key: cord-0952267-4j1vhuqi
authors: Ferrara, Pietro; Franceschini, Giulia; Corsello, Giovanni; Mestrovic, Julije; Giardino, Ida; Vural, Mehmet; Pop, Tudor Lucian; Namazova-Baranova, Leyla; Somekh, Eli; Indrio, Flavia; Pettoello-Mantovani, Massimo
title: Children Witnessing Domestic and Family Violence: A Widespread Occurrence during the Coronavirus Disease 2019 (COVID-19) Pandemic
date: 2021-05-05
journal: J Pediatr
DOI: 10.1016/j.jpeds.2021.04.071
sha: e77a96839e75b03100728a7d1363ac05921c3834
doc_id: 952267
cord_uid: 4j1vhuqi

nan

A cross the world, children and adolescents are exposed daily to toxic levels of violent behaviors, including domestic and family violence. Violence increasingly has permeated and profoundly affected the lives of children, who are the most vulnerable members of society. 1 Pediatric societies in Europe and North America have raised great concern over the effect that abusive experiences will have on present and future generations. [1] [2] [3] [4] The global spread of coronavirus disease 2019 (COVID-19) during the past year has dramatically worsened the situation, contributing to a further increase in violence and aggression within households. Reports of domestic abuse and family violence have increased around the world with social isolation and quarantine measures, and national health and social care systems worldwide have faced serious challenges posed by the rising rates of domestic and family abuse. 5 Children are typically the primary victims of family violence 2 ; however, children who live in homes in which partner abuse occurs are described as secondary victims. 6 Minors increasingly are witnessing various forms of unprecedented emotional and physical domestic abuse, often resulting in femicide, and exposed to the emotional, behavioral, physical, social, and cognitive effects. 2 There are documented gendered patterns in violence perpetration and victimization. 7 This commentary, authored by the working group on social pediatrics of the European Paediatric Association/Union of National European Paediatric Societies and Associations, discusses children witnessing family violence and domestic abuse, including femicide as the most extreme and irreversible expression of domestic violence involving parents or household members. Our aim is to raise awareness regarding this phenomenon, which is rapidly expanding during the COVID-19 pandemic, and on the serious long-term effects on the well-being of children.

The broad term of family violence refers to abusive behaviors and violence occurring between family members, which can include violence between current or former intimate partners, as well as acts of violence between parents and children, siblings, and kinship relationships in general. Domestic violence describes violent behavior between current or former intimate partners, where one partner tries to impose power and control over the other through fear and threats. This includes physical, sexual, psychological, social, verbal, spiritual, and economic abuse 8 (Table; available at www. jpeds.com). Consequent detectable physical injuries may involve the head and neck, musculoskeletal system, chest, abdomen, and skin, which are important indicators of an abusive condition. 8 Although the devastating consequences of domestic violence on women are well described, much less is documented about their impact on children who witness a parent or caregiver who is being abused and a victim of violence. Concern has been expressed by the European pediatric societies over the effects these experiences will have on present and future generations. 9 Data collected during the first year of the COVID-19 pandemic show a widespread spike in domestic violence as a result of social distancing and quarantine, including a rise in the number of women experiencing intimate partner violence and escalation into femicide. 10 A report from the Canadian Minister for Women and Gender Equality emphasized that the COVID-19 crisis had empowered perpetrators of domestic violence, which resulted in a 20%-30% increase in rates of gender-based violence in some regions of the country, compared with the same period of the previous year. 11 Similarly, in France and Argentina, the cases of intimate partner violence also increased by 30% and 25%, respectively, after the onset of the pandemic. In China, family violence tripled in Hubei province, and in Italy the number of homicides of women in cohabiting relationships increased by 10% during the first 10 months of 2020 compared with 2019. 12, 13 In the US, during the pandemic, domestic violence increased 12% on average and 20% during working hours 14, 15 ; 18 law enforcement agencies reported a sharp increase of 6%-20% in major US cities. 16 Domestic violence is likely to involve children, who often become secondary victims. Growing up in a violent home may be a terrifying and traumatic experience that can impact every aspect of a child's life, growth, and development and cause long-term health effects. 17 Witnessed violence has a significant impact on youth mental health and on the likelihood of engaging in aggressive and antisocial behavior later in life. 18 These children are at a greater risk to externalize destructive behaviors such as fighting, bullying, lying, or cheating and to internalize negative behaviors such as anxiety and depression. 19 The important reality of a child's close tie to their mother or female role model or custodian is a consolidated notion, 20 and an increasing number of children witnessing family and domestic violence to the extreme outcome of femicide suffer severe symptoms of post-traumatic stress disorder. 21 Typically, child witnesses are predisposed to an inappropriate use of violence as a means of resolving conflicts and show a greater willingness to use violence themselves. 21 They are also at greater risk than their peers of developing an array of age-dependent negative effects, including several clinical disorders such as allergies, asthma, gastrointestinal problems, bed-wetting or nightmares, and headaches. 22 However, the definition should not be restricted to children who witness abuse visually but expanded to include children who also hear violence, such as yelling or other forms of nonphysical violence. 23 

Physicians and pediatricians should be trained to recognize indicators of domestic and family violence and to address this issue on multiple levels. 24 Educational programs about domestic violence have focused particularly on the primary victims, and important progress has been made in this area. 25 However, medical schools also should include in their educational programs on child abuse and neglect the potential negative effects on children who witness domestic violence, and existing programs must be broadened to include effects on silent witnesses and to encourage physicians to screen for and help prevent violence.

Violence-prevention measures can begin in the clinic. Physicians may raise the issue of family and domestic violence with couples planning to have a child or during prenatal ex-aminations, and pediatricians should be able to assess the parents' methods of resolving conflict and their responses to anger. It is important that pediatricians are trained to discuss nonviolent forms of discipline, such as time-outs and removal of privileges, and couples should be educated about the negative effects that arguments and fights have on children. Parents and household members also must be informed of the negative consequences of watching violence on television or any other media. Of particular importance is exploring the presence of guns and other weapons in the home, as it increases the risk of negative events, including a disempowering and demoralizing effect on women, psychological and/or sexual coercion, and women being killed by intimate partners. Children should be told that if they see a gun, they must not touch it and should leave the area immediately and tell an adult. Screening for family violence should be routinely and preferably privately performed with mothers by asking open, nonjudgmental questions.

Finally, helping children to develop resilience is of importance, as children may mitigate the effects of witnessing violence due to their ability to build resilience. 26 Pediatricians, schoolteachers, and social workers can have a key role in identifying potential protective factors that mediate the negative effects of witnessing domestic violence and assist children in developing their resilience skills. 26 

The impact of COVID-19 upon domestic violence is well documented. [27] [28] [29] However, insufficient attention has been given to children who witnessed family and domestic violence during the current pandemic, particularly on those children whose mothers were murdered by a family member. Studies will provide a better understanding of this phenomenon, as well a way as to develop strategies useful to intercept risk factors and to plan for prevention programs, 30 including the promotion of healthy, respectful, nonviolent relationships. 31 Pediatricians should be professionally trained to recognize family and domestic violence and the risks for children to be victims of witnessed violence. 24 Physical abuse: a person using physical force on the partner, which causes, or could cause, harm. It includes direct assaults on the body, use of weapons, driving dangerously, destruction of property, abuse of pets in front of family members, assault of children, and forced sleep deprivation. Indicators: slapping, shaking, beating with one's fist or with an object, strangulation, burning, kicking, and threats with a knife. Various cutaneous signs may include bruises, lacerations, abrasions, burns, oral trauma, bite marks, and traumatic alopecia. Psychological/emotional abuse: a person's attempts to frighten, control, or isolate the partner. Frequently due to excessive jealousy, the intent is to control the partner's activities. It is in the abuser's words and actions, as well as their persistence in these behaviors. It includes name calling, derogatory pet naming, character assassination, yelling, patronizing, public embarrassment, dismissiveness, jokes that might have a grain of truth or be a complete fabrication with the intent to make the partner look foolish, sarcasm, insults and derision about the partner's appearance, belittling the partner's accomplishments, and putting-down partner's interests. Indicators: isolation from others, weeks of silence, difficulty identifying and processing emotions (alexithymia), being unconfident or lacking self-assurance, struggling to control emotions, difficulty making or maintaining relationships, acting inappropriately. Sexual abuse: any form of sexual activity without consent, coerced sex through threats or intimidation or through physical force, forcing unwanted sexual acts, forcing sex in front of others, and forcing sex with others. Causing pain during sex, assaulting the genitals, coercive sex without protection against pregnancy or sexually transmitted disease, criticizing, or using sexually degrading insults. Indicators: unusual anger, sudden anxiety, negative self-talk, declining physical health, drug and alcohol abuse Social abuse: a behavior that seeks to cut the partner off from family, friends, or community and in general to harm partner's relationships with others. It also could include the attempt at systematic isolation from family and friends through techniques, such as ongoing rudeness to family and friends, moving to locations where the victim knows nobody, and forbidding or physically preventing the victim from going out and meeting people. Indicators: partner encourages friends who are abusive, gossips or spread rumors about the victim, monitors social activities, treats the victim disrespectfully in front of others, reports secrets or embarrassing stories, refuses to socialize with the victim's family or friends, prohibits the partner from working outside the home, demands the partner to account for all social contacts, selects visitors, alienates them from family and friends, and forces the victim to move away from friends and a supportive environment Verbal abuse: the act of forcefully criticizing, insulting, or denouncing another person. Usually perpetrated through continual put downs and humiliation, either privately or publicly, with attacks following clear themes that focus on intelligence, sexuality, body image, and capacity as a family member, parent, or spouse. Indicators: verbal assault, constant disagreement, sarcastic jokes, controlling conversations, blaming, dismissal of partner's feelings, threatening and intimidation, victim-blaming for loss of temper, gaslighting, abusive anger and rage, use of words of shame, name calling, yelling, gender privilege, racism (religious, cultural, skinrelated). Spiritual abuse: any attempt to exert power and control over someone using religion, faith, or beliefs. It can be exerted by denying access to ceremonies, land or family, preventing religious observance, forcing victims to do things against their beliefs, denigration of cultural background, or using religious teachings or cultural tradition as a reason for violence. Indicators: shame, make fun of, or ridicule the religious beliefs or practices of the victim. Use beliefs with manipulating or bullying intents, demand that children are raised with/without a certain religion. Using scriptures or religious beliefs to control clothing, behavior, sexuality, decision making, choice to have children or not, finances. Economic abuse: Economic abuse occurs when one partner gains full or partial control of the other's finances or employment opportunities. Victims have incomplete or no control on money and provided only an inadequate allowance. Subjects abused may be unable to manage their checking accounts or income without the interference of their abusive spouse, who forces them to be dependent on others. It can impact victim's ability to care for children, meet their financial obligations, and obtain education or employment. Indicators: victims prohibited from working, forced to turn over paychecks, imposed to take an allowance. Partners refuse to share financial information and/or takes credit cards out or opens accounts in the victim's name. Victims forced to add the partner's name on their accounts or property.

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