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Children’s Mental Health and Intervention in View of Domestic Violence, Parental Alcoholism and Parental Separation

Gary Direnfeld, MSW, RSW

A parent sees the physician, complaining of a child’s behavior and possibly even somatic concerns. The child may present with any number of issues such as, school anxiety, inattention, depression, anxiety, social withdrawal, aggressive behavior, non-compliance, substance abuse, headaches, and/or stomachaches. Attention is typically drawn directly to the child and interventions tend to be behavioral in nature. The parent is advised on appropriate discipline strategies. As for the somatic complaints, while there may be medical investigations, they tend to be ambiguous at best in terms of determining a physiological basis for the somatic complaints. Despite behavioral and medical intervention, problematic behavior and somatic complaints continue unabated.

Underneath the child’s behavior problems and somatic complaints, may be lurking a number of contributing problems. The child may be subject to witnessing domestic violence, or the child may be coping with the effects of parental alcoholism, or if the parents are in the throws of a separation, the child may be caught in the legal web of their parents’ high-conflict entanglements. Of course, just like you can have a broken leg and the flu at the same time, the child may be subject to several or all of these underlying problems, concurrently.

Persons with specific training and expertise, best provide intervention in view of these variables. Inappropriate intervention is akin to arranging the deck chairs on the Titanic. While it may look good, the ship still sinks. Hence it is vital for physicians to understand the challenges underlying these issues to appreciate what appropriate intervention may be and may not be.

Domestic Violence

Domestic violence is not gender specific. Either gender may offend. However, the rationale for violent behavior between adult intimate partners is known to differ by gender. Statistically, men are more apt to engage in violent behavior as control strategies than their female counterparts. Women are more apt to engage in violent behavior as a defensive strategy to cope with their partner’s behavior. Further, lethality studies demonstrate that women are at substantially greater risk of harm, the result of male partner violence than are men of women. Violence between intimate partners is not at all restricted to heterosexual partners, and is seen similarly in same sex partners.

Brian Schwartz, MD, CCFP (EM), FCFP, Director, Division of Prehospital Care and Staff, Emergency, Sunnybrook and Women's Health Sciences Centre; Assistant professor, Family Medicine, University of Toronto, Toronto, Ontario looks at domestic violence in the context of abuse against women. He provides a definition of violence against women as well as incidence statistics in terms of female versus male victimization rates. Accordingly:

Abuse against women may be defined as "physical or psychological abuse directed by a man against his female partner, in an attempt to control her behavior or intimidate her." While abuse may take many forms including sexual, emotional, psychological and financial this [his] article will focus on physical abuse, or violence against women (VAW). It should also be noted that males constitute 15% of victims (62 male victims vs 344 female per 100,000 population in 2001) and that domestic violence occurs in same-sex relationships with approximately the same frequency as in heterosexual relationships.1

Estimates of the incidence of children witnessing domestic violence vary widely. However the most recent and scientifically rigorous estimates suggests 1 in 100 Canadian children are exposed to domestic violence.2 Further, the impact of witnessing domestic violence on children is known to have serious consequences for their psychological, social, academic, behavioral and emotional development:

Children who witness domestic violence are at risk for emotional and physical harm. Canadian research suggests that children who are exposed to adults or teenagers physically fighting in the home are less likely to have positive or effective interactions with their parents, and have lower levels of social competence than other children. They are also more likely to be living in households with high parental depression, and to experience depression, anxiety, health problems and stress-related disorders themselves.3

Witnessing family violence is also linked to negative behavior in children, including physical aggression, indirect aggression, emotional disorders, social withdrawal, hyperactivity, bullying and delinquent acts against property.4

In addition to witnessing domestic violence, statistically, in a national survey of more than 6,000 American families, 50 percent of the men who frequently assaulted their wives also frequently abused their children.5 Thus wife assault and child abuse are often co-occurring events.

Assessment for domestic violence requires sensitivity to issues of trust and safety, often achieved by specific training or experience in screening for these matters. Intervention typically begins with a view to determining safety issues and making sure family members are and will be safe from harm or retaliation the result of disclosure. Further, while all persons in the Province of Ontario are required to report even suspected child abuse, the onus on health care professionals is perceived to be even greater. Noteworthy, one cannot discharge the obligation to report to a third party. Section 72 (3) of the Child and Family Services Act states:

A person who has a duty to report a matter under subsection (1) or (2) shall make the report directly to the society and shall not rely on any other person to report on his or her behalf.6

Thus physicians must report suspected child abuse even if it is known that a third party such as a counselor may also report.

After safety issues have been addressed, then intervention can proceed to address the sequelae of issues emanating from the domestic violence.

Parental Alcoholism

The definition of alcoholism has been the subject of much public scrutiny. Definitions vary from physiological to psychosocial. In view of the discrepancies in definition, a 23-member multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine conducted a 2-year study of the definition of alcoholism in the light of current concepts printed in the Journal of the America Medical Association:

The committee agreed to define alcoholism as a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.7
In terms of impact on self and others, reaching criteria alcoholism increases the risk of academic, vocational, social, familial or marital

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