
AAccording to NHS England, nearly 380,000 children and young people were treated through NHS-commissioned community services in 2018/19 – approximately 36.1% of children and young people were diagnosed with a mental health conditions (Murdoch and Kendall, 2020).
Further, adolescent suicidal ideations in Western countries range from 15% to 25%, with adolescent females at the higher end of the spectrum and males at the lower end (Grunbaum et al., 2004). Additionally, it has been reported that approximately 13-50% of adolescents exposed to interparental violence, are being recognised more frequently by professionals as qualifying for diagnosis of PTSD, (Rea and Rossman, 2005), (Rossman, Hughes & Rosenberg, 2000).
These figures demonstrate an alarming increase in recorded ‘Mental Health’ issues for children and young people. In order to sensitively examine the impact of domestic violence and sexual abuse on adolescents it is important to acknowledge the link between a child exposed to traumatic events and the adolescent that he/she will grow into (Margolin & Vickerman 2007). Sexual abuse and domestic violence can expose a young person to a huge range of physical, social, emotional and psychological impacts with far reaching consequences. Alarmingly, it has been noted that exposure to violence for youth in their home setting is one of the most prevalent of adverse events that can occur during childhood, (Mangolin & Gordis 2000).
Due, to the fact that domestic violence is not a single event but manifests as unpredictable episodes which, are likely to become more frequent as well as more severe across time. The risk posed to adolescents is that in this stage of their development they are already victims. According to research, adolescents who grew up in environments where they witnessed violence are as affected, in the same way as those who have been the target of physical and sexual abuse. It has been suggested according to research that there is causal link between domestic violence and sexual abuse with the overlap between the two categories ranging between 30-50%. Further, it has been suggested that within both forms of abuse the prevalence crosses race, ethnicity, religion, culture and economic status is similar (Olds, 1996), (Goodman & Rosenberg 1987).
However, it is important to note that contra to recorded data that research also acknowledges that many adolescents who experience domestic violence within their familial contexts remain as ‘invisible victims’. This is due, to their early life experiences remaining hidden inside their homes and not coming to light until they are adults (Fantuzzo JW, Mohr WK, Noone MJ. 2000). The further complication to the concept of ‘invisible victims’, is impacted by cultural norms. The implication being that cultural and community influences have profound effect on how an adolescent, family and community understand, normalise
and perceive domestic violence and abuse to be, (American Academy of Child and Adolescent Psychiatry), AACAP (1998).
While it is acknowledged that trauma occurs across cultural lines, cultural assumptions and influences affect the way symptoms transpire are recognised and manifest (Cohen, Deblinger, Mannarino, & de Arellano 2001). This phenomenon, places a responsibility on professionals including teachers, carers and community leaders to sustain and develop trauma related knowledge so that they can effectively recognise and respond to the unique needs of diverse communities. (How Race, Ethnicity, Culture, and Identity Impact Treatment of Trauma, 2020). Further to this, obstacles can include the complications presented by an individual family’s openness to strategies of intervention due, to perceptions influenced by culture and community (AACAP, 1998), (Graham-Bermannn & Hughes, 2003).
Another important consideration which, equally deserves focus within the context of adolescent victims of domestic violence and sexual abuse, are those who are considered to be intellectually disabled. This group can include amongst others, adolescents with ‘Down Syndrome’ or, ‘Autism’. According to researchers in this area, a female with down syndrome is 80% more likely to be sexually abused by a primary care giver, including family, friends and relatives (History of Down Syndrome, 2020). Further to this, due to the implications and effects of adolescents with intellectual disabilities it has been found that when the adolescent has tried to communicate any abuse that they are far more likely to be disbelieved (Zaviršek, 2002). Another finding is that adolescents with intellectual disabilities who have been recorded as being sexually abused remain marginalised, traumatised and silenced as it has been indicated that services are inadequate, inappropriate, inaccessible and to a high proportion, unavailable (Mansell, Sobsey and Calder, 1992).
According to research, adolescents that are exposed to domestic violence and sexual abuse are at more risk of experiencing mental health and behavioral problems which, can manifest and increase the likelihood of depression, anxiety, anger, conduct disorders and suicidal ideation (Margolin & Gordis, 2000). Part of the trauma that manifests in adolescents is related to what is known as ‘disorganised attachment’, where a parent or, significant care giver contradictorily and simultaneously presents as a source of safety and then danger, (Hess & Main, 2006). The compromising of emotional availability is a unique indication of DV being a traumatic stressor. Particularly when the threat of violence or, actual violence is directed within the familiar context towards the other parent, a child or sibling (Margolin, 1998), (van del Kolk, 2005). Furthermore, issues around the perspective of ‘disorganised attachment’, could arguably be impacted by the lack of security and safety that a victimised parent is emotively, psychologically and physically, stopped from giving due, to the unfortunate consequences that are result of cycles of abuse and violence. (Dutton, 2000).
Markedly, the early part of adolescence appears to be more significantly related to the development of more depressive disorders including anxiety and panic attacks (Angold, Costello & Worthman, 1998), combined with the development of behavioural issues manifesting into symptoms associated to conduct disorders (Odgers, Moffitt, et al. 2008). Additionally, it is mindful to mention that the perception a child has as it develops into an adolescent whose perception of self-worth and self-esteem impacts inadvertently on their future outcomes within education. This can directly have lifelong implications in terms of unemployment, successful and meaningful relationships as well as the implications of poverty.
Further, it has been indicated that exposure in early adolescence to DV and SA can trigger the emergence of behaviours that are related to self-medicating with drugs and alcohol, along with risky sexual behaviours which, can then lead to a wide range of physical health problems as well as exacerbating mental health and socio-economic issues (Odgers, C. & Russell, M. 2017). Hence, it has been acknowledged that co-occurring forms of exposure to DV and SA can increase and account for more negative outcomes for adolescents (Toth & Cichetti, 2006).
Findings also suggest that pervasive exposure to DV and SA can increase the likelihood of violent adult relationships as well as increasing the risk factors associated to repeating cycles of sexual abuse (Gruber & Jones, 1983; Ray, Jackson, & Townsley, 1991). In research conducted by Odgers & Russell (2017), a correlation was made between daily violence exposure within the family context being causally linked to increased mental health symptoms and escalating behaviour. The implication being that adolescents who were exposed more frequently to violence, were more inclined to being involved and more vulnerable to community-based violence. (Margolin & Gordis, 2000). The consequence of which, indicated that this group were less reactive to violent events and due, to persistent traumatic stressors which, manifest psychologically ‘emotional desensitisation’ becomes the suggested outcome. The majority of research conducted in this area has been related to understanding, decreases in empathy for children and adolescents exposed to exposure of video games (Funk, 2005).
More recently, it has been recognised that due to the escalation in episode frequency across DV and SA that the exposure to violence that adolescents have been exposed to constitutes the conditions that can potentially lead to recognition and diagnosis of PTSD. (AASAP 1998).
Systematic exposure to trauma can over long periods create pathological disturbances causing complex developmental delays as well as psychological and physiological reactions. The complexity of interrelated disturbances can result in the manifestation of PTSD (van der Kolk, 2005). The symptoms of which, can manifest as nightmares, flashbacks, insomnia, eating disorders, dissociations, isolation, lethargy, intrusive thoughts, self-harm and suicidal tendencies.
The recognition of interpersonal violence exposure in the form of DV and SA as being a significant factor and precursor to PTSD in youth has led to the development and discussion of a proposed diagnostic category, ‘developmental trauma disorder’ (DTD). The distinction from PTSD is that it recognises the overlaps of comorbidities and therefore, extends the category drawing attention to the wide-ranging symptoms that are presented by adolescents who have been exposed to trauma of an interpersonal nature. The goal being that the diagnostic category would enable professionals to identify more easily children who have and are experiencing complex trauma, in order to create smoother pathways to trauma related intervention services (DeAngelis, 2007).
However, while some professionals have hailed the category as being crucial in exposing multiple and prolonged interpersonal trauma, a task force of trauma experts and psychiatrists between 2002-2003 conducted a survey of 1.700 children receiving trauma focused treatments, having initially suffered the effects of childhood abuse. The evidence they gathered suggested that fewer than 25% met the diagnostic category of PTSD. Whereas the new category opened up the ability to explore contradictory pattens combined with pervasive, complex and extreme emotional and physiological dysregulation. The categories ability to acknowledge the contradictions within moods and feelings revealed that approximately 80% of the surveyed children where suffering from the results of prolonged, severe, traumatic episodes. The importance of this is that the category would have enabled diagnostic tools that would have created visibility of the multi-faceted experiences of chronically abused children, with the ultimate goal being to capture trauma before a child had developed into adolescence where by, the intention would be that damage could be minimised. To date the addition of the category remains under discussion (van Der Kolk, Ford and Spinazzola, 2019).
Victims of domestic violence and sexual abuse can face a long journey as they work towards recovery. Further, the outcomes and manifestations of maladaptive behaviour that adolescents who have experienced domestic violence and sexual abuse may well differ from victim to victim (Pynoos et al. 1999).
Adolescents who have been exposed to domestic violence, sexual abuse or, who have experienced comorbidities in relation to pervasive trauma have been increasingly recognised as experiencing a symptomology that leans towards PTDS. Increasingly professionals have started to further, recognise that the reactions presented as a response to trauma are complicated, causing overlaps and extensions outside the diagnostic category of PTSD. This has led clinicians and other medical experts to explore categories that may be better able to recognise the variants within trauma that adolescents experience and which, are significant to their age range. Consequently, the category of DTD could be highly supportive in addressing the holes in the area. The hope being that, in having tools that can readily assess the category of child, not only would more children be supported but, the potential to work towards recovery would be increased greatly. As opposed to working with adolescents who have been exposed to a frequency of traumatic events that has already established maladaptive behaviours as a response to their traumatic experiences.
Further, to this, the age of the adolescent and the frequency of the events has more often than not culminated in complex mental health issues. The result of which, can increase the propensity towards substance misuse, conduct disorders and issues related to physical health. A factor that further complicates the category of adolescence is the embeddedness that is created by mere fact of their age, in relation to their family, culture, religion and community. This in and of itself potentially means that while adolescents are still evolving, abnormal circumstances become complicated by reactivity, normalisation and desensitisation which, are far more difficult to work with and see far less successful outcomes. In consideration to this, it seems pertinent to suggest that misunderstanding in relation to the recognition of trauma related symptoms that are culturally specific and cultural attitudes towards perceptions and understanding of violence require more research that can support professionals in order for them to be able to support multi-cultural communities.
Knowing that fear, confusion, shame, uncertainty, low self-esteem, feelings of low self-worth, anger, anxiety and the many more symptoms that can emerge as a direct consequence of DV and SA, can cause lasting damage to an individual raises the question of where else we may be able to improve and respond to the impact of trauma. With the development of the DTD diagnostic tool and potentially its integration into DSM 5, it could be hoped that trauma informed services, agencies, educators, service providers could work more effectively to screen trauma exposure.
Finally, with the emphasis of working with parents and care givers, collaborating across child services and incorporating culturally responsive assessment tools the extent and impact of domestic violence and sexual abuse on adolescents could be dramatically reduced which, would create better outcomes for society as a whole.
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Fortunately, as people are more aware of mental health conditions, this misconception is not very common anymore. Studies have shown that even people with severe mental health conditions are mostly nonviolent.