In his speech to a crowded room in Newtown, Connecticut, President Obama stated, "This is our first task, caring for our children. It's our first job. If we don't get that right, we don't get anything right." President Obama called for a comprehensive response to the tragic shootings, asking Americans to come together to ensure the safety and well-being of our children.
Following the Newtown shooting, the country first mourned and examined how to prevent such tragedies in the future, with prevention strategies emphasizing gun control. Weeks later the focus now includes establishing how to most effectively help the children in the school who witnessed the tragedy, especially how to treat them to prevent Post Traumatic Stress Disorder (PTSD). The events at Sandy Hook (as well as the highly publicized shooting of an honor student in Chicago and the child abduction in Georgia) should raise public awareness of the prevalence and widespread impact of childhood trauma, and should lead to public outcry to change our current policies surrounding children and mental health.
As pediatricians, we and our colleagues see thousands of children similarly traumatized, most of whom come from underserved communities and most of whom who have been chronically exposed to violence. In some cases these children have witnessed shootings in their neighborhood or even their home. Our experiences mirror national statistics -- the National Survey of Children's Exposure to Violence reported that more than 60 percent of children in the U.S. were exposed to violence within the past year. However, the direct victims of violence are identified in news stories, but the children who witness such violence generally remain silent victims.
In addition, many people do not realize that, amongst all forms of violence exposure, childhood exposure to domestic violence (DV) is one of the most prevalent and potent stressors -- a fact that is particularly relevant now as Congress reauthorizes the Violence Against Women Act. Almost 15 million children in the U.S. are exposed to DV each year; this is twice the number of children in the country with asthma, one of the most common chronic conditions of childhood. A school age patient recently described to us the terror she felt while watching her father hold her mother down with a knife to her throat; the child knew that she should run down to her grandparent's house but was too afraid to move. Her nightmares and fear continue to this day. While generally not as deadly as witnessing a shooting, children exposed to DV experience the horror of seeing the important adults in their lives who are supposed to protect them engage in violent acts; one caregiver is a victim while the other is inflicting the violence.
Traumatic stressors like DV exposure change children's developing brain and physiology, which has a negative impact across the lifespan. Compared to non-exposed peers, children exposed to DV are more likely to be diagnosed with mental health problems, to have developmental and neuro-cognitive delay, to be truant, and to be suspended from school. Exposed adolescents are more likely to engage in risky behaviors including substance use and abuse. We have seen firsthand how this trauma, and the perception of the world as unsafe, interferes with children's ability to develop mutually satisfying peer relationships, pay attention, learn and achieve in school.
What should we do to improve the health and well-being of all traumatized children who have been exposed to violence? For the first time this question is in the media because of Sandy Hook. There are no easy answers as is the case with many complex issues. First, though, the greater public must recognize the prevalence and impact of violence exposure in general, and DV exposure specifically. Witnessing shootings is only the tip of the iceberg. Millions of children remain "silent" victims even as their health and functioning (including their school work) suffers.
Second, all violence in our homes and communities needs to be reduced so children can grow up safely, learn in school, not need drugs to self-medicate their trauma as they get older and not perpetuate the violence they witnessed. Passage of the Violence Against Women Act will help in this effort. Effective violence reduction also will require comprehensive strategies to build neighborhoods and communities with broad social support. Free, quality early childhood education must be available to every family. And, all families must have access to basic needs such as housing and food.
Third, appropriate evidence-based mental health services need to be available to all traumatized children. As Steven Sharfstein, MD, former President of the American Academy of Psychiatry, stated, "Violence is to mental illness as cigarettes are to cancer." More child mental health providers must be trained to provide easier access for families. Access to proper mental health care will be facilitated if the traditional medical home successfully integrates with behavioral health partners. All insurance plans must provide adequate coverage for mental and behavioral health services. Treatment is most effective in children before the full blown diagnosis -- why wait?
We are at an historic moment in time, in which we have a unique opportunity to directly improve the lives of children who will be or have been traumatized by violence exposure. Only by confronting these problems directly and purposefully will it be possible to "do right" by our children, improve child and adult health, and fully develop our nation's vital resource: productive and emotionally stable citizens.
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