Violence begins at home

Physical violence in the family probably blights the lives of more people than all genetic disorders put together, yet research on the issue has struggled to achieve scientific legitimacy.¹ Violence in the family includes “any act or omission committed within the framework of the family by one of its members that undermines the life, the bodily or psychological integrity, or liberty of another member of the same family or that seriously harms the development of his or her personality.”² Separating the causes and effects of domestic violence from those of poor parenting, poverty, homelessness, substance abuse, and violent neighbours and schools is a tough research challenge.³ 

Estimates of how many people experience violence in the family depend on definition, circumstances, and the method of inquiry,¹ but even the lowest figures show that this is a common and serious problem. Several forms of violence and abuse may occur in the same family; children, parents and their partners, and older family members may be victims or perpetrators and may switch roles at different times.⁴,⁵

Violence between adult partners occurs in all social classes, all ethnic groups and cultures, all age groups, in disabled people as well as able bodied, and in both homosexual and heterosexual relationships. It may involve abuse, accusation, and innuendo; deprivation of freedom; or physical or sexual assault. Women are more likely to be injured than men in domestic incidents, but men are not necessarily the initial aggressors.

Adult victims of repeated violence suffer physical injuries; a range of emotional and psychological problems, including self harm, eating disorders, post traumatic stress disorder, suicide; and somatic complaints such as irritable bowel syndrome. Children in violent households are three to nine times more likely to be injured and abused, either directly or while trying to protect their parent. Conversely, in 60% of cases where children have been abused the mother will also have been a victim. The impact on children depends on the intensity and frequency of the violence more than their gender or age, but the presenting features are as varied as in adults. Affected children often have other problems, such as involvement in endemic street and playground violence, bullying in school, educational failure, and exclusion from or dropping out of school, and an increased incidence of attention deficit hyperactivity disorder.⁶ If the mother changes address often or enters a refuge to escape her violent partner, social isolation and loss of friends add to the children’s insecurity.

Exposure to violence in the home is linked to juvenile crime. Conduct disorder and antisocial behaviour, even at the age of 7, are powerful predictors of violent behaviour towards partners in adolescence and early adult life. The history of violence between partners often begins with fights and assaults on dates. These complex sequences and associations are probably mediated through a mixture of stress, poor parenting, low self esteem, shame, and self blame. A genetic predisposition to violent behaviour may make a small contribution.⁷

What can be done about it? Many of the causes of violence are beyond the reach of health professionals, but in the case of child abuse acknowledgement by professionals and society that child abuse happened and was unacceptable was the first step towards protecting children. The same may be true for other forms of violence in the family.

Next, all health professionals should be more aware of domestic violence in clinical practice. Health visitors, school nurses, and community midwives are well placed to prevent, identify, and intervene when domestic violence affects children or partners. They do not need a detailed knowledge of family law,⁸ but they do need to know when and how to seek expert help and how to avoid making matters worse. Sensitive questions about unacceptable behaviour at home may help children and parents to reveal distressing situations. Simplistic assumptions about why women get into and remain in violent situations must be discarded—life for these families is seldom simple. Training about violence should be included in routine multiagency teaching on child protection.⁹

What about prevention? Largescale interventions aimed at improving mental health in general and reducing aggressive behaviour in particular seem ambitious. Nevertheless, the pooled effect sizes for a range of community-wide mental health interventions are impressive.¹⁰ Parent support, use of voluntary groups, community parent advisers,¹¹ and school programmes to promote better interpersonal skills and reduce bullying have all been shown to have positive benefits. One thing is certain, however: there will never be one quick, simple, or universal solution.