the effects of trauma and violence on children and adolescents

Dr Paul Carey
MRC Research Unit for Anxiety & Stress Disorders
Department Psychiatry, University of Stellenbosch

Introduction
A recent report suggests childhood rape has increased by 400% in South Africa in the last decade. In all, 25% of females and 15% of males report being victimized in their childhood and adolescent years. A greater awareness of the victimization of children has been created in recent years with the involvement of community social networks, specialized law enforcement agencies, education and the media. Higher reporting rates seem likely to explain only some of the escalation in recent years. Many in the field believe current statistics do not begin to define the full extent of the problem. Attention is regularly focused on sexual crimes against children and may at times serve to divert attention from the equally harmful affects of physical and emotional abuse on children from all quarters of society.

Trauma demographics
While certain vulnerable groups of children experience higher levels of abuse, victimization of children occurs in all communities of our country irrespective of socio-economic or racial background. Specific childhood demographic and environmental factors that are associated with trauma and violence have been identified and include:

• Female gender
• Family disharmony and fragmentation (divorced and single parent families)
• Poverty
• Parental/caregiver
  • substance abuse
  • psychopathology
  • criminal activity/arrest
  • experience of violence

Behavioral effects of trauma and violence
A variety of behavioral effects may persist for years following childhood sexual abuse (CSA) as illustrated by a recent study1 (Table 1).

Table 1: Percentage of children for whom difficulties were reported following physical and sexual abuse

Other effects include:

• Often-unwanted teenage pregnancies
• High-risk sexual activity
• HIV infection
• Posttraumatic stress disorder (PTSD).

This array of consequences serves to highlight the need for vigilance on the part of health and social welfare professionals when assessing both young and adult people. This will avoid dismissing behaviors that may point to a past or ongoing pattern of abuse and victimization. There is evidence that persistence of the behavioral symptoms predominantly in respect of higher-risk behavior will increase the likelihood of future exposure to similar situations which in turn have been shown to compound the risk for future psychiatric illness.

Reasons for non-disclosure
Childhood and adolescents are correctly regarded as vulnerable groups within our society. In addition numerous reasons exist to make disclosure difficult, including:

• Remaining in the abuse environment – isolated from help
• Fear of retribution/further abuse
• Fear of precipitating disintegration of the family structure/security
• Pressure from perpetrator to maintain secrecy
• Childs perception that abuse was provoked by him/her
• Poor self-esteem and shame
• Date-rape drugs - altered awareness and recall

Living with the secret of abuse has (see table above) far-reaching consequences in a sensitive period of social, cognitive and personality development as will be discussed in the following section

Trauma and the brain
The vast majority of brain development occurs in childhood and adolescence. Components of this development are variably genetically programmed and experience dependent. Failure or distortion of requisite experiences through abuse and victimization, for example, may have long-term effects on brain function and even structure. Poorer functioning commonly affects mood regulation, frustration-tolerance and levels of attention. Numerous brain hormones are normally released in response to stress and regulate a wide range of body functions through structures including the hypothalamus, pituitary and adrenal glands. Severe childhood stress damages the normal responsiveness of this system and this may persist into adulthood. Repeated stress may alter the sensitivity of brain cells in certain regions and in some particularly vulnerable people cause significant damage to the cells in the hippocampus for example. It is this damage that seemingly explains the abnormalities in brain function mentioned above. Given these findings it seems clearer how effective prevention and early intervention programs can have significant benefits for the individual child’s development.

Mental health outcomes
It is now accepted that childhood abuse and victimization is associated with higher rates of psychiatric illness. Much debate however surrounds the cause and effect relationship of abuse and psychiatric illness, invoking questions as to the validity of these commonly accepted associations.

Confounding social risk factors for childhood abuse may also be factors that independently render children vulnerable to later development of psychiatric illness. Those with psychiatric illness are more likely to be directly questioned about a history of abuse resulting in disclosure. Furthermore people with psychiatric illness are more likely to disclose abuse histories spontaneously. Both of these factors may lead to recall bias and incorrect assumptions about association.

Mention of this debate should caution clinicians when assessing suspected abuse victims. Identifying abuse should always be a priority, but disclosure should not necessarily elevate it to centre-stage as the causal factor of the psychiatric symptoms at the expense other potentially equally aggravating social factors.

Theoretical variation in the expression of psychiatric symptoms exists for different developmental age groups. This has not been exhaustively studied, but some patterns are clear2. Early childhood (3-5 years) is associated with internalizing, externalizing and inappropriate sexual behavior. Middle childhood (6-12 years) emotional associations include depression, suicidal thoughts, PTSD and other early childhood expressions. The adolescent child is more likely to engage in risky sexual and criminal behavior, be depressed, suicidal, conduct disordered (truant, gangs), have unwanted pregnancies, abuse substances and have low self-esteem. The wide range of psychiatric symptoms that bring young people to the attention of clinicians is evidence of the vigilance required in any assessment of behavioral problems or changes in this age group.

PTSD and depression result in 30-40% of survivors of childhood abuse. The severity of childhood trauma is a significant predictor of the number and severity of PTSD and depressive symptoms. Childhood neglect, often said to be of lower traumatic intensity, is also significantly associated with later development of depression and PTSD.

The development of substance abuse disorders in children and adolescents continues to increase in South Africa. Adolescent victims of abuse tend to abuse more substances in higher doses than their non-abused counterparts. As such, this group demand improved intervention and prevention strategies.

Prevention and the collective responsibility of intervention
Abuse and victimization of children is a worldwide and increasing phenomenon. Most constitutions around the world, including our own, now enshrine the rights of children to safe and protected environments in which to grow up. As social and health care service providers we are entrusted with a significant responsibility to partner community organizations to instill a culture of no-tolerance of continued victimization of children and adolescents. This demands involvement in community development to alter high high-risk environments for children. Broad-based education of caregivers and victims is also a shared responsibility. In our practice settings suspicion of abuse or potential risk confers a legal responsibility to notify appropriate professionals and should coupled with responsible collaboration with local health, social and legal services. Active involvement in these areas should help protect the rights to a safe environment for the young of today as well as the potential victims of tomorrow.

References

1. Calam R, Horne L, Galsgow D, Cox, A. Psychological disturbance and childhood sexual abuse: A follow-up study. Child Abuse and Neglect 1998; 22: 901-913
2. Tyler KA. Social and emotional outcomes of childhood sexual abuse: A review of recent research. Aggression and Violent Behavior. 2002; 7: 567-589