The startling toll on children who witness domestic violence is just now being understood
This story was produced as part of a larger project led by Jayne O'Donnell, a participant in the USC Center for Health Journalism's 2018 Data Fellowship.
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Witnessing abuse carries the same risk of harm to children's mental health and learning as if the children had been abused directly, new research shows.
SAVANNAH, Ga. – Latrelle Huff says her twins were conceived by rape.
Now she blames domestic violence for her children's health problems.
The Georgia woman says she had been in an abusive, on-and-off relationship for six years when she became pregnant. While pregnant, she says, the conflict continued. Huff spent 25 of 37 weeks on bed rest, she says, due in part to rectal bleeding her doctors said was caused by stress.
Two days after the twins were born in 2014, Huff says, the father took a swing at her. He was holding their newborn son. They were still in the hospital. Huff had just delivered by Cesarean section. "He was so angry at me because my milk wouldn't come in," Huff, 39, told USA TODAY.
The boy was born with "floppy baby syndrome," a muscular condition doctors said might be attributed to abuse during pregnancy. Both children struggle with health issues, including speech disorders, and have spent months in instructional therapy to learn how to follow directions.
The father denies sexually assaulting or abusing Huff. He was charged last year with assault and battery against her; his lawyer says he completed a pretrial program in September to avoid a conviction. In 2015, a grand jury in Savannah declined to indict him on sexual assault charges.
New research is giving scientists more insight into the far-reaching and long-lasting harms of domestic violence to the children who grow up around it – including a startling finding: Witnessing abuse carries the same risk of harm to children's mental health and learning as being abused directly.
Brain imaging in infants shows that exposure to domestic violence – even as they are sleeping, or in utero – can reduce parts of the brain, change its overall structure and affect the way its circuits work together.
Studies show that when babies born to mothers who were subjected to violence during pregnancy become adults, they have three times as much inflammation in their bodies as those whose mothers weren't. Inflammation causes a much higher risk of poor health, and a far greater likelihood of depression.
And research also shows that these children are as likely to have Post-Traumatic Stress Disorder as soldiers returning from war.
Psychologist Kathleen Kendall-Tackett, past president of the American Psychological Association's division of trauma psychology, said "babies are like a blank slate."
"If a mother is beaten while pregnant, there is a chance the baby will be injured, delivered prematurely, and there is a stack of other things that can happen – including physiological programming of the hyperactive stress system that leads to inflammation as an adult," she said.
"It's like when a soldier comes back from combat, hears a click and hits the ground."
Researchers estimate that between 4.5 million and 15 million children are exposed to physical violence in the home. Verbal and emotional abuse in the home is more difficult to track.
Social workers, health care providers and academics have long tracked the effects of trauma suffered by children growing up in urban neighborhoods with frequent gunfire and other violence. But outside of medical journals, there has been little reporting on the effect of the more common domestic violence on the millions of children who grow up on the residential battlefields where it occurs.
Neuroscientist Tanja Jovanovic directs the Grady Trauma Project, a research institute based at Emory University in Atlanta. The risk of PTSD from domestic violence is high, she says, because it's a "betrayal by someone who is supposed to be to a protector."
Making matters worse, Jovanovic said, domestic violence often eliminates the "buffering effect of another positive adult," because the adult who is targeted can't provide comfort to the children who witness it.
Psychologist Abigail Gewirtz says domestic violence can feel scarier than war. Gewirtz is the director of the Institute of Translational Research in Children's Mental Health at the University of Minnesota. It's "one of the most terrifying forms of violence because it happens in a place which is supposed to be safe," she said. "Children are totally powerless, especially very young children. They are totally dependent on their parents.”
Exposure also reduces the potential of babies and toddlers to learn. Alissa Huth-Bocks, a child psychologist at University Hospitals in Cleveland, said the "most damaging time" is during pregnancy and the first three years of life, when development "takes the biggest hit at the brain level."
Negative consequences continue well into adulthood. Among childhood adversities, Ronald Kessler says, those involving family violence inflict the worst long-term effects.
Kessler is a professor of health care policy at Harvard Medical School, the principal investigator of the U.S. National Comorbidity Survey –the first nationally representative survey of mental disorders in the United States. He is co-director of the World Health Organization’s World Mental Health Survey Initiative.
"One of the long-term effects of childhood adversity is that they create emotional scars that get reopened when people are exposed to traumas in adulthood – leading to adult PTSD," Kessler said.
For people of color, especially African-Americans, Latinos and Native Americans, the effects of trauma are often magnified, federally funded research shows, because they are more likely to suffer from systemic racism, discrimination and microaggressions.
The nonprofit research organization Child Trends reported last year that 6 percent of kids nationally – about 4.5 million children – had seen or heard parents or other adults slap, hit, kick or punch each other in the home. Four percent had been exposed to or victims of neighborhood violence.
The results were based on a survey of parents about their children. In five states – Arizona, Mississippi, Arkansas, Hawaii and Tennessee – at least 10 percent of children had been exposed to domestic violence at home.
Child Trends says parents likely under-report violence in the home out of embarrassment or fear of stigma. The research doesn't include the psychological and emotional abuse, including gaslighting, that many women and some men told USA TODAY was far worse for them and their children to live with.
The findings, children's health advocates say, underscore a need for improved detection and prevention of domestic violence, and better treatment of abuse survivors and their children in the health care system, schools and the courts.
Georgia, Huff's home, is among the states where the law recognizes the effects of domestic violence on children. The state has created criminal charges for domestic violence that happens anywhere in a house where children are present, not just when it occurs in front of the child.
In other ways, specialists say, the law and courts have a long way to go in recognizing the impact on children's well-being. Parents accused or even convicted of domestic violence in many cases are able to gain unsupervised visits with their children, or partial or full partial custody – even when children are afraid of the offender.
When parents in an abusive relationship separate, conditions for their children can become even riskier. The nonprofit group Center for Judicial Excellence, which monitors family courts, found that more than 650 children were killed by a parent in a "divorce, separation, custody, visitation, child support situation" from 2008 through 2018.
Domestic violence crosses racial, ethnic and socioeconomic lines. Cheryl Branch, executive director at Savannah's SAFE women's shelter, says the calls she gets from abused women in The Landings, an exclusive gated community, are as horrific as those that come from low-income clients.
She says women are afraid to leave husbands who threaten to spend whatever it takes to gain full custody of the children. When shelter residents go back to their domestic abusers – as many do – Branch is required to notify child protection authorities, just as she would be if a parent returned to someone who has sexually abused his or her child.
Huth-Bocks, the Cleveland psychologist, says researchers' ability to study human brain development has "exploded in the last five to six years." So has data on the mental health and addiction effects of adverse childhood experiences, or ACEs – 10 harmful experiences or conditions, including domestic violence, tracked by health professionals.
Generations of violence
In San Diego, the children of now-divorced Eric and Yadira Sanchez – Angel, Noel and their 15-year-old brother – say they can vividly recall visiting their maternal grandparents' house when they were young.
They talk about seeing their grandmother punch cabinet doors and throw drinking glasses. She and their grandfather would hit each other in front of them, they say. The grandparents could not be reached for comment.
Later, Angel and Noel say, they watched as their mother chased their father with a kitchen knife and smashed a piece of a wood across his back. In December 2011, police arrested Yadira Sanchez on charges of felony assault with a deadly weapon and felony spousal battery, but prosecutors declined to pursue the charges.
As the alleged violence escalated, the children's grades and mental health declined, a review of school and medical records shows. (USA TODAY is not identifying the youngest son because he is a minor.)
"When these high levels of stress happen too often and too intensely, it creates a toxic pathway that alters how our brains and bodies operate and how we think, learn and behave," said psychologist Sheri Madigan, a professor at the University of Calgary in Canada.
Yadira Sanchez did not respond to requests for comment. Her lawyer, Ethan Marcus, acknowledges that the boys were exposed to domestic violence. But he claims Eric Sanchez's efforts to separate the boys from their mother likely hurt them far more.
"This is not a case where physical violence was the primary factor," Marcus said.
Change to brain, body
Researchers who followed 1,420 children in North Carolina from age 9 to 30 found that exposure to domestic violence in the home had the same serious and life-changing effects as experiencing the abuse directly.
The American Medical Association published the study in November. University of Vermont psychologist William Copeland was its lead author. These children "have the same type of poor outcomes 10, 20 years down the road" as children who "experience it directly themselves," he said.
A global study out last year of more than 125,000 people from all socioeconomic backgrounds found children who witnessed domestic violence had the same risk and incidence of PTSD as soldiers returning from war.
Research presented in November at the International Society for Traumatic Stress Studies shows that children exposed at an early age to trauma, including domestic violence, have a smaller hippocampus – the brain area related to learning and memory formation – a risk factor for PTSD.
Other research shows that the amygdala – the part of the brain that processes emotions, memory and fear – in children who have been exposed to violence reacts more strongly to threats than in children who haven't.
Eamon McCrory, a professor of developmental neuroscience at University College London, says the changes make it more difficult for these children to get along with others. Other studies have shown that exposing children to violence leads to lower grades and a greater probability of dropping out of school.
Psychologist and professor Katie McLaughlin directs the Stress and Development Lab at Harvard. "This change in size and likely the function of the hippocampus could be one potential mechanism that's underlying those differences in school achievement," she said. The brain works to help protect from danger. But when children are dealing with adversity, their brains can be overwhelmed.
Catholic high schools around San Diego began scouting Angel Sanchez when he was in middle school, according to Phillip Lomax, his coach at the time. The strapping middle linebacker – he was 6-foot-tall and 225 pounds in high school – was hard to miss.
Problem was, Sanchez said, just as his athletic abilities began gaining notice, his home life deteriorated and his grades dropped.
His mother stayed out late at night, his father found other men's numbers on her phone, and a pattern of erratic and often violent behavior against the boys and their father developed, Eric Sanchez said in requests for restraining orders and police reports.
The three boys each had an Individual Education Program detailing how they best learn given their disabilities. Angel has a speech impairment that affects his oral and written communication, reading comprehension and math problem solving. Noel was granted accommodations to receive extra time for homework and tests. The youngest boy struggles with reading and writing. All the boys were given intensive tutoring, language therapy and case managers.
As tensions between the parents rose, Angel's grade point average dropped from 3.0 at the beginning of his sixth grade to 1.3 by the start of 7th grade, school transcripts show.
That was the year – 2008 – that their mother chased their father around a table with a steak knife and stabbed the padded kitchen stools, Eric Sanchez and the boys told child welfare workers.
Noel Sanchez, now 18, recalls that period. "Oh man, I can still see and hear what happened those nights. That’s not going to go anywhere," he said.
In children exposed to domestic violence, the parts of the brain that detect threats and anticipate pain – the anterior insula and amygdala – are strongly affected by threatening faces during brain imaging.
Researchers at University College London wrote in 2011 that the results might predict a later risk factor for anxiety disorders and increasing vulnerability to mental illness. A more recent study by the same authors showed this heightened responsiveness was present even when children weren't consciously aware of a threat.
"If you've grown up in a situation that's dangerous, you're much more likely to react to something that's actually totally safe(as if it were) a potential threat," McLaughlin said.
The two younger Sanchez boys went back and forth between their feuding parents. Angel stayed with his father. School progress reports show that Noel missed 57 classes in the first three months of 2017. His younger brother missed 137.
In 2016, Yadira Sanchez was granted a restraining order against Angel. Her lawyer, Ethan Marcus, says Angel kept trying to take his brothers away from their mother. Yadira lost custody of the boys in March 2017.
Lomax, the coach, says the chaos hurt Angel's future plans. "If you’d asked me, when he was going into 9th grade, what Angel’s potential as a linebacker was, he was certainly a Division I contender, for sure," he said.
Eric Sanchez, the father, says one high school withdrew a scholarship offer after it saw Angel's grades. He missed practice often during high school during the parents' custody fight.
Noel Sanchez says that the turmoil before their parents separated, and stays with their mother after the split, were so traumatic that he attempted suicide in 2014 and considered it at other times. "I was just trying to hurt myself to let the pain go away," he said.
From mother to daughter
Debbie Ricker says domestic violence looms over three generations of her family. Both the California woman and her daughter Desiree say it led to Desiree's drug and alcohol abuse, and other mental and physical health struggles.
Ricker fought a 15-year custody battle with her ex-husband. It ended only when her son turned 18. She says the emotional abuse she suffered and her children witnessed still affects them. "My ex was very open with his abuse toward me," she said. "The abuse occurred in front of our kids, friends, family."
Desiree, now 29, said "I never heard him be nice to her. He belittled her every step of the way."
Marc Loehren, Debbie Ricker's ex-husband and Desiree's father, denies their allegations. He was never charged with a crime against them. “My two children had a wonderful childhood," he told USA TODAY. "There was no violence in this household. ... if anything, the mom hit me with a car.”
He acknowledges the children have been to multiple psychologists. But he cites Ricker's family background and marriages before and after their relationship. He alleges that Ricker tried to undermine his relationship with the children.
"The children are fairly disturbed from anything that the mom has told them – which is alienation," Loehren said.
During an interview for a family evaluation during the custody fight, Loehren said Ricker was scaring the children by calling the police when he allegedly violated restraining orders.
Based on the evaluator's recommendation, a family court judge ordered the parents into joint counseling. The judge said each had to educate themselves on "child development and high parental conflict."
Ricker, 62, says she asked for a divorce. She says Loehren suggested the two of them sit down and explain it to the children. She says he opened he conversation by saying "Mommy doesn't like daddy anymore, so she is breaking our family apart." The kids started screaming and crying, Ricker says. Then they started to hit her.
Desiree started to gain weight when she was about 5. A therapist would later attribute the weight gain to the family dysfunction. When Desiree was 12, the family doctor told Ricker that her daughter had pre-diabetes. "It just made me cry," Ricker says.
In high school, Desiree says, she gained about 100 pounds – weight she still carries. At 12, Desiree says, she began an abusive relationship with a boyfriend who also came from a violent home. It lasted, on and off, until she was 27. The ex-boyfriend was never charged with abusing her.
Studies show that childhood adversities can lead to obesity later in life. Duke University researchers reported last year that children aged 12 to 15 were far more likely to eat poorly and less likely to get physical activity after exposure to domestic violence.
'These things go together'
It's common for children who are exposed to domestic violence to also suffer other adverse childhood experiences. ACEs are linked to a range of mental and physical health consequences throughout life, up to and including early death.
“If there's domestic violence in the household, it's statistically likely that there's also physical abuse and emotional abuse and maybe drug abuse or alcohol abuse," said Canan Karatekin, a professor of the Institute of Child Development at the University of Minnesota. "These things go together.”
Huff took on the role of protector of her younger siblings. It carried its own burden.
During the summer before fifth grade, she says, she remembers holding one of her sisters in her lap as another was rushed to the hospital after the first of several suicide attempts. "I had to grow up fast and be a second mom to my siblings," she says. "It made me stronger. ... I was determined not to be like my sister or my mother."
But that was nearly impossible.
Huff and her mother say domestic violence spans generations in their family.
Denise Boyd was caring for a year-old daughter while she was pregnant with Huff at 21. Boyd was having a breakdown, she says, after years living with the abusive father of her children.
The father could not be reached for comment. He was never charged with a crime against Boyd.
Boyd's mother went to take her home to Georgia. Once in her parents' home, Boyd says, she rarely went out. On rare occasions when she did, she would hide on the floor of the family car. "I felt like I wasn’t the same anymore," Boyd said. "I didn't know what was happening to me."
Huff was born in August 1979. As a little girl, she developed a speech disorder. In eighth grade, Huff says, she was so anxious she tried to run away. She was sent briefly to a juvenile detention facility.
David Murphey, director of the Child Trends DataBank, describes domestic violence as a type of toxic stress linked to health problems later in life. Domestic violence rewires the brain, he said, harming executive function – "the ability to weigh options and make well-considered choices."
How can communities best address abuse?
Detecting, treating and preventing exposure to domestic abuse are the keys to reducing it, specialists say.
Certified nurse midwife Pamela Glenn, field education supervisor at Minneapolis's Walden University School of Nursing, has screened her patients for abuse for 30 years.
She says health care professionals should create a safe space for patients, don't judge or blame, and avoid using the word "abuse."
“Most people, when they hear the word 'abuse,' they automatically think physical violence," Glenn said. "The abuse may be emotional abuse only – but that can be extremely damaging to people's health.”
She asks questions such as “Does your partner support you?" And "Do you ever find that your partner is constantly checking up on you when you're not together and almost interrogating you at times?" If she suspects abuse, she says, she offers resources such as information for an advocate or safe place.
Specialists say screening alone is not enough. "Screening is the great first step, but it's only a first step," said Jess Bartlett, a trauma researcher with Child Trends. "Too often we look at what kids have experienced, but not how they function." She says health care providers should look at children's needs, and whether the community has the resources to respond.
Murphey agrees. “Unless there are adequate networks of services and referral practices to follow the results up," he said, "what you're doing is you're really setting up an unfortunate situation where you know you've got lots of problems but you don't have services in place yet to respond to them.”
With treatment, researchers wrote in a report for the National Scientific Council on the Developing Child, children exposed to early trauma including domestic violence can overcome the experiences without developing stress-related disorders.
Often the support of parents, friends, family and school can help alleviate the effects of stress and trauma in children, according to the National Child Traumatic Stress Network.
"A strong relationship with a caring, nonviolent parent is one of the most important factors in helping children grow in a positive way despite their experiences," the group wrote in a 2014 report.
But Huth-Bocks said the parents she works with are often "preoccupied keeping everyone alive and can't always be the most sensitive parent.
"There’s bigger fish to fry."
Huff says it was a violent world that her twins entered in July 2014.
She says the father was holding the boy two days after their birth when he took a swing at her. The girl was the crib behind Huff, she says. She says she had to hold onto the crib to keep it from falling.
The father, Ignacio Ramirez Vallejo, denies her account. "It never happened," he told USA TODAY. He was not charged in the alleged incident. “I’ve been in court many times," he said. "Latrelle tried to accuse me for many different things. We were together almost seven years. They never find me guilty.”
Ramirez Vallejo says he did not sexually assault Huff.
His lawyer, A.J. Balbo, gave USA TODAY copies of letters he says Huff wrote to Ramirez Vallejo two years before the twins' birth saying she wanted to have children with him. “Everything they say about me is not true," Ignacio Ramirez said. "I’m a Christian.”
Jeanne Fell, a nurse practitioner who specializes in neurology and has treated Huff's twins, says the pregnancy was about as complicated as they come. Huff had severe vomiting during much of the pregnancy and required intravenous medication. A cesarean section was scheduled at 37 weeks. A typical pregnancy lasts 40.
"It's been pure chaos since these kids have been born," Fell said. "She does her very best, but certainly there are limits to how much she can give of herself to the children."
Both babies were poor eaters, Fell says. The boy had hyptonia, or floppy baby syndrome, which can be caused by nerve or brain damage. He's now on a powerful antipsychotic drug to help with aggression or and self injury, a review of his medical records show. Fell said he's "done really well and is much more calm," but if he goes off the drug, she said, he hits others and tries to escape.
Huff has been getting reports from her daughter's school, including one reviewed by USA TODAY from October in which she was described as "extra tearful today" and accused of "mooning" several other children.
Neither child sleeps more than five hours a night, Huff says. Before he started on his current medication, Huff's son rarely slept more than three hours.
Huff has a master's degree in mental health counseling and is pursuing a second master's in social work. She recently lost her job as an armed security guard after missing work to attend to her children's health appointments She's now looking for a job in mental health case work.
An undocumented immigrant, Ramirez-Vallejo was apprehended in Savannah not long after President Donald Trump took office, an Immigration and Customs Enforcement spokesman said. His case is pending in immigration court. He has argued he should be allowed to stay in this country because he has children here. He sees the children every other weekend for two full days, but is not allowed to spend the night with them.
Huff says she tries to focus on the future.
"My dream is for my children to not grow up in a dysfunctional family, as I did and as their father did," she said. "I want both children to feel safe and to be able to grow in an environment where they will be successful, stable and happy.
"The new generation needs an opportunity to live life without continuing the cycle."
If you or your child is experiencing domestic violence and/or mental health problems:
- Contact the National Domestic Violence Hotline at 1-800-799-SAFE (7233) or online
- Contact the National Suicide Prevention Lifeline at 1-800-273-8255
- Visit the National Child Traumatic Stress Network to learn about resources and treatment.
[This story was originally published by USA Today.]