Mother-Child Attachment in Violent Contexts: Effect of Complex Trauma and Maternal Trauma History
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The present chapter aims to present the deleterious effects of dual exposure to domestic violence (DV) and other traumatic experiences on the quality of mother-child relating patterns. Outcomes of early exposure to DV are presented. Using an ecological-developmental perspective that accounts for child and environmental characteristics, this chapter presents updated literature on the effects of DV in child development and the parent-child relationship. Early childhood interventions targeting mother-child interactions in the context of exposure to DV are presented.
KeywordsDomestic violence Early childhood Attachment Trauma Dual exposure Child development Complex trauma Mother-child relationship
The detrimental effects of child exposure to Domestic Violence (DV) have been studied extensively in the literature over the last four decades. The impact on child’s physiological, emotional, and behavioral development has been well documented, and numerous studies have concluded that exposure to violent contexts during childhood has negative effects on all aspects of development. An ecological-developmental perspective offers comprehensive theoretical lens through which to examine the multiple pathways in which violence affects development in early and later childhood. DV occurs within a family system, and therefore disrupts development in a multilayered manner that includes stressors such as disrupted attachment, child abuse, parental substance abuse and mental health difficulties, unemployment, homelessness, social isolation, and involvement with legal and social services.
Caregivers are responsible for protecting and caring for developing children, and in contexts of family violence, a caregiver’s ability to provide safety and care can be severely compromised. The child’s expectation that the parent will consistently serve as a protector is compromised, and depending on the situation, the parent can become in fact the source of danger. DV therefore poses a severe threat to the parent-child attachment, independently of maternal psychopathology, parenting stress, and trauma symptomatology. As a result, children exposed to DV are at risk of forming insecure and disorganized attachment relationships with their caregivers.
The complicated nature of DV and the frequent co-occurrence with child maltreatment pose methodological difficulties in researching and further understanding the pathways to compromised development. Systematic, controlled research on exposure to DV during early childhood (0–3 years old) remains scarce, as well as research on parent-child intervention effectiveness for families affected by DV.
In the United States, DV accounts for 15% of all violent crime and is considered the most common source of exposure to traumatic events for children, with an estimated 15 million children yearly witnessing violence between adult partners (McDonald et al. 2006a). According to the National Survey of Children’s Exposure to Violence (NatSCEV) in 2011, 1 in 4 children (26%) are exposed to at least one form of violence in their lifetime, and 1 in 16 (6.6%) are exposed to violence between parents. Domestic violence is a pervasive public health concern, common in the general population and impacting families from all socioeconomic and racial backgrounds (Gustafsson et al. 2016).
Seeing the consequences of violence
Hearing the violence
Witnessing the violence and/or
Becoming directly involved in a violent act
Even though the most described and researched “classic” DV paradigm is one with a passive victim in an abusive relationship who lives in fear for the next episode of abuse, either psychological, emotional, financial, physical, or a combination of the different potential types of abuse, it is important to consider that DV can also be bidirectional or mutual, or it may take the form of “violent resistance” in which the identified victim fights back and injures the perpetrator. In the most comprehensive collection of evidence regarding rates of physical violence among 8,145 heterosexual American families, 50% of youth exposed to family violence reported that only their fathers were violent, 31% both parents were perpetrators, and 19% reported that only their mothers were perpetrators (Straus et al. 1990).
Children’s exposure to DV only became of public concern in the early 1990s following the slow progress made in the feminist movements of the 1960s and 1970s. Once violence within marital relationships was defined as a social, rather than an interpersonal problem, the groundwork was set for the “Battered Women’s” movement to evolve, which led to the passage of the Violence Against Women Act in 1994. At that time, services for the children of battered women began to grow – a growth that was also significantly influenced by the newly gained awareness of the deleterious impact of environmental trauma on children’s brain development and functioning (Groves 2002).
Outcomes of Witnessing Domestic Violence in Childhood
In the last three decades the dramatic influence of traumatic experiences in childhood has been extensively documented in literature (e.g., Herrenkohl et al. 2008; Sternberg et al. 2006; Kernic et al. 2003). Exposure to domestic violence in childhood is often considered by researchers a nonspecific developmental risk factor that is part of a group of contextual factors that are harmful to development. Research has shown that children exposed to DV typically experience multiple additional traumatic events (Cohen et al. 2006). DV exposure often co-occurs with other adverse experiences such as parental drug abuse, psychopathology, and criminal activity (Dong et al. 2004). Witnessing family violence affects all five primary areas of development: physiological, behavioral, cognitive, emotional, and social (Adams 2006).
Internalizing/externalizing behaviors. There is extensive research that provides corroborating evidence that there is a strong relationship between internalizing and externalizing behaviors and exposure to DV (Kitzmann et al. 2003; Margolin and Gordis 2000; Edleson 1999 for reviews). Children that have been exposed to DV have twice the rate of exhibiting clinically problematic behavioral presentation than children without exposure (Wolfe et al. 2003).
Internalizing behaviors of children exposed to DV include withdrawal, depression, clinginess, physical complaints, sleep disturbances, and frequent crying. Externalizing behaviors consist of attention problems, rule-breaking actions, and aggressiveness. A meta-analysis examining the association between DV exposure and childhood and adolescent internalizing and externalizing behaviors revealed significant mean-weighted effect sizes of 0.48 (SE = 0.04) for internalizing behaviors and 0.47 (SE = 0.05) for externalizing behaviors (Evans et al. 2008).
Research conducted with preschoolers also identifies behavioral problems for witnessing of DV (Huth-Bocks et al. 2001). Decreased capacity for verbal expression of emotional experience due to developmental limitations could contribute to increased frequency of temper tantrums, aggression, and anxiety (Jaffe et al. 2004). DV exposure is also associated with psychosomatic problems such as headaches, stomachaches, asthma, insomnia, and nightmares, and problematic behaviors such as sleepwalking and enuresis (Martin 2002). Preschoolers also show disturbances in their relationship with their peers and family, and post-traumatic stress symptomatology such as play reenactment of aggressive themes, hypervigilance, and crying. DV exposure can also result in developmental regressions in areas of eating, language, and toileting.
Although research on early childhood (0–3 years) exposure to DV is limited, the literature suggests that younger children might experience even more incidents of violence exposure than older children and they are more likely to be also exposed to parental substance abuse (Fantuzzo and Mohr 1999). An example of a community-based study with 1,788 participants that included age data, and early childhood participants, evaluated whether exposure to violence toward a family member and nonviolent, angry verbal conflict were associated with problems among children in the 1- to 3-year age range (McDonald et al. 2006b). The findings indicated that young children who were exposed to DV exhibited significantly increased behavioral disorganization or other very unusual or maladaptive coping responses when compared with young children who had been exposed to angry verbal altercations, but not violence.
Davies and Cummings (1994) proposed a theoretical model based on emotional security (the “emotional security hypothesis”) that posits that children’s distress from conflict between their parents stems from a sensed threat to emotional security, to their personal safety, or to their relationship with their caregivers. Children’s attempts to relieve their distress lead to negative reactions that, with chronic exposure, become generalized and applied in multiple situations. For example, children who are exposed to high levels of hostility and aggression might organize their emotional responses around anger, making it their default response to up-regulating experiences that usually do not elicit anger as a response (Jenkins 2000). Alternatively, these children might establish that anger is the most effective response that results in getting their needs met, and develop automatic anger responses in the context of conflict with others. Therefore, threats to emotional security increase risk for the development of behavioral problems. One study with DV-exposed infants younger than 12 months old found that after simulated adult conflict, these infants displayed more distressed facial expressions than infants who had not been exposed to DV (Dejonghe et al. 2005). This study provides some evidence for the emotional security hypothesis (Davies and Cummings 1994).
The pervasive impact on emotion regulation difficulties is also sustained into later childhood and adolescence. In a survey of 1,965 adolescents, participants who had been exposed to DV while growing up showed high levels of anger outbursts as well as internalized anger (Wolf and Foshee 2003). In another study conducted with female college students exposed to DV during childhood, results showed high levels of depression and lower self-esteem (Silvern et al. 1995).
It has also been theorized that children’s response to DV is dependent on their cognitive appraisals and emotional responses to the traumatic event. One study of 46 3-to-7-year-old children examined maternal, self, and marital representations following exposure to DV. Results revealed that children’s attempts to understand the violent acts, and more specifically, the degree to which they placed blame on themselves, the perpetrator, or their mother had significant implications in the development of maladaptive behaviors (DeBoard-Lucas and Grych 2011).
Post-traumatic stress symptoms. Repeated exposure to violence, especially in the early years, while brain structures are forming, carries a risk for psychopathology. Research has demonstrated genetic involvement in PTSD and suggests risk for PTSD is likely determined by the interaction of genetic dispositions and early caregiving. Although DV-exposed children do not always meet full diagnostic criteria for PTSD, the incidence of diagnosable PTSD has ranged from 3% to 56% (Graham-Bermann et al. 2006). Even when PTSD criteria are not met, behavioral and emotional reactions to witnessing DV can be still conceptualized as post-traumatic responses. Children who may not fit the full diagnostic criteria for PTSD often exhibit partial post-traumatic symptoms such as intrusive and unwanted remembering of the traumatic events, avoidance, and hyperarousal (Graham-Bermann and Levendosky 1998). A study examining symptomatology among 62 preschool children exposed to DV found that hypervigilance, separation anxiety, repeated verbal expressions of the traumatic event, and high reactivity to reminders of the event were prominent (Levendosky et al. 2002). Chemtob and Carlson (2004) analyzed a sample of 50 mothers and children looking at PTSD symptoms among families with history of violence exposure two or more years prior. They reported PTSD rates of 40% for children and 50% for the mothers. Importantly, 91% of the mothers with PTSD indicated that they did not seek psychological help for their children, while 46% of the mothers without PTSD failed to seek such help. This finding emphasizes the increased barrier to seeking treatment that a PTSD diagnosis introduces to parent-child dyads that have been exposed to DV.
Research on the effect of DV exposure on brain development has revealed compelling findings. Reviews of the literature implicate the stress response system (hypothalamic–pituitary–adrenal, or HPA axis) in changes in brain development that are believed to arise from traumatic experiences such as exposure to DV. The hypercortisolism hypothesis posits that chronic exposure to environmental challenges may lead to increased sensitivity of the HPA axis system, which then results in heightened reactivity in stressful or threatening contexts (Sturge-Apple et al. 2012).
Conversely, the hypocortisolism hypothesis suggests that chronic exposure to stressful contexts results in eventual suppression of adrenocortical reactivity (Sturge-Apple et al. 2012). This suppression could lead to tolerance and/or facilitation of more destructive family contexts. Studies on child maltreatment have shown that infants and young children exposed to chronic stress or traumas have increased levels of the stress hormones cortisol, epinephrine, and norepinephrine. When heightened hormone levels become chronic, they can have a significant effect on brain development (De Bellis 2005; Schore 2001). More specifically, chronic trauma exposure has been shown to affect the limbic system and the frontal regions of the brain. The limbic system is involved in emotion and behavior regulation, memory and fear and stress reactions, and the frontal lobes are responsible for learning and expression of language (Carlson 2005). Such findings are consistent with the aforementioned research on emotional dysregulation occurring in children exposed to DV, showing a biological basis for adverse emotional and behavioral outcomes.
Cognitive/intellectual functioning . Very few studies have explored the question of the effect of DV exposure to preschool children’s intellectual functioning and the few that have have yielded mixed results. Some of the issues that complicate the ability to get linear answers on this topic are the high percentage of dual exposure to DV and other types of trauma, as well as the lack of appropriate control samples. A study conducted by Ybarra et al. (2007) demonstrated that DV-exposed children had lower levels of full scale IQ than nonexposed children. All children in this study were within the “Average” range. In another study of 100 high-risk mother-child dyads, children exposed to DV within the previous year showed lower verbal abilities than those who had not been exposed, following controlling for other trauma and socioeconomic status (Huth-Bocks et al. 2001). This study further revealed an indirect association between maternal depression and children’s intellectual functioning through a less stimulating home environment.
Mediating Factors Identified in Literature: Early Childhood and Complex Trauma
Age and the co-occurrence of multiple forms of trauma have been identified as mediating the effects of DV. Children aged 0 to 5 are significantly more likely to witness DV than children of any other age. In most circumstances, those infants and toddlers are at risk of multiple developmental risk factors, such as externalizing and internalizing maladaptive behaviors, as well as academic and conduct difficulties. These findings underscore the importance of accurate assessment and early intervention for families that have been exposed to DV.
The emotional impact of DV varies with age. Cummings et al. (1991) reported age differences in children’s coping with simulated marital conflict. They found that 5-year-olds reacted to anger with more sadness when compared to 9-year-olds in the same conditions. The authors hypothesize that the 9-year-olds were likely more habituated to the events and have more cognitive resources to cope with such stressors. Children under five are also more prone to attributional errors, resulting in self-blame and shame for not being able to protect the victimized parent (DeBoard-Lucas and Grych 2011). Another possible explanation is that the effects of DV are amplified for younger children who experience higher levels of dependency on parents for their care, and may therefore spend increased amounts of time with their caregivers (Huth-Bocks et al. 2001).
Another important mediating factor DV exposure is the co-occurrence of other types of trauma in the child’s life, such as abuse and neglect. This finding has been named the “double whammy” phenomenon (Hughes et al. 1989), and research suggests that children doubly exposed to abuse and DV fare worse and are at greater risk than children who are either not exposed or exposed to abuse or DV alone. However, the findings supporting the “double whammy” effect are not consistent in literature and further investigation of the overlap in child abuse and children’s exposure to DV is warranted in order to determine whether the effects on youth development are distinguishable.
A meta-analysis of studies on dual exposure found only four studies that adequately documented the developmental impact of dual exposure on children’s later development and risk of internalizing and externalizing behaviors (Wolfe et al. 2003). Effect sizes given in this review supported the effect of dual exposure and showed that children with multiple traumas were indeed more vulnerable to future psychopathology. However, results have been mixed in other studies. Some studies did not find differences between groups that had experienced the impacts of child abuse and DV when compared to those with single exposures. In those studies maltreatment was predictive of poor outcomes in children, and neither DV alone nor in combination with maltreatment resulted in a statistically significant increase of child behavior problems above those of nonexposed peers. However, a later study found that children who had dual exposure to violence (both witnessed and directly experienced) were 1.5 times more likely to have externalizing problems and 1.9 times more likely to have internalizing problems, as compared to children who had experienced one type of trauma (Sternberg et al. 2006). In another study with 457 young adults, results showed that child maltreatment, exposure to DV, and the combination of the two increased the risk of internalizing and externalizing behavioral issues (Moylan et al. 2010). In this study, the differences between single exposure and dual exposure were trending toward significance. Thus, while some research shows a cumulative effect of DV when combined with other traumas, others find no difference. Further research is needed to disentangle the unique risk factor conferred by DV.
Domestic Violence Assessment: Methodological Issues for Exposure in Early Childhood
There are several methodological issues in DV research that result in a weaker than expected link found between exposure to DV and children outcomes. Inadequate control groups, small sample sizes, and the degree to which the severity, frequency, and type of abuse are specified are some of the factors identified so far. A comprehensive review of 46 instruments utilized in the research and clinical domains to measure children’s exposure to violence identified a lack of measures for early childhood (0–3) as well as a lack of measures that had both a parent and a child version (Acosta et al. 2012). Moreover, researchers tend to use one source of information, both for the presence of DV and the children’s problematic behaviors.
For example, most studies have used samples from women in shelters, which place mothers in the primary informant role. This is potentially problematic, as research examining the reliability of information received from only one participant revealed that violence was underreported by both men and women. Moreover, parents have been shown to underreport the occurrence of children witnessing the violence. Parents tend to minimize or deny the presence of children during incidents of DV by suggesting that the children were asleep or playing outside. From interviews with children, however, it was found that the very same children whose parents thought were unaware of the conflict were able to provide clinicians with detailed accounts of parents’ violent behavior (Jaffe et al. 1990). O’Brien and colleagues (O’Brien et al. 1994) found that 78% of children who reported witnessing DV had at least one parent report either that the child had not witnessed violence or that no violence had occurred. It is possible that adults are unaware that their children witness or overhear incidents of violence. Additionally, individuals may not view specific events similarly, and may define an abusive act as normative, especially in cases where the individual is suffering from chronic exposure to trauma and abuse. In a comprehensive review of the methodology of 21 studies in the DV field, the lack of third-party verification with regard to the nature of the violence and the exposure was consistently identified as a limitation (Mohr et al. 2000).
Ecological System of Child Maltreatment
The diverse developmental pathways create a large array of outcomes for children exposed to domestic violence in early childhood that poses a challenge for researchers, along with the methodological issues described. Among several theoretical perspectives that have been conceptualized in the effort to provide a framework to understand the complex effects of exposure to domestic violence in development, an ecological-developmental perspective offers a comprehensive view of different maladaptive factors that contribute to child development in DV contexts.
The ontogenic system involves elements of what the parent brings into the family setting and the parenting role (e.g., the parent’s own childhood). Maternal past history of trauma is an ontogenic factor that has been researched in the context of caregiving behaviors and child outcomes. Steele et al. (1996) discussed the revolutionary finding that the quality of the infants’ relationship with both parents at 12 and 18 months could be predicted from the parents’ accounts of their own childhoods collected before the birth of the child.
Highly associated with traumatic experiences in the parent’s life (Dube et al. 2002), maternal psychopathology is another ontogenic factor that has been identified in research as a mediating factor between exposure to DV and children’s mental health outcomes (Levendosky and Graham-Bermann 2001; Levendosky et al. 2003; Owen et al. 2009). Better maternal mental health was identified as a factor that positively influences resilience in 219 children exposed to DV (Graham-Bermann et al. 2009). Other research has shown evidence that exposure to both violence and maternal depression places children at compound risk for poor school functioning and behavior (Silverstein et al. 2006).
Parenting stress is another ontogenic factor that has been shown to negatively impact parenting behaviors. In DV families, parenting stress has been shown to be higher than in nonviolent families, and has also been identified as a significant predictor of children’s behavior problems (Levendosky and Graham-Bermann 1998; Wolfe et al. 1985). Levendosky and Graham-Bermann (1998) measured maternal stress as the self-report of experienced parenting stress in mothers of school-age children in a sample of sheltered and non-sheltered women. They found that parenting stress predicted children’s adjustment, controlling for maternal experiences of physical and psychological abuse. Wolfe and colleagues (1985) used an ecological framework in designing their maternal stress variable. Maternal stress in their study was comprised of maternal physical and emotional health, negative life events, and sociodemographic variables. While these are two distinct ways of defining maternal stress, both were significantly associated with DV.
The microsystem is the family system and the immediate content of the child’s upbringing. According to this theoretical conceptualization, DV is a microsystemic stressor that is embedded or nested within all the other systems. Therefore, DV cannot be investigated and/ or conceptualized without taking into consideration the ontogenic features that the parent brings into the parent-child relationship, the immediate upbringing context of the child, the environmental stressors such as housing, poverty, community violence, availability of medical, mental health and child rearing resources, and finally culture and diversity issues.
The exosystem consists of social structures, socioeconomic status, neighborhood, and the availability of resources. Social isolation is an exosystemic factor that has been linked to negative mental health in many different populations (Cohen and Wills 1985; Kemp et al. 1995). Research indicates that women exposed to DV have poorer quality support than nonexposed women (Thompson et al. 2000). Levendosky and Graham-Bermann (2000) explain, “[The mother’s] undermined trust in loved ones may cause mothers who have experienced DV to withdraw from their friends and family, furthering their social isolation.” Presence of DV also results in less emotional and practical support. In a qualitative study with a group of 145 pregnant battered women, participants reported experiencing more criticism from network members than from outsiders (Levendosky et al. 2004). As the qualitative research revealed, mothers who have experienced DV tended to socialize with other women that had also experienced DV. However, due to possible projection of feelings of shame for not escaping the situation, woman who had experienced DV were more critical of their social network members than outsiders. Additionally, little research has examined the structural aspects of support. For example, Bowker (1984) found that tangible (i.e., practical) support was the most helpful support that battered women residing in a shelter received from family and friends. Moreover, Levendosky et al. (Levendosky et al. 2004) found that the availability of practical support during pregnancy was related to higher self-esteem and less anxiety among women experiencing DV. There is research that has shown that individuals exposed to DV might have compromised perceptions of resources available to them, rather than lacking resources (Carlson et al. 2002; Tan et al. 1995).
Negative life events or life stressors such as poverty and community violence are other exosystemic factors that have been linked with DV in the literature. According to the family stress model, economic disadvantage increases economic pressure, thereby inducing feelings of frustration, anger, and emotional distress in caregivers. These distressing feelings, in turn, contribute to conflict among family members, including conflict between parents (Conger et al. 2002). Income is a significant predictor of parenting behaviors, specifically authoritarian and controlling behaviors (Elder et al. 1995). Poverty and the unavoidable outcome of living in unsafe neighborhoods with increased community violence incidents have been linked also in research with increased DV occurrences (Capaldi et al. 2012). In a longitudinal study of 184 low-income families at risk for child maltreatment showed that low socioeconomic status was a strong predictor for DV and child maltreatment (Cox et al. 2003). Low-income parents are faced with additional stressors such as fewer childcare resources and more crowded living space that can contribute to increased family context tension and aggression, which, in turn, affects children’s adjustment.
The macrosystem includes the cultural values and belief systems and social structures that inform the child’s world.
The Role of the Attachment Relationship in DV Contexts
According to attachment theory, infants become attached to their primary caregiver in order to ensure survival. They learn to effectively communicate their needs, as they develop the expectation that there will be someone there, who is physically and emotionally synched with them and in normative contexts meets their needs and makes them feel understood. Bowlby (1977) described secure attachment as the secure base from which the toddler moves out to the world, feels safe enough to explore and engage with the environment, and holds the internalized perception that if distress arises, she has the capacity to either regulate herself or turn to a caregiver that will aid with the regulating process. Insecure and disorganized attachment patterns develop in the context of a caregiver who is inconsistent or unable to meet their child’s needs and provide comfort and safety (Ainsworth et al. 1978; Main and Solomon 1990).
Maternal exposure to DV during pregnancy is strongly associated to parenting behaviors and child attachment patterns (Huth-Bocks et al. 2004; Levendosky et al. 2006). Attachment theory also proposes that an important component of a secure attachment is emotion regulation. Over time, children who experience a safe bond with their caregiver learn to cope when they are distressed, whereas insecurely attached children have difficulty managing their emotions and do not develop effective strategies to manage emotions and exhibit control. The potential for family violence to disrupt the development of secure attachment, therefore, has significant implications for children’s emotional functioning.
Mothers who have experienced DV tend to have more negative representations of self and their child, which in turn influences the attachment pattern of the child (Gewirtz et al. 2011). This really important research established that in the context of exposure to DV in the prenatal phase, mother’s perceptions of their maternal identity and their perceptions of their child were disrupted. Those disrupted internalized perceptions were then found to be associated with parenting behaviors and child’s attachment at year 1 (Dayton et al. 2010; Huth-Bocks et al. 2004). Maternal perceptions of self and child have been shown to be affected directly by changes in DV exposure and frequency, income, and maternal depression (Theran et al. 2005). The pathway in which DV affects maternal representations could be through evoked feelings of shame, anger, helplessness, guilt, and traumatic experiences of the past (Lieberman and Van Horn 1998).
Mother-child relationships have the quality of being able to either lessen or amplify child adjustment difficulties and exposure to family violence appears to exacerbate often already difficult parent-child situations by undermining the supportive, sensitive, and appropriately responsive nature of this dyad. Moreover, the parent-child relationship has been shown to be a separate factor from maternal psychopathology in predicting internalizing and externalizing problems for children in the context of DV (Lieberman et al. 2005). Krishnakumar and Buehler (2000) found that hostility and conflict in the marital relationship negatively influences the parent-child relationship, and marks the relationship with decreased parental warmth levels. In a clinical sample of 85 preschoolers who witnessed DV, maternal psychopathology and mother-child relationship quality each contributed unique variance in concurrently predicting children’s internalizing and externalizing problems (Gewirtz et al. 2011).
Quality of attachment is significantly influenced by trauma and, specifically, exposure to DV, with women exposed to DV and their children being at greater risk of disorganized and insecure attachment (Quinlivan and Evans 2005; Zeanah et al. 1999). Young children’s recovery from traumatic events is deeply reliant on the quality of the attachment relationship and by the parent’s ability to respond sensitively to the infant’s traumatic responses. In cases where both parent and child are exposed to DV, the parent’s ability to appropriately attend to the child’s complex needs is significantly compromised. Parent-child interventions can serve to restore a sense of safety to the child-parent relationship as a vehicle to promoting healthier development. Research on efficacy of intervention models is scarce in the DV field and little systematic evaluation of effectiveness has been conducted (Graham-Bermann and Hughes 2003).
Maternal History of Trauma
Childhood trauma and parenting: Individuals who grew up with domestic violence have a two to six times higher odds ratio to have experienced other types of trauma, when compared with individuals who grew up without DV (Dube et al. 2002). Moreover, as the reported frequency of DV increases there is a positive graded risk for self-reported alcoholism, drug use, and depressed affect. Maternal past history of trauma has been strongly associated with caregiving behaviors and child outcomes. Murphy et al. (2014) investigated the relationship between adverse childhood experiences (ACEs) and adult state of mind in regards to attachment. They concluded that high adversity in the parent’s childhood is related to increased risk of intergenerational transmission of trauma through problematic parenting. Others found that when interacting with their children, women with histories of physical abuse showed more hostile behaviors, whereas women with histories of sexual abuse were more likely to show withdrawn interactions, characterized by flat affect (Lyons-Ruth and Block 1996). Mothers’ history of violence victimization was shown to predict externalizing and internalizing behavioral problems in 4- to 6-year-old children (Morrel et al. 2003). In a study that looked at the associations between exposure to DV and infant and parent trauma history, maternal trauma history was highly associated with child trauma history, especially among infants exposed to severe DV (Bogat et al. 2006). The association between exposure to DV in childhood and adult victimization has been established in literature and it is indicated that females from clinical sample populations who have been exposed to DV are more likely to be victimized as adults from intimate partners (Stith et al. 2000). Another study reported as high as fourfold increased probability to engage in violent relationships as an adult when exposed to violence as a child (Coker et al. 2000). Even though the link between childhood and adult violence victimization has been firmly established, few studies have looked at the effect of maternal exposure to DV during her own childhood and the effect on current parenting behaviors. Thompson (2007) conducted a study with 197 low-income mother-child dyads in order to examine the link between mother’s childhood victimization, current ongoing DV, and child outcomes. Results revealed that the effects of mother’s status of current victimization appeared to have little impact on child outcomes once maternal childhood history of victimization was taken into account. Abusive parenting is associated with parental childhood abuse history (Cunningham 2003). Mechanisms such as poor mental health and maladaptive coping mechanisms have been implicated in the intergenerational cycle of abuse (Hetzel-Riggin and Meads 2011).
PTSD and parenting: Maternal exposure to trauma during her childhood affects her brain chemistry which in turn affects her parenting. Brain studies have associated the methylation of serotonin receptors with parent-child attachment dysregulation. More specifically the percentage of methylation of the brain region that promotes serotonin (HTP3A gene) is considered to be significantly associated with maternal childhood history of exposure to childhood maltreatment and subsequent violence victimization, maternal PTSD related to current DV, maternal aggression, and parent-child problematic attachment (Schechter et al. 2017). From this study it was concluded that the peripheral level of HTR3A methylation could be representing a marker for a maternal DV-PTSD endophenotype that introduces risk to the mother-child relationship and the child’s social-emotional development.
Psychopathology and parenting: Women involved in violent relationships and a history of childhood physical abuse report obsessive-compulsive tendencies and high depression levels (Miller 2006). Other mental health problems associated with DV include low self-esteem levels, anxiety, and PTSD (e.g., Bogat et al. 2003). However, the relationship between maternal psychopathology, parenting, DV, and child outcomes is complicated and multidirectional. While some studies establish a strong association between maternal mental health and parenting in violent homes independent from DV (Levendosky and Graham-Bermann 2001; Rea and Rossman 2005), other studies find that the association is accounted for by the interaction of these two variables with DV (Levendosky et al. 2006).
The multiple pathways in which maternal history of trauma affects child development and the relational patterns of the mother-child bond speaks to the significant effects of intergenerational transmission of violence (Neppl et al. 2017) and to the increased importance of early intervention in the efforts to break the cycle.
Considering the importance of the early parent-child relationship for child development and recovery from exposure to traumatic events, the amount of evidence-based interventions that target the parent-child relationship in the context of DV and complex trauma is extremely limited. Despite the abundance of evidence that mother-child relationships are significant factors in DV outcomes, there are few dyadic interventions for DV that utilize the parent-child relationship.
Perinatal-Child Parent Psychotherapy (Perinatal CPP) adapted for pregnant women and babies exposed to DV (Lieberman et al. 2011). The innovation of this therapeutic approach is that it presents an integrated model of mental health with primary care and offers services to mothers during pregnancy and up to 6 months following birth. The intervention draws from trauma and attachment research as well as cognitive-behavioral and social learning theories. It involves dyadic work with parent and child using play, and routine caregiving behaviors as well as spontaneous interactions in order to build safety and increase reciprocity. Therapeutic interventions include increasing mindfulness to track maternal somatic and affective experience which in turn increases maternal ability to synch with the baby’s biological rhythms, providing insight-oriented interpretations that help mothers become aware of intergenerational patterns of attachment and offering tangible assistance with crisis and/or housing situations. Participation of fathers who have perpetrated violence in treatment is considered if the case that the mother expresses such wish following careful consideration of the mother’s and baby’s safety risk in case the father is indeed included.
Parent-child interaction therapy (PCIT). PCIT is an evidenced-based intervention for disruptive behavior problems in children between the ages of 2–7 years (Eyberg et al. 1995) and has been suggested as an effective treatment for dyads that have been exposed to DV (Borrego et al. 2008). Treatment targets dyadic interactions by offering a broad skill set to the parent in order to improve their interactions with their children. PCIT focuses on positive and negative attention techniques, as well as praising, consistent discipline, and problem solving in order to increase or decrease the child’s behaviors. Parents learn through live coaching and hands-on exercises. The treatment plan includes didactic sessions and parent-child play sessions. PCIT is conducted in weekly 1-h sessions and the average number of coaching sessions is 13.
Early childhood exposure to DV occurs within a family system and disrupts development in a multilayered manner introducing multiple developmental risk factors, such as externalizing and internalizing maladaptive behaviors, as well as academic and conduct difficulties, emotion regulation difficulties, and neurobiological outcomes. In contexts of family violence, the attachment relationship between child and caregiver is compromised and children are at risk of forming insecure and disorganized attachment relationships with their caregivers. When considering violence in a child’s upbringing context, it is important to take an ecological-developmental perspective. Children aged 0 to 5 are significantly more likely to witness DV than children of any other age. Children exposed to DV are often exposed to other types of trauma such as abuse and neglect; however, due to multiple methodological issues in DV research, it is difficult to discern whether children doubly exposed to abuse/neglect and DV fare worse and are at greater risk than children who are either not exposed or exposed to abuse or DV alone. The relationship between maternal psychopathology, parenting, DV, and child outcomes is complicated and multidirectional. Early childhood parent-child interventions for children exposed to DV are of increased importance in order to break the intergenerational transmission of trauma and violence.
Summary and Conclusion
DV impacts child development in a multilayered manner that can result in disruptions in the attachment system with the caregivers and disruptions in the child’s physiological, emotional, cognitive, social, and behavioral development. To date, research on the effects of child exposure to DV indicates that the exposure has adverse impact across a range of functioning, produces different effects at different ages, increases risk for other abuse, and is associated with other risk factors such as poverty and substance abuse. Research has shown mixed results regarding the developmental impact of dual exposure on children’s later development and risk of internalizing and externalizing behaviors. The mother child relationship, when it is experienced as safe and consistent, can be a buffer to adversity. In violent contexts, the relationship often becomes compromised and disorganized and insecure attachment patterns develop. Further undermining of the mother child bond occurs when the mother has been exposed to complex trauma and DV in her own childhood. PTSD, high violence tolerance, maternal mental health, and maladaptive coping mechanisms, stemming from the mother’s own childhood history, are factors that have been identified to introduce risk to the mother-child relationship. Parent-child interventions for DV exposure can be extremely beneficial for child development and recovery from the traumatic events.
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