Abstract

Across 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.1French National Academy of ScienceImpact of the covid-19 pandemic on domestic violence.https://www.academie-medecine.fr/impact-of-the-covid-19-pandemic-on-domestic-violence/?lang=enGoogle Scholar Pediatric societies in Europe and North America have raised great concern over the effect that abusive experiences will have on present and future generations.1French National Academy of ScienceImpact of the covid-19 pandemic on domestic violence.https://www.academie-medecine.fr/impact-of-the-covid-19-pandemic-on-domestic-violence/?lang=enGoogle Scholar, 2Keeshin B. Forkey H.C. Fouras G. MacMillan H.L. American Academy of Pediatrics Council on Child Abuse and Neglect Council on Foster Care, Adoption, and Kinship Care American Academy of Child and Adolescent Psychiatry Committee on Child Maltreatment and Violence Committee on Adoption and Foster Care Children exposed to maltreatment: assessment and the role of psychotropic medication.Pediatrics. 2020; 145: e20193751Crossref PubMed Scopus (13) Google Scholar, 3Ferrara P. Corsello G. Basile M.C. Nigri L. Campanozzi A. Ehrich J. et al.The economic burden of child maltreatment in high income countries.J Pediatr. 2015; 167: 1457-1459Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 4Ferrara P. Guadagno C. Sbordone A. Amato M. Spina G. Perrone G. et al.Child abuse and neglect and its psycho-physical and social consequences: a review of the literature.Curr Pediatr Rev. 2016; 12: 301-310Crossref PubMed Scopus (30) Google Scholar 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.5UNICEFCOVID-19: Children at heightened risk of abuse, neglect, exploitation and violence amidst intensifying containment measures.http://www.unicef.org/press-releases/covid-19-children-heightened-risk-abuse-neglect-exploitation-and-violence-amidstDate: 2020Google Scholar Children are typically the primary victims of family violence2Keeshin B. Forkey H.C. Fouras G. MacMillan H.L. American Academy of Pediatrics Council on Child Abuse and Neglect Council on Foster Care, Adoption, and Kinship Care American Academy of Child and Adolescent Psychiatry Committee on Child Maltreatment and Violence Committee on Adoption and Foster Care Children exposed to maltreatment: assessment and the role of psychotropic medication.Pediatrics. 2020; 145: e20193751Crossref PubMed Scopus (13) Google Scholar; however, children who live in homes in which partner abuse occurs are described as secondary victims.6Black D. Newman M. Children: secondary victims of domestic violence.in: Shalev A.Y. Yehuda R. McFarlane A.C. International handbook of human response to trauma. Springer Series on stress and coping. Springer, Boston2000: 129-138https://doi.org/10.1007/978-1-4615-4177-6_9Crossref Google Scholar 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.2Keeshin B. Forkey H.C. Fouras G. MacMillan H.L. American Academy of Pediatrics Council on Child Abuse and Neglect Council on Foster Care, Adoption, and Kinship Care American Academy of Child and Adolescent Psychiatry Committee on Child Maltreatment and Violence Committee on Adoption and Foster Care Children exposed to maltreatment: assessment and the role of psychotropic medication.Pediatrics. 2020; 145: e20193751Crossref PubMed Scopus (13) Google Scholar There are documented gendered patterns in violence perpetration and victimization.7Krahé B. Bieneck S. Möller I. Understanding gender and intimate partner violence from an international perspective.Sex Roles. 2005; 52: 807-827Crossref Scopus (88) Google Scholar 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 abuse8Bhandari M. Dosanjh S. Tornetta 3rd, P. Matthews D. Violence Against Women Health Research CollaborativeMusculoskeletal manifestations of physical abuse after intimate partner violence.J Trauma. 2006; 61: 1473-1479Crossref PubMed Scopus (94) Google Scholar (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.8Bhandari M. Dosanjh S. Tornetta 3rd, P. Matthews D. Violence Against Women Health Research CollaborativeMusculoskeletal manifestations of physical abuse after intimate partner violence.J Trauma. 2006; 61: 1473-1479Crossref PubMed Scopus (94) Google Scholar 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.9European Young Pediatrician Association-EPA/UNEPSA Joint Conference. Istanbul, December 1-2, 2019. Proceedings. EPA/UNEPSA, Berlin, Germany2019Google Scholar 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.10United Nations Human Rights CommissionStates must combat domestic violence in the context of COVID-19 lockdown. UN Human Rights Reports.www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=25749&LangID=EGoogle Scholar 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.11Koshan J. Mosher J. Wiegers W. COVID-19, the shadow pandemic, and access to justice for survivors of domestic violence.Osgoode Hall Law J. 2021; 57: 739-799https://digitalcommons.osgoode.yorku.ca/ohlj/vol57/iss3/8Google Scholar 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 2019.12Government of Canada, Official WebsiteCovid-19 and gender-based violence.https://femmes-egalite-genres.canada.ca/en/gender-based-violence-knowledge-centre/snapshot-covid-19-gender-based-violence.htmlGoogle Scholar,13European Employment Services (EURES)7th annual. (2020). Violence against women has increased due to the lockdown: in 2020 one woman was killed every 3 days and the number of femicides-suicides has doubled.https://www.eures.it/con-il-lockdown-e-aumentata-la-violenza-sulle-donne-nel-2020-uccisa-una-donna-ogni-3-giorni-raddoppiano-i-femminicidi-suicidi/Google Scholar In the US, during the pandemic, domestic violence increased 12% on average and 20% during working hours14Sanga S. McCrary J. The impact of the coronavirus lockdown on domestic violence.2020https://ssrn.com/abstract=3612491http://doi.org/10.2139/ssrn.3612491Crossref Scopus (0) Google Scholar,15Boserup B. McKenney M. Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic.Am J Emerg Med. 2020; 38: 2753-2755Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar; 18 law enforcement agencies reported a sharp increase of 6%-20% in major US cities.16Kingkade T. “Domestic violence calls increase amid coronavirus lockdown, police say”.https://www.nbcnews.com/news/us-news/police-see-rise-domestic-violence-calls-amid-coronavirus-lockdown-n1176151Date: 2020Google Scholar 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.17Buckner J.C. Beardslee W.R. Bassuk E.L. Exposure to violence and low-income children's mental health: direct, moderated, and mediated relations.Am J Orthopsychiatry. 2004; 74: 413-423Crossref PubMed Scopus (113) Google Scholar Witnessed violence has a significant impact on youth mental health and on the likelihood of engaging in aggressive and antisocial behavior later in life.18Ferrara P. Caporale O. Cutrona C. Sbordone A. Amato M. Spina G. et al.Femicide and murdered women's children: which future for these children orphans of a living parent?.Ital J Pediatr. 2015; 41: 68Crossref PubMed Scopus (30) Google Scholar 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.19Lewis T. Kotch J. Thompson R. Litrownik A.J. English D.J. Proctor L.J. et al.Witnessed violence and youth behavior problems: a multi-informant study.Am J Orthopsychiatry. 2010; 80: 443-450Crossref PubMed Scopus (23) Google Scholar The important reality of a child's close tie to their mother or female role model or custodian is a consolidated notion,20Bowlby J. The nature of the child's tie to his mother.Int J Psychoanal. 1958; 39: 350-373PubMed Google Scholar 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.21Stiles M.M. Witnessing domestic violence: the effect on children.Am Fam Physician. 2002; 66: 2052-2067PubMed Google Scholar 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.21Stiles M.M. Witnessing domestic violence: the effect on children.Am Fam Physician. 2002; 66: 2052-2067PubMed Google Scholar 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.22US House of Representatives. Congressional Record, Government Publishing Office, Volume 151, Issue 168 (2005). Speech of Hon. Carolyn B. Maloney of New York. (December 17, 2005). Accessed April 19, 2021. https://www.govinfo.gov/content/pkg/CREC-2005-12-22/html/CREC-2005-12-22-pt1-PgE2633.htmGoogle Scholar 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.23Smith J. O'Connor I. Berthelsen D. The effects of witnessing domestic violence on young children's psycho-social adjustment.Australian Social Work. 1996; 49: 3-10Crossref Scopus (7) Google Scholar Physicians and pediatricians should be trained to recognize indicators of domestic and family violence and to address this issue on multiple levels.24Beck Weiss L. Kipke E.N. Coonse H.L. O'Brien M.K. Integrating a domestic violence education program into a medical school curriculum: challenges and strategies.Teach Learn Med. 2000; 12: 133-140Crossref PubMed Scopus (11) Google Scholar Educational programs about domestic violence have focused particularly on the primary victims, and important progress has been made in this area.25Lloyd M. Domestic violence and education: examining the impact of domestic violence on young children, children, and young people and the potential role of schools.Front Psychol. 2018; 9: 2094Crossref PubMed Scopus (30) Google Scholar 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 examinations, 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.26Pettoello-Mantovani M. Pop T.L. Mestrovic J. Ferrara P. Giardino I. Carrasco-Sanz A. et al.Fostering resilience in children: the essential role of healthcare professionals and families.J Pediatr. 2019; 205: 298-299.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar 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.26Pettoello-Mantovani M. Pop T.L. Mestrovic J. Ferrara P. Giardino I. Carrasco-Sanz A. et al.Fostering resilience in children: the essential role of healthcare professionals and families.J Pediatr. 2019; 205: 298-299.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The impact of COVID-19 upon domestic violence is well documented.27Weil S. Two global pandemics: femicide and COVID-19.Trauma Memory. 2020; 8: 110-112Google Scholar, 28Ferrara P. Franceschini G. Corsello G. Mestrovic J. Giardino I. Vural M. et al.The dark side of the web-a risk for children and adolescents challenged by isolation during the novel coronavirus 2019 pandemic.J Pediatr. 2021; 228: 324-325.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 29Ferrara P. Corsello G. Ianniello F. Sbordone A. Ehrich J. Giardino I. et al.internet addiction: starting the debate on health and well-being of children overexposed to digital media.J Pediatr. 2017; 191: 280-281.e1Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar 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,30McIntosh E.D. Janda J. Ehrich J.H. Pettoello-Mantovani M. Somekh E. Vaccine hesitancy and refusal.J Pediatr. 2016; 175: 248-249.e1Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar including the promotion of healthy, respectful, nonviolent relationships.31Pettoello-Mantovani M. Namazova-Baranova L. Ehrich J. Integrating and rationalizing public healthcare services as a source of cost containment in times of economic crises.Ital J Pediatr. 2016; 42: 18Crossref PubMed Scopus (26) Google Scholar Pediatricians should be professionally trained to recognize family and domestic violence and the risks for children to be victims of witnessed violence.24Beck Weiss L. Kipke E.N. Coonse H.L. O'Brien M.K. Integrating a domestic violence education program into a medical school curriculum: challenges and strategies.Teach Learn Med. 2000; 12: 133-140Crossref PubMed Scopus (11) Google Scholar

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