Children are not passive witnesses to family violence, but experience a range of abuses (emotional, physical, sexual) and neglect within the dynamic of power and control that is central to family violence. Research suggests family violence is gendered, predominately perpetrated by males against females, and occurs in the presence of children (ABS 2006, 2012). Family violence is frequently repetitive and the harm experienced by children is cumulative, and directly impacts on outcoes in adulthood (see www.acestudy.org). Psychologists are often called upon when children and young people exhibit impacts from family violence, and therefore have a pivotal role in the identification, and treatment, of family violence trauma.
Attachment and emotional regulation
Attachment theory suggests that humans have innate survival strategies which require children to connect with their primary caregiver if they are to survive and thrive (Bowlby, 1958). Children who feel safe and have a secure relational base are more likely to meet developmental goals. Family violence is interpersonal trauma and directly impairs the quality of attachment between a child and their primary caregiver (Buchanan, 2008). In family violence, children do not experience their caregiving relationships as safe and protective, instead parents are either ‘frightening’ or ‘frightened’, and are likely to be unavailable to consistently meet the child’s attachment needs, which leads to impaired relationships with each parent and possibly attachment trauma for the child.
Children do not need to directly witness family violence to be hurt. Hearing physical and verbal abuse, being neglected or directly abused, experiencing constant fear and disruptions to attunement within caregiving relationships, can change the way a child’s brain grows and develops and can present as complex trauma (Perry, 2001). Whether children experience enduring symptoms of trauma is determined, in part, by whether a child has the protective experience of secure attachment with their primary caregiver (Van der Kolk, 2014). If a child experiences family violence without the availability of a secure attachment, they do not receive the benefits of comfort and co-regulation during and after distressing incidents of family violence. As a result, the child develops neural pathways primed for threat, without developing the capacity to manage distress and emotionally self-regulate. Children in family violence are less likely to have the protective experience of secure attachment as, within the dynamic of power and control, perpetrators often attack the attachment between the mother and child.
Family violence trauma symptoms in children and young people
Children who experience family violence often present with symptoms of Post-Traumatic Stress Disorder (APA, 2013). Intrusive re-experiencing is the triggered remembering, while avoidance is used to reduce triggered distress. Hyperarousal and dissociation (hypoarousal) symptoms reflect a child with a dysregulated system, who has a small ‘window of tolerance’ for distress, and limited capacity to self-regulate. If a child’s brain has developed in the context of danger, their brain continues to operate on ‘high alert’ to deal with real or perceived threats. As a result, the child may have difficulty focusing attention on anything not directly relevant to survival, and present as easily distracted with hyperactivity and aggression. Dissociative symptoms are also common. Children may also present with sleep disturbance, impaired cognitive functioning, developmental delays and regressions, learning difficulties, somatic symptoms, poor sensory integration, and may engage in problematic self-soothing strategies. Controlling behaviours are often present as children attempt to enhance their sense of safety. They often have poor self-worth (feel shame and defective) and an unstable sense of self. How children feel about themselves directly impacts on their capacity to initiate and maintain meaningful relationships. Children in family violence have poor relational templates and often perceive danger in any person, whether a caregiver, peer, or a professional who is trying to assist.
Informed assessment
Family violence may not always be acknowledged, disclosed, or apparent at the time of referral. Psychologists need to be aware of family violence indicators, and have an understanding of family violence and trauma frameworks, to contextualise and inform accurate assessment of a child’s symptom presentation. If a psychologist conceptualises a case based on symptom presentation without considering the presence or possible impacts of family violence, there is a risk of providing the child with a diagnosis that just represents the dominant aspect of the family violence trauma. It is not uncommon for a child who has experienced family violence to be diagnosed and unsuccessfully treated for a range of disorders, such as, anxiety, depression, ADHD, Oppositional Defiant Disorder, Conduct Disorder, among others. DSM-V diagnoses do little to help clarify what is happening to create the symptom presentation for a traumatised child in the context of family violence (see Van der Kolk, 2014). If psychologists are able to accurately identify the significant impacts of family violence, we avert pathologising and continuing adverse impacts for that child, and may prevent reinforcing the power and control agenda of the abusive parent to identify the child, rather than the family violence, as the problem that needs to be ‘fixed’.
Referral to a psychologist may be a rare opportunity for a child to obtain appropriate help, and possibly safety. Children are rarely able to articulate their distress and we need to look beneath their behaviours to contextualise symptoms. Assessment then measures the impact of family violence, assessing symptoms of post-traumatic distress and any attachment impairments. Accurate identification of family violence trauma will therefore enable the psychologist to focus on trauma resolution rather than simple symptom management.
Safety and stability
Sufficient safety and stability are required for children to experience therapeutic change. Psychologists must make an explicit assessment about whether the child is currently safe from the physical and emotional harm that occurs in family violence. Simply separating from a perpetrator is often not enough to secure safety of the protective parent and child, as family violence frequently escalates post-separation. Due consideration of sufficient safety around the following factors is required:
- Is family violence current?
- Is there legal protection?
- Are there contact arrangements with the abusive parent and if so, what is the nature and impact of contact on the child?
Children are often the final link through which perpetrators continue to exert power and control over the victim. This might take the form of denigrating the mother to the child, undermining her parenting, or it could include more direct abuse of the child as a means of hurting the mother. If current risk issues are identified, a therapeutic response might not be indicated, instead the protective parent may require other types of support to enhance safety, or a notification to child protective services may be required.
Psychologists not only need to assess the child, but the systems supporting them to ensure adequate stability and resources exist to support the child in the therapeutic work. This includes assessment with the protective caregiver, who is often the victim of family violence and may have their own trauma impacts. The protective caregiver may require referral for therapeutic support to enhance functioning prior to, or alongside, commencing therapy with the child.
Trauma resolution
Therapeutic intervention primarily focuses on trauma resolution using the evidence-based treatments of Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) and Eye-Movement Desensitisation and Reprocessing (EMDR) (WHO, 2013). Symbolic play and expressive mediums help individualise treatments to be developmentally appropriate for children and young people.
Resolving family violence trauma involves resourcing the child to increase emotional regulation, repairing core beliefs, and enabling them to integrate family violence experiences in a way that improves self-worth and stabilises their sense of self. TF-CBT and EDMR are used within a family therapy framework to support any necessary relational repair. Throughout treatment, it is important to keep the child at the centre of therapeutic work while focusing on strengthening the caregiving dyad. To be most effective, interventions used in conjunction with other systems around the child will facilitate relational repair within these systems too (Saxe, Ellis, & Kaplow, 2007), allowing the child to create generalised healthy relational templates.
Resourcing the primary caregiver with a therapeutic parenting approach (see Wesselmann, Schweitzer, & Armstrong, 2014), and supporting schools to understand and manage the child’s behaviour in ways that support inclusion, not exclusion, is also important. As children begin to have an alternative experience of being safe and cared for within an attuned caregiving relationship, they can experience themselves, others, and the world differently, and demonstrate significant therapeutic change.
Conclusion
Family violence and trauma-informed assessment will assist psychologists to identify family violence when it is present, and contextualise a child’s symptom presentation to ensure children are not pathologised for their normal response to adverse events. Therapeutic intervention requires a child-centred approach, and focuses on resolving post-traumatic distress and attachment trauma using TF-CBT and EMDR within a family therapy and systems framework.
Practice Tips
The following suggestions are provided, in order of priority, to help facilitate positive outcomes for children and young people who have experienced family violence:
- If family violence is current the initial response should be protective.
- Complete a family violence and trauma-informed assessment of the child or young person and their systems.
- Provide psychoeducation to the caregiver and the child or young person to enhance understanding of the child’s behaviours within the context of family violence trauma.
- Develop an appropriate treatment plan that clearly identifies the family violence trauma and the child’s therapeutic needs.
- Provide a treatment plan overview to the caregiver so they know what type of therapeutic support the child or young person requires for trauma resolution.
- Identify what resources are required for stabilisation in functioning for the child or young person and caregiver.
- Build resources and make appropriate referrals.
- Support the child or young person’s systems to strengthen existing external resources.
- Commence trauma resolution work if appropriate.
The authors can be contacted at [email protected] and [email protected]