declared that there was nothing wrong with me and that I was just ‘a bit of a softie.’ Doctors and other health professionals must gain an awareness of the complex trauma that often stems from child abuse and more to the point, they must dare to step outside of their biomedical bubble. I believe that only when the ideological, economic and political rationale for framing child abuse within DSM-V speak to the exclusion of all other considerations is challenged and overcome, primarily by reference to the actual evidence, can positive change in this long-neglected area be realised.
This recent story from New Zealand gives me some hope…
http://www.stuff.co.nz/dominion-post/news/9491319/ACC-to-rethink-abuse-link
We urgently need widespread roll out of programmes like the Nurse Family Partnership (NFP), developed by David Olds. Professor Olds was awarded the Stockholm Prize in 2008 for crime prevention, based on the results of his early intervention programme with “at risk” mothers.
Interestingly, DOH, during Tony Abbott’s period as minister, implemented a trial of the NFP as part of the NT Intervention.
We might hope that the measure of the Coalition’s social/health policies will be its successful roll out of this and similar policies across the country. Information about the NFP pilots in Australia, including preliminary outcome data, is available at http://www.anfpp.com.au/.
Couldn’t agree more Nick. We must be actively screening for this ‘silent epidemic’ given it’s huge impact on so many individuals. If we can break the intergenerational cycle the benefits will be massive, as will the savings both from a health and total economy point of view.
Having the right services available in the right places will be a critical factor. Getting GPs, early childhood centres and other primary care providers doing the appropriate screening is one thing; having the pathways to help with intervention is another. The expansion of ATAPS to children 0-11 is a real boost to these pathways, and hopefully the Medicare Locals will get it right and administer these services in the way required to best utilise these important health dollars.