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Impact of Violence on Children


The reach of violence, whether as the victim, perpetrator, or witness, whether in person or through the media, is far, deep, and long-standing across the globe. In the home, it is estimated that 80–95% of such aggression is witnessed by a child. Exposure to violence disrupts the healthy development of children in a myriad of ways. Pediatric clinicians must be competent to address these issues in impacted children and families under their care ( trauma-informed care ). Clinicians also have a wider responsibility to advocate on local, state, national, and international levels for safer environments in which all children can grow and thrive.

Witnessing violence is detrimental to children. Because their scars as bystanders are emotional and not physical, the pediatric clinician may not fully appreciate their distress and thereby miss an opportunity to provide needed interventions. For children not living in war zones, the source of first exposure to violence is often intimate partner violence (IPV). In the United States alone, >1 in 15 children witness IPV each year, and worldwide approximately 275 million children are exposed to IPV yearly. Exposure to IPV in infancy and toddlerhood impacts attachment relationships, and school-age children who witness IPV have difficulties in developing and maintaining friendships, as well as an increased likelihood of developing maladaptive peer relations.

Another source of witnessed violence is community violence , a serious problem in the United States that disproportionately affects children from low-income areas. Approximately 22% of children witness violence in their family or in their community each year; witnessed violence includes assaults and bullying, sexual victimization, maltreatment by a caregiver, and theft or vandalism. Almost 60% of children will experience or witness violence during childhood. Witnessing acts of violence may be a significant stressor in children's lives. Witnessed community violence is related to internalizing problems such as depression and posttraumatic stress disorder (PTSD) as well as externalizing problems, including delinquent behavior, aggression, and substance abuse.

The most ubiquitous source of witnessing violence for U.S. children is media violence , sometimes referred to as virtual violence . This form of violence is not experienced physically; rather it is experienced in realistic ways through technology and ever more intense and realistic games. There is an ever-widening array of screens that are part of children's everyday lives, including computers, tablets, and cell phones, in addition to long-standing platforms, such as televisions and movies. Recent tragic events, including mass shootings and acts of terrorism, have increased the specter of fear among children as these events are reenacted for them on the multiple screens they encounter. Although exposure to media/virtual violence cannot be equated to exposure to real-life violence, many studies confirm that media/virtual violence desensitizes children to the meaning and impact of violent behavior. Violent video game exposure is associated with: an increased composite aggression score; increased aggressive behavior; increased aggressive cognitions; increased aggressive affect, increased desensitization, and decreased empathy; and increased physiological arousal. Violent video game use is a risk factor for adverse outcomes; however, insufficient data exist to examine any potential link between violent video game use and delinquency or criminal behavior. Table 14.1 lists interventions to reduce exposure to media violence.

Table 14.1
From Browne KD, Hamilton-Giachritsis C: The influence of violent media on children and adolescents: a public-health approach, Lancet 365:702–710, 2005.
Public Health Recommendations to Reduce Effects of Media Violence on Children and Adolescents

  • Parents should:

    • Be made aware of the risks associated with children viewing violent imagery, as it promotes aggressive attitudes, antisocial behavior, fear, and desensitization.

    • Review the nature, extent, and context of violence in media available to their children before children view.

    • Assist children's understanding of violent imagery appropriate to their developmental level.

  • Professionals should:

    • Offer support and advice to parents who allow their children unsupervised access to extreme violent imagery, as this could be seen as a form of emotional abuse and neglect.

    • Educate all young people in critical film appraisal, in terms of realism, justification, and consequences.

    • Exercise greater control over access to inappropriate violent media entertainment by young people in secure institutions.

    • Use violent film material in anger management programs under guidance.

  • Media producers should:

    • Reduce violent content, and promote antiviolence themes and publicity campaigns.

    • Ensure that when violence is presented, it is in context and associated with remorse, criticism, and penalty.

    • Ensure that violent action is not justified, or its consequences understated.

  • Policymakers should:

    • Monitor the nature, extent, and context of violence in all forms of media, and implement appropriate guidelines, standards, and penalties.

    • Ensure that education in media awareness is a priority and a part of school curricula.

Impacts of Violence

All types of violence have a profound impact on health and development both psychologically and behaviorally; it may influence how children view the world and their place in it. Children can come to see the world as a dangerous and unpredictable place. This fear may thwart their exploration of the environment, which is essential to learning in childhood. Children may experience overwhelming terror, helplessness, and fear, even if they are not immediately in danger. Preschoolers are most vulnerable to threats that involve the safety (or perceived safety) of their caretakers. High exposure to violence in older children correlates with poorer performances in school, symptoms of anxiety and depression, and lower self-esteem. Violence, particularly IPV, can also teach children especially powerful early lessons about the role of violence in relationships. Violence may change the way that children view their future; they may believe that they could die at an early age and thus take more risks, such as drinking alcohol, abusing drugs, not wearing a seatbelt, and not taking prescribed medication.

Some children exposed to severe and/or chronic violence may suffer from PTSD, exhibiting constricted emotions, difficulty concentrating, autonomic disturbances, and reenactment of the trauma through play or action (see Chapter 38 ). Based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for PTSD in children ≤6 yr old, >50% of preschoolers may experience clinically significant symptoms of PTSD after exposure to IPV. Although young children may not fully meet these criteria, certain behavioral changes are associated with exposure to trauma, such as sleep disturbances, aggressive behavior, new fears, and increased anxiety about separations (clinginess). A challenge in treating and diagnosing pediatric PTSD is that a child's caregiver exposed to the same trauma may be suffering from it as well.

Diagnosis and Follow-Up

The simplest way to recognize whether violence has become a problem in a family is to screen both the parents and the children (after approximately 8 yr of age) on a regular basis. This practice is particularly important during pregnancy and the immediate postpartum period, when women may be at highest risk for being abused. It is important to assure families that they are not being singled out, but that all families are asked about their exposure to violence. A direct approach may be useful: “Violence is a major problem in our world today and one that impacts everyone in our society. So I ask all my patients and families about violence that they are experiencing in their lives. …” In other cases, beginning with general questions and then moving to the specific may be helpful: “Do you feel safe in your home and neighborhood? Has anyone ever hurt you or your child?” When violence has impacted the child, it is important to gather details about symptoms and behaviors.

The pediatric clinician can effectively counsel many parents and children who have been exposed to violence. Regardless of the type of violence to which the child has been exposed, the following components are part of the guidance: (1) careful review of the facts and details of the event, (2) gaining access to support services, (3) providing information about the symptoms and behaviors common in children exposed to violence, (4) assistance in restoring a sense of stability to the family in order to enhance the child's feelings of safety, and (5) helping parents talk to their children about the event. When the symptoms are chronic (>6 mo) or not improving, if the violent event involved the death or departure of a parent, if the caregivers are unable to empathize with the child, or if the ongoing safety of the child is a concern, it is important that the family be referred to mental health professionals for additional treatment.

Bullying, Cyberbullying, and School Violence

Megan A. Moreno
Elizabeth Englander

Keywords

  • aggression

  • bullying

  • cyberbullying

  • online harassment

  • peer victimization

  • perpetrator

  • school climate

  • target

Bullying and Cyberbullying

Bullying behavior affects people throughout the life span, but much of the focus has been on children and adolescents. In the past, bullying was sometimes considered a rite of passage, or was written off as “kids being kids.” It is now recognized that bullying can have profound short- and long-term negative consequences on all those involved, including perpetrators, targets, and bystanders. The consequences of bullying can affect a child's social experiences, academic progress, and health.

Bullying is defined as any unwanted aggressive behavior by another youth or group of youths that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. Generally, sibling aggression and dating violence are excluded, but research has associated these problems with peer bullying . Digital technology was initially viewed as a context in which bullying can occur. Further research studies have suggested that cyberbullying is not merely bullying that occurs through electronic communications, but rather a type of bullying with distinct elements, such as the potential for a single event to “go viral” and the use of technology as a tool to achieve power imbalance.

It is thought that bullying and cyberbullying are more alike than dissimilar, and that surveillance efforts, as well as prevention and intervention approaches, should address both types of bullying.

Bullying Roles and Nomenclature

Bullying represents a dynamic social interaction in which an individual may play different roles at different stages. A child can be a perpetrator of bullying, a target of bullying, a witness or bystander, or simply a child whose environment is affected by pervasive bullying. In any bullying experience, the roles that each child plays may be fluid; such that a target of bullying may then become a perpetrator, or vice versa. Thus, common nomenclature has evolved to refer to children as perpetrators of bullying or targets of bullying to represent a present state, rather than labeling a child as a bully or a victim, which suggests a static role and may impact that child's self-image.

Epidemiology

Bullying is a widespread problem during childhood and adolescence. Current estimates suggest that school-based bullying likely affects 18–31% of children and youth and that cyberbullying affects 7–15% of youth. Apparent rates of bullying are influenced by the questions that are asked; the word “bully” is stigmatized, and absent that label, youth are more willing to acknowledge having engaged in activities that can be categorized as bullying. Estimates of bullying prevalence are typically based on self-reported victimization (not perpetration), but here too, language can influence results. Targets of other types of social conflict may overestimate or underestimate their bullying victimization unless precise language is used during assessment.

Risk Factors

Certain groups are more vulnerable to bullying, including youth who are lesbian, gay, bisexual, transgender, and questioning (LGBTQ); immigrant and racial minority youth; obese youth; and youth with disabilities. However, it is important to recognize that while these individual risk factors exist, the context and situation can also present unique risk factors. Some studies have found that African Americans are bullied more often than Latinos, whereas other studies have found no group differences. Contextual factors, such as the school climate or prevalence of a particular ethnic group in a school setting, may be important factors in a given bullying situation. The 2015 Youth Risk Behavior Survey found that white students were much more likely than black teens to report being bullied at school or online. Thus, it is important to recognize that in any bullying situation, an individual is embedded within a situation that is within a larger social context. This person by situation by context approach is useful to consider in identifying why bullying takes place in some situations but not others.

Bullying may occur with other high-risk behaviors. Students who carry weapons, smoke, and drink alcohol >5-6 days/wk are at greatest risk for moderate bullying. Those who carry weapons, smoke, have >1 alcoholic drink/day, have above-average academic performance, moderate/high family affluence, and feel irritable or bad-tempered daily are at greatest risk for engaging in frequent bullying. Negative parenting behavior is related to a moderately increased risk of becoming a bully/victim (youth who are both perpetrators and targets) and small to moderate effects on being targeted for bullying at school.

Some risk factors may be specific to cyberbullying. Among preadolescent children, more access to technology (e.g., cell phone ownership) predicts cyberbullying behaviors and some types of digital victimization. Also, communications through digital technology can be misperceived as hostility, and those misperceptions can in turn increase electronic forms of bullying.

Consequences of Bullying

Involvement in any type of bullying is associated with poorer psychosocial adjustment; perpetrators, targets, and those both perpetrator and target report greater health problems and poorer emotional and social adjustment. Bullying consequences of both traditional and cyber forms of bullying are particularly significant in the areas of physical health, mental health, and academic achievement. Being the target of bullying is typically viewed as particularly stressful. The impact of this stress has been shown to affect the developing brain and to be associated with changes to the stress response system, which confers an increased risk for future health and academic difficulties. The long-term consequences of being bullied as a child include increased risk for depression, poor self-esteem, and abusive relationships. Negative outcomes for perpetrating bullying include higher risks of depression as well as substance abuse. Mental health consequences for both perpetrator and target include, across types of bullying, increased risks of depression, poor-self-esteem, increased suicidality, and anxiety. Academic difficulties include increased risk of poor school performance, school failure, and dropping out.

School Violence

Epidemiology

School violence is a significant problem in the United States. Almost 40% of U.S. schools report a least 1 violent incident to police, with >600,000 victims of violent crime per year. Among 9th to 12th graders, 8% were threatened or injured on school property in the last 12 mo, and 14% were involved in a physical fight over the last year. Still, school-associated violent deaths are rare. Seventeen homicides of children age 5-18 yr occurred at school during the 2009–2010 school year. Of all youth homicides, <2% occur at school. While urban schools experience more episodes of violence, the rare rampage gun violence that happens in rural and suburban schools demonstrates that no region is immune to lethal violence.

Risk Factors

Bullying and weapon carrying may be important precursors to more serious school violence. Among perpetrators of violent deaths at school, 20% had been bullying victims, and 6% carried a weapon to school in the last 30 days. Nonlethal violence, mental health problems, racial tensions, student attacks on teachers, and the effects of rapid economic change in communities can all lead to school violence. Individual risk factors for violence include prior history of violence, drug, alcohol, or tobacco use, association with delinquent peers, poor family functioning, poor grades in school, and poverty in the community.

Family risk factors include early childbearing, low parental attachment and involvement, authoritarian or permissive parenting styles (see Chapter 19 ), and poverty. There is more school violence in areas with higher crime rates and more street gangs, which take away students’ ability to learn in a safe environment and leave many children with traumatic stress and grief reactions.

Treatment and Prevention of Bullying and School Violence

Pediatric providers are in a unique position to screen, treat, and advocate for reducing the impact of bullying and school violence by assisting those affected and seeking to prevent further occurrences.

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