Violence, Stress and Childhood Development

No one would argue that violence has long term effects on children. A child who is the victim of first-hand violence often suffers impacts to her biopsychosocial development. The Center on the Developing Child out of Harvard University, reminds us that no developmental domain develops in isolation, and traumas that seemingly effect one area, also effect the others. 

For years I have worked with bereaved children and adults. I'm always surprised by resilience that human beings can demonstrate after a significant loss; however, with a child, there is more to be considered. One study found that there is no significant difference in the complicated grief or occurrence of PTSD in children  who have experienced parental loss, whether it be a sudden/traumatic death, or an expected death (McClatchy, Vonk, Palardy, 2009). Studies also indicate that children how have experienced parental loss are more likely to experience psychiatric disorders and/or delinquent behaviors later (Draper & Hancock, 2011). Therefore, it would not be inaccurate to state that children who have experienced violence bi-proxy, in the form of traumatic parental death, are impacted developmentally. 

As an example, I once worked with a family who's teenage son was killed by a hit and run drunk driver. In addition to the deceased son, the family had three additional children, ages 5, 8, and 11. I worked with all of the children and witnessed the diverse grief experiences of each. The youngest, a beautiful 5 year old girl, struggled with the permanence of her brother's death; the 8 year old and the 11 year old demonstrated significant anger over the unfairness of the death; and the 11 year old also struggled with now, very suddenly, being the oldest sibling and what this would mean for him. At 5 years of age, the young girl was at a sensitive period for reading development and language learning. This was particularly significant for her because her family is Latino, and the primary language spoken at home was Spanish. Over the course of 18 months in working with her, she demonstrated significant social withdrawal and isolation, decreased use of English (which she previously was doing great with), and regression in her reading and early academic development (according to her pre-K teacher). I struggled deeply with how best to work with her, and while we made some great success during out time together, it was clear that her developmental status effected her grief, which in turn effected her further development. Three years after the family's loss, I was informed that the children were continuing to adapt, however, the eldest (now 14) was beginning to have risk factors for self-harming behaviors. 

Consider Syria, then, where the number of children who have lost parents due to violence and war continues to rise. One source reports that there are two million child refugees from Syria, and "8,000 children fled Syria without their parents" (International Business Times, 2015).  According to UNICEF, 7.5 million children have been affected by unrelenting violence, crumbling infrastructure, ruined schools and hospitals and shortages of essential supplies (UNICEF, n.d.). The majority of the children who have sough refuge in Turkey live in substandard accommodations (often camps), with little to no money to support basic needs, and do not attend school (AlJazeera, 2016). The effects to the development of these children is enormous and holistic. Provided the child survives, she will likely suffer cognitive delays, PTSD related to toxic stress, and physical issues related to inadequate medical support and malnutrition. While countries like Turkey have made attempts to support the refugees, and families across the world have opened their homes to orphaned children, the conflict continues with no end in sight. This means that it is highly likely that an entire generation of children will suffer the long term effects of this war: physically, cognitively, socially, emotionally, and spiritually. 

References

AlJazeera. (2016). The Orphans of Syria's War. Retrieved from http://www.aljazeera.com/indepth/inpictures/2016/05/orphans-syria-war-160528083608975.html

Center on the Developing Child–Harvard University. (n.d.). InBrief: Early childhood program effectiveness. [Video file]. Retrieved from http://developingchild.harvard.edu/index.php/resources/multimedia/videos/inbrief_series/inbrief_program_effectiveness/
 
Draper, A., & Hancock, M. (2011). Childhood parental bereavement: the risk of vulnerability to delinquency and factors that compromise resilience. Mortality, 16(4), 285-306. doi:10.1080/13576275.2011.613266

International Business Times. (2015). Amid Refugee Debate, Unaccompanied Syrian Children Have Willing US Families Ready to Foster, Experts Say. Retrieve from http://www.ibtimes.com/amid-refugee-debate-unaccompanied-syrian-children-have-willing-us-families-ready-2192977


McClatchy, I. S., Vonk, M. E., & Palardy, G. (2009). The Prevalence of Childhood Traumatic Grief—A Comparison of Violent/Sudden and Expected Loss. Omega: Journal Of Death & Dying, 59(4), 305-323. doi:10.2190/OM.59.4.b

UNICEF (n.d.). Help Syrian Children. Retrieved from https://www.unicefusa.org/donate/help-syrian-children/16078?utm_campaign=2016_misc&utm_medium=cpc&utm_source=20160107_google&utm_content=syria&ms=cpc_dig_2016_misc_20160107_google_syria&initialms=cpc_dig_2016_misc_20160107_google_syria

Child Abuse and Maltreatment

• 
  Violence against a child always surprises me. Now, I am not a perfect mother, caregiver, or person. I admit that there have been times I've fantasized about putting a "Free Carseat: Baby Included" sign on the front lawn, or have smacked my child's hand during or after a particularly heinous tantrum that involved hitting or kicking at me. I understand the exhaustion, stress, anxiety and frustration that many parents feel from time to time. What I do not understand however, is how societies worldwide have not done more to prevent abuse/maltreatment, stop if from happening when it's evident, or provide better treatment and support to those who have suffered from it.
   
  The World Health Organization (WHO)  defines child maltreatment as "all forms of

  physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power" and identifies 5 broad categories of child maltreatment including: physical abuse; sexual abuse; neglect and negligent treatment; emotional abuse; and exploitation. Internationally, their data reports that a quarter of all adults report being victims of physical abuse as children; and 1 in 5 women and 1 in 13 men have been victims of sexual abuse as children (WHO, 2014). This doesn't take into account the number of children who have been emotionally abused, neglected (physically, emotionally, educationally, medically), or exploitation including human trafficking. 
   
  The Centers for Disease Control have some number of their own, and since numbers speak to people, here's a few from the CDC's 2012 Fact Sheet: 
  • An estimated 686,000 children were victims of abuse and neglect in the US, of those:
  • 78% were victims of neglect, 
  • 18% victims of physical abuse;
  • 9% were victims of sexual abuse, and:
  • 11% were victims of maltreatment including emotional abuse, victims of parental drug/alcohol abuse, or lack of supervision
  • 27% were under 3 years of age, with children under 1 being the most highly represented

  • 1640 children died from maltreatment
  • 70% from neglect and
  • 44% the result of abuse or abuse and neglect. 

   
  And we call ourselves "civilized".  
   
  But isn't simply the acts of maltreatment, violence and neglect that are dangerous; it is the long term effects to the survivors.  The WHO reports in it's Fact Sheet  (2014) that maltreatment can result in:
  • disruption in early brain development. 
  • impaired development of the nervous and immune systems resulting in increased risk for behavioral, physical and mental health problems such as:
  • perpetrating or being a victim of violence

  • depression
  • smoking
  • obesity
  • high-risk sexual behaviors
  • unintended pregnancy
  • alcohol and drug misuse.

  • The behavioral and mental health consequences can contribute to heart disease, cancer, suicide and sexually transmitted infections in young adults. 

   
  Here's the kicker, we've identified risk factors and protective factors, and have developed prevention programs, but it continues to happen every day, in every state across the US. 
   
  We aren't alone, though.  It happens the world over. However, because not all countries have the same (or any) definitions of abuse/maltreatment, reporting structures or practices in place, it can be difficult to find accurate data. And without these types of data, it's easy to see why many don't have prevention or treatment programs in place either. 

  • Ark of Hope for Children reports that internationally: 
  • 40 million children subjected to abuse each year. 
  • Suicide is the third leading cause of death among adolescents worldwide.
  • 30% of severely disabled children in special homes in the Ukraine die before 18 years of age.
  • Approximately 20% of women and 5–10% of men report being sexually abused as children, while 25–50% of all children report being physically abused. 
  • Statistics indicate that 3 million young girls are subjected to genital mutilation every year.

   
  Consider India where 19% of the world's children live. In 2007, UNICEF and the Government of India's Ministry of Women and Child Development published a Study on Child Abuse.  Traditionally in India, the support and care of children has been the responsibility of the family and community, and while children had some rights under the Constitution, "the approach to ensure the fulfillment of these rights was more needs based rather than rights based" (Ministry of Women and Child Development, 2007). General findings included:
  • Children 5-12 were most at risk for maltreatment and exploitation
  • Two out of every 3 children were victims of physical abuse
  • 14975 children were reported to be victims of crimes against children including:
  • Rape, kidnapping, procurement, buying or selling for prostitution, exposure and abandonment, infanticide, etc.
  • 53% of children were victims of sexual abuse, with 21% reporting severe sexual abuse.
  • 50% of the child victims reported knowing their abuser and was often in a position of trust and authority. 
  • 50% of children reported emotional abuse (boys and girls equally)
  • 83% of the abusers were parents
  • 48% of the girls wished they were boys 
    
  The report provides potential risk factors and reasons for the high maltreatment rate: 
  

  "Harmful traditional practices like child marriage, caste system, discrimination against the girl child, child labour and Devadasi tradition impact negatively on children and increase their vulnerability to abuse and neglect. Lack of adequate nutrition, poor access to medical and educational facilities, migration from rural to urban areas leading to rise in urban poverty, children on the streets and child beggars, all result in break down of families. These increase the vulnerabilities of children and exposes them to situations of abuse and exploitation"  (Ministry of Women and Child Development, 2007, p 6).

  
  So, what does this mean for us, for all of us, as co-contributors to child health and development? It means we have work to do. It means that each and every center that works with children needs to train and retrain employees on child abuse risk assessment, identification, and reporting. It means that we, as caregivers and professionals, need to create caring environments free from abuse where children can feel safe, secure, and worthy of love and respect. It means we need to educate children on their worth, rights, and resources; advise them of safety plans; and refer them to professionals training in the assessment and treatment of childhood maltreatment and abuse. It also means supporting parents and communities that have higher risk factors, fewer resources, and little support. Prevention is the key, however, where prevention fails we need to re-double our efforts to protect young lives and mitigate the harm done. 
  
  Links:
  Ark of Hope for Children
  Centers for Disease Control
  Ministry of Women and Child Development, India
  World Health Organization
  UNICEF 
  
  

Birth

What could be a better place to start a new course in early childhood studies than birth? This week, I'm to compare my own birthing experience with the experience of someone from another country.

I had my first and only child at 36 years of age. I went for every prenatal exam, ultrasound, and testing (aside from the intrusive amneo), as well as childbirth classes. My birth was attended by my partner, nurses in the birthing suite, and my physician (a family practice doc who I had chosen specifically because she would be able to provide our care prior to birth as well as all our care after birth and beyond).

My goal was to go natural. I would have loved to do a water birth, or a home birth, but seeing as how I had some physical complications, I chose early on to deliver in the hospital at the birthing center. For the last week of my pregnancy, I was on modified bed rest to due increasing blood pressure. On my due date, my doc decided it was best to go ahead and schedule for induction before my blood pressure got in to dangerous places.

After the induction process was started I labored naturally for hours. I was encouraged to walk, take a bath, do whatever felt comfortable.  At some point I decided that I had had enough and asked for  pain medication but was told, after a quick peek, that I was too far dilated and that it was time to start pushing. I pushed sitting, laying down, on a ball, on my knees, on my side, but regardless of what I did, my son would not come. And with each push, his heart rate dropped and my BP rose. An on call doc was called to assist with forceps, but to no avail. The umbilical cord was wrapped around my son's throat and pressed between my pelvic bone and his head. Each push was killing him, and the stress, medication, and pain were raising my BP to dangerous places. A c-section was decided upon and I was rush, rather indelicately, to surgery for a c-section with my partner wide-eyed and fearful. In the operating room, with my partner at my head, I was told (after much labor inducing medication) NOT to push and to be still (just try, I dare you), so that they could put a needle in my spine. Moments later my son was delivered, quietly. He was blue, and had an APGAR of 3. He was taken to the NICU right away and put on oxygen. Due to health issues of another child in the NICU, no one was allowed to enter or leave the NICU, including my son. So for the first 6 hours after his birth, my son was alone, not on my chest as I had hoped/planned him to be.

When he was finally given to me, I didn't let go. Five days after he was born, we went home (on Mother's Day no less).

Part of me felt that the c-section was a failure on my part. Like I didn't try hard enough, or I did something wrong. The other part of me knows that this is wrong. I did, however, get to experience all styles of childbirth in one event: induced, natural, medication assisted, and c-section. I stayed home for 6 weeks full time with my son, worked the next 2 weeks from home (part time), worked another two weeks part time in the office and part time from home, and from then on often brought my son in to work with me about once a week. I consider myself very lucky to have an employer who would allow this, and we kind of set a precedent for other mothers/children after us who also brought their children in from time to time.

In comparing my experience to others in other countries, I am impressed by the similarities and differences.  While the Western medical model of hospital births seems to be on the rise in many countries, even c-sections seem to be on the rise. Lara Schalken from American Baby magazine (and reprinted on Parents magazine online) reports that in Brazil, the overall c-section rate is 40 percent, and even higher in private hospitals. Lisa Selin Davis, from Parenting magazine online, reports that for wealthy Chinese women, the c-section rate is as high as 90%, and for the rest of the country about 40%, however in Uganda a "c-section is seen by the entire community as a failure".  Davis reports that in Tibet, may of the "old ways" persist, and that women largely labor and deliver at home or in an animal pen as childbirth is considered dirty/unclean, and will cut the umbilical cord themselves with a dirty knife that is later cleaned. Unfortunately, the infant mortality rate is also quite high, 20-30%, which may be in impart due to childbirth practices, but also due to geographical/topographical challenges in the ability of pregnant women to get to hospitals for care. So in many ways, my birthing experience was wonderful. Now, if I could just get my hands on the 2-3 years of maternity leave that countries like Holland, Germany, and Romania....

Links:
http://www.parenting.com/article/birth-maternal-health
http://www.parents.com/pregnancy/giving-birth/vaginal/birth-customs-around-the-world/