1. C HILD A BUSE P ROFESSIONAL T RAINING S ERIES #4 H OW DOES CHILD SEXUAL ABUSE AND WITNESSING DOMESTIC VIOLENCE ALTER AND AFFECT THE COURSE OF DEVELOPMENT ? Fawn McNeil-Haber, PhD

2. C HILDHOOD T RAUMA Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms the personality. The child trapped in an abusive environment is faced with formidable tasks of adaptation. She must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness. Unable to care for or protect herself, she must compensate for the failures of adult care and protection with the only means at her disposal, an immature system of psychological defenses. - Judith Herman, 1992

3. C HILDHOOD Rapid brain development most rapid between birth and 5 years old by 3 years old ~ 85% of adult volume Primed to learn from our experiences Early development and experiences provides a foundation for later development. The following slides are provided courtesy of The National Child and Traumatic Stress Network's Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (2010) Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (2010)

12. N ORMATIVE D EVELOPMENTAL T ASKS Infants and toddlers Attachment Security Trust Emotion regulation Autonomy Recognition of and response to emotional cues Preschoolers Autonomy Agency Initiative Emotion regulation Self control

13. D EVELOPMENTAL TASKS School-aged Sustain attention for learning and problem solving Control Impulses Becoming Industrious Emotional Awareness Complex reasoning Friendships Manage anxieties Adolescence Independence Relationships Achievement Identity (Values) Abstract thought Anticipate and consider consequences of behavior Control behaviors for long term goals Accurately judge danger and safety

14. In what ways does trauma impact these normative developmental tasks?

15. C OMPLEX T RAUMA Childrens experiences of multiple traumatic events that occur within the caregiving system Neglect Emotional abuse Physical abuse Sexual abuse Witnessing Domestic Violence (Cook et. al, 2003)

16. C HILD S EXUAL A BUSE A sexual act imposed on a child who lacks emotional, maturational, and cognitive development to understand and consent to such acts. 1 in 5 girls 1 in 10 boys 70% of sexual assaults occur before age 18 > 90% of offenders are known to and trusted by victims Crime of control, betrayal, secrecy, isolation, intimidation and helplessness A crime that is misunderstood by most adults including non- offending parents (Finklerhor & Jones, 2012; Snyder, 2000)

17. D OMESTIC V IOLENCE E XPOSURE Commonly defined as a behavior, or pattern of behaviors, that occurs between intimate partners with the aim of one partner exerting control over the other through aggression, coercion, abuse and/or violence. 43% of female victims and 25% of male victims of DV live in households with children (Bureau of Justice Statistics) Occurs disproportionately in home with children under 5 (Taylor et. al, 1994) 45%-70% also physically abused 1 15 times more likely to be physically abused or neglected 1 Evidence for a raised cooccurrence of DV and CSA 1 The ability to parent is compromised 1 1.(Holt et al, 2008)

18. S IMPLE VS. C OMPLEX T RAUMA Simple Non-interpersonal Limited exposure (single event) Shorter duration Occurrence at later developmental stage Support of caretaker/family Secure attachment with with primary caretaker(s) Complex Interpersonal Multiple exposures/types Longer duration Occurrence at an earlier developmental stage Limited or no support Insecure attachment with primary caretakers (Lanktree & Briere, 2008)

19. C OMPLEX T RAUMA Mental, Emotional, Biological and Behavioral effects of experiencing recurrent childhood abuse. Seven domains of impairment Attachment Biology Affect Regulation Dissociation Behavioral Control Cognition Self Concept (Cook et. al, 2003)

20. A TTACHMENT The emotional bond between an infant and caregiver serves to create safety and security for that child. Secure attachment Insecure attachments (avoidant and resistant) Disorganized attachments Attachment continues to evolve throughout childhood and adulthood.

21. D ISORGANIZED ATTACHMENTS For some infants the caregiving environment so bizarre, threatening, unpredictable, violent or frightening that not only are the infants insecure, but they also cannot organize a strategy for ensuring protective access to their caregivers. When in need of comfort, these infants demonstrate undirected, odd, and contradictory behaviors. (Cassidy & Mohr, 2001)

22. A TTACHMENT Uncertainty about the reliability and predictability of the world Problems with boundaries Distrust and suspiciousness Inappropriate help seeking (e.g.social isolation; undiscriminating affection) Interpersonal difficulties Difficulty attuning to other peoples emotional states Difficulty with perspective taking Difficulty enlisting other people as allies (Cook et. al, 2003)

23. B IOLOGY Brain development Hypersensitivity to physical contact Somatization Increased medical problems across a wide span, e.g., pelvic pain, asthma, skin problems,autoimmune disorders, pseudoseizures (Cook et. al, 2003)

24. A FFECT R EGULATION Involves the ability to identify emotion and regulate the experience of emotion Begins at a very young age and continues throughout childhood

25. A FFECT R EGULATION Difficulty with emotional self-regulation Depression, Anger, Anxiety Difficulty describing feelings and internal experience Problems knowing and describing internal states Difficulty communicating wishes and desires (Cook et. al, 2003)

26. D ISSOCIATION Three primary functions of dissociation: 1. Automatization of behavior in the face of psychologically overwhelming circumstances 2. Compartmentalization of painful memories and feelings 3. The detachment from ones self when confronting extreme trauma (Putnam, 1997)

27. D ISSOCIATION Distinct alterations in states of consciousness Amnesia Two or more distinct states of consciousness, with impaired memory for state-based events (Cook et. al, 2003)

28. B EHAVIORAL C ONTROL Refers to a person's ability to control their impulsive and manage and direct their behavior in a responsible manner. When attachment, affect regulation, biological functioning and perceptual integration has been compromised behaviors become dysregulated.

29. B EHAVIORAL C ONTROL Poor modulation of impulses Self-destructive behavior Aggression against others Pathological self-soothing behaviors Communication of traumatic past by reenactment in day-to- day behavior or play (sexual,aggressive, etc.) Difficulty understanding and complying with rules Sleep disturbances Eating disorders Substance abuse Excessive compliance Oppositional behavior (Cook et. al, 2003)

30. C OGNITION Refers to higher brain functioning needed for Executive Function Academic Advancement Abstract Reasoning Sustained Attention Flexibility Creativity

31. C OGNITION Difficulties in attention regulation and executive functioning Lack of sustained curiosity Problems with processing novel information Problems focusing on and completing tasks Difficulty planning and anticipating Problems understanding own contribution to what happens to them Learning difficulties Problems with language development Problems with orientation in time and space (Cook et. al, 2003)

32. S ELF C ONCEPT The mental image or perception that an individual has of his/herself and his/her abilities

33. S ELF C ONCEPT Lack of a continuous, predictable sense of self Poor sense of separateness Disturbances of body image Low self-esteem Shame and guilt Feeling stigmatized

34. P OST T RAUMATIC S TRESS D ISORDER Exposed to a traumatic event that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others resulting in: Recurrent intrusive recollections nightmares, intrusive thoughts, physical/emotional distress Avoidance of reminders of thoughts, of feelings, feeling distant, difficulty feeling positive feelings Increased physical arousal sleep difficulties, concentration difficulties, anger, hypervigilance

35. T RAUMA S YMPTOMS FOR CSA ( BIRTH TO AGE 8) Eating disorders Fear of sleeping alone Nightmares/Night terrors Separation anxiety Thumb- or object-sucking Enuresis (wetting accidents) Encopresis (soiling) Language regression Sexual talk Excessive masturbation Sexual acting out, posturing Crying spells Hyperactivity Change in school behavior Regular tantrums Excessive fear (including of men or women) Sadness or depression Suicidal thoughts Extreme nervousness

36. T RAUMA S YMPTOMS FOR CSA ( AGE 9 THROUGH ADOLESCENCE ) Fear of being alone Nightmares/Night terrors Peer problems Fights with family Poor self esteem Memory problems Intrusive recurrent thoughts or flashbacks Excessive guilt/shame Mood swings Sexual acting out Overly compliant Self mutilation Hypervigilance Substance abuse Avoidant, phobic behaviors including sexual topics Sadness or depression Suicidal thoughts or gestures Excessive nervousness Violent fantasies

37. T RAUMA S YMPTOMS FOR DVE Birth to 5 Sleep disruption Eating disruptions Withdrawal Separation anxiety Inconsolable crying Regression Anxiety, fears Increased aggression Impulsive behavior 6 to 11 Sleep disruptions School Difficulties Aggression/Difficulty with peer relationships Concentration problems Withdrawal and/or emotional numbing School avoidance and/or truancy Age Birth to 5Age 6 to 11Age 12 to 18 Nightmares, sleep disruptions Aggression and difficulty with peer relationships in school Difficulty with concentration and task completion in school Withdrawal and/or emotional numbing School avoidance and/or truancy Antisocial behavior School failure Impulsive and/or reckless behavior, e.g., o School truancy o Substance abuse o Running away o Involvement in violent or abusive dating relationships Depression Anxiety Withdrawal

38. T RAUMA S YMPTOMS FOR DVE 12-18 Antisocial behavior School failure Impulsive/reckless behavior School truancy Substance abuse Running away Abusive dating relationships Depression Anxiety Withdrawal Adulthood Depression Child Maltreatment Substance Abuse Intimate Partner Violence Age Birth to 5Age 6 to 11Age 12 to 18 Nightmares, sleep disruptions Aggression and difficulty with peer relationships in school Difficulty with concentration and task completion in school Withdrawal and/or emotional numbing School avoidance and/or truancy Antisocial behavior School failure Impulsive and/or reckless behavior, e.g., o School truancy o Substance abuse o Running away o Involvement in violent or abusive dating relationships Depression Anxiety Withdrawal

39. A DVERSE C HILDHOOD E XPERIENCES (ACE) S TUDY Ace Score 0-10 emotional abuse physical abuse sexual abuse neglect lack of emotional support domestic violence exposure separated/divorced parents mentally ill household member alcoholic household member household member who went to prison ~ 2/3 experienced 1+ ACEs 1 in 5 reported 3+ http://www.cdc.gov/ace/prevalence.htm http://acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf

40. A DVERSE C HILDHOOD E XPERIENCES (ACE) S TUDY

41. Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy http://www.cdc.gov/ace/findings.htm

42. Do all children who witness domestic violence grow up to become domestic violence perpetrators?

43. D O ALL CHILDREN WHO WITNESS DV GROW UP TO BECOME DV PERPETRATORS ? Family of Origin Violence is one of risk factors in Intimate Partner Violence (Franklin et. al, 2011) Several studies to suggest that many children show resilience in the face of interparental violence. 54% of 2-4 yr. olds showed positive adaptation. (Martinez-Toreya, 2009) 31% of 8-14 yr. olds in a DV shelter didn't exhibit any signs of maladjustment. (Gyrch et. al, 2000) 67% of 8-16 yr. olds in a community sample score below clinical cutoffs on internalizing and externalizing. (Spilsbury et. al, 2008) 118 studies were analyzed. Results 37% of DV exposed children were doing similarly or better than non-witnesses. (Kitzmann, 2003)

44. W HY DO PEOPLE RESPOND DIFFERENTLY TO THE " SAME " TRAUMATIC EVENT ? Risk and Protective factors Pre-trauma factors Factors specific to the trauma Post-trauma factors

45. R ESILIENCY FACTORS Having a supportive parent who can: 1. Believe and validate their childs experience 2. Tolerate the childs affect 3. Manage their own emotional response (Cook, et. al, 2003)

46. R ESILIENCY FACTORS Easy disposition Positive beliefs about self Positive Temperment Internal locus of control external attribution of blame High degree of mastery Spirituality High self esteem in one area Positive attachment to emotionally supportive and competent adults Motivation to act effectively Development of cognitive and self regulation abilities

47. R ISK F ACTORS Poverty, which is related to poor educational achievement (a protective factor) Parental unemployment Alcohol use Poor social supports Violence with a weapon Witnessing sexual abuse against the mother Co Occurrence of Physical Abuse Self blame appraisals

48. D O ALL CHILDREN WHO EXPOSED TO DOMESTIC VIOLENCE GROW UP TO HAVE VIOLENT RELATIONSHIPS ? Nope

49. R EFERENCES Bureau of Justice Statistics, Intimate Partner Violence in the U.S. 1993-2004, 2006. Cassidy, J., & Mohr, J.J. (2001). Unsolvable fear, trauma, and psychopathology: Theory, research, and clinical considerations related to disorganized attachment across the life span. Clinical Psychology: Science and Practice, 8, 275-298. Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2003). Complex Trauma in Children: White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. [White Paper] Retrieved from http://www.nctsn.org/sites/default/files/assets/pdfs/ComplexTrauma_All.pdf Finklerhor, D. & Jones, L. (2012). Have sexual abuse and physical abuse declined since the 1990s? Crimes Against Children Research Center, C267. Franklin, C.A., Menaker, T.A., & Kercher, G.A. (2011). The effects of Family-of-Origin Violence on Intimate Partner Violence. Retrieved from http://dev.cjcenter.org/_files/cvi/7935%20Family%20of%20Origin%20Violence.pdf Grych, J.H., Jouriles, E.N., Swank, P.R., McDonald, R., & Norwood, W.D. (2000). Patterns of adjustment among children of battered women. Journal of Consulting and Clinical Psychology, 68, 84-94. Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books Holt, S., Buckley, H., & Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse and Neglect, 32, 797-810. Kitzmann, K.M., Gaylord, N. K., Holt, A. R., & Kenny, E. D. (2003). Childwitness to domestic violence: Ameta-analytic review. Journal of Consulting and Clinical Psychology, 71(2), 339–352. Lanktree, C. & Briere, J. (2008). Integrative Treatment of Complex Trauma for Children (ITCT-C): A guide for the treatment of multiply-traumatized children aged eight to twelve years. Retrieved from http://www.johnbriere.com/Child%20Trauma%20Tx%20Manual%20(LC%20PDF).pdf Martinez-Torteya, C., Bogat, A., von Eye, A., & Levendonsky, A.A., (2009). Resilience among children exposed to domestic violence: The role of risk and protective factors. Child Development, 80 562-577. Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. New York, NY: Guilford Press. Spilsbury, J.C., Kahana, S., Drotar, D., Creeden, R., Flannery, D.J., & Friedman, S. (2008). Profiles of behavioral problems in children who witness domestic violence. Violence and Victims, 23, 3-17. Snyder, H N. (2000). Sexual assault of young children as reported to law enforcement: Victim, incident, and offender characteristics. National Center for Juvenile Justice, U.S. Department of Justice. Retrieved December 31st, 2008, from http://www.ojp.usdoj.gov/bjs/abstract/saycrle.htm Taylor, L., Zuckerman, B., Harik, V. & Groves, B. (1994).Witnessing violence by young children and their mothers. Journal of Developmental and Behavioral Pediatrics. 15, 120–123.