15 MILLION CHILDREN...SILENT VICTIMS OF EXPOSURE TO DOMESTIC VIOLENCE

In the October 31, 2013 [Vol.369, No. 18] New England Journal of Medicine, Drs. Bair-Merritt, Zuckerman, Augustynand Cronholm report on the fact that there are evidence-based recommendations from the Institue of Medicine and the U.S. Preventive Services Task Force regarding detecting the presence of domestic violence [termed Intimate Partner Violence [IPV]] and reducing the impact of this on the intimate partner without considering the impact on their children.  These Pediatricians and Family Physicians consider these children to be silent victims as their plight is not addressed as a public health problem.  The impact on children of being exposed to domestic violence has been noted in a number of studies with more than 15 million children living in homes where domestic violence occurs.  Also, 7 million of these children are exposed to severe violence. The consequences of this exposure includes increased risk of developing a number of physical problems with some of these problems linked to an altered neuroendocrine stress response.  Being in highly stressful environments leads to repeated fight or flight type reactions that then activates the autonomic nervous system and the hypothalamic-pituitary-adrenal [HPA] axis resulting in changes in multiple systems that then can lead to physical problems.  As an example, repeated exposure to domestic violence can lead to chronic activation of the HPA with repeated cortisol release that can lead to an excess of type 2 helper T cells compared to type 1 helper T cells that then causes airway inflammation and airway hyperreactivity, increasing the incidence and the severity of childhood asthma.  

There are also consequences of witnessing domestic violence that affects social and emotional health. These health problems are also related to the impact of chronic stress that can actually change the brains of children such that the stress response area of the brain is overrepresented and the interpretive functioning part of the brain is underrepresented.  This change in the brain makes it difficult to help children stop reacting with fear to so many situations. There are trauma based cognitive-behavioral therapies [TB-CBT] that can be very helpful but is often not available for these children who are still mostly not even identified as being exposed to this violence.

Hopefully, more attention will be given to stopping domestic violence and identifying the victims of this, including the children, and being sure that protection from the ongoing violence is available and treatment of the consequences of chronic stress is also available.