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Stress as a Factor in Family Violence

23 Sep 2013
Aaron J. Miller, MD, MPA - Executive Director of BRANCH - Building Regional Alliances to Nurture Child Health,
Aaron J. Miller
As discussions evolve over the Millennium Development Goals and "after 2015", imagine, for a moment, a development goal which would address 61% of the incidence of people missing 14+ days of work because of mental health conditions, 26% of the incidence of cardiovascular disease, 24% of cancer, 59% of high risk sex behavior and infection transmission, 50% of teen pregnancy, 21% of alcoholism and heavy drinking, 33% of separation or divorce, 43% of hopelessness, and 67% of life dissatisfaction. Adverse childhood experiences - from abuse and neglect to having parents who were violent with each other or had mental illness - are responsible for these poor health outcomes.1,2

Research on child maltreatment - from prevention to diagnosis and treatment - has reached such fascinating levels of detail that front-line practitioners and policy makers can be guided not only by the concept of Child Rights, but also by a scientific base of best practices and a clearer understanding of the costs of not investing in children and families.

Some types of stress - like a family member dying, or a serious illness - can be tolerated by children if they have a supportive caregiver to help them through the experience.3 However, if children do not have a supportive caregiver, or if the stressor is intense enough or frequent enough, the stress can become toxic and disrupt the normal circuitry of the brain with prolonged elevation of stress hormones, including cortisol, norepinephrine and adrenaline, which eventually lead to permanent changes in the telomeres of the child’s DNA.4,5,6 Unable to cope with this toxic stress, children exhibit a wide range of responses, from internalizing all their fears and frustrations and becoming depressed, to externalizing everything and being hyperactive, inattentive, and causing problems with family members and in school.

Child maltreatment affects not only the behavioral, cognitive, affective and physical functioning of school age children, it even can affect the health of fetuses if the mother is experiencing significant stress.7,8 And while violence against children garners some attention, neglect in the first 3 years of life is responsible for more deaths than abuse and can cause worse behavior outcomes than abuse.9,10

This cumulative "wear and tear" on the body and mind, known as "allostatic load" 11, leads not only to much higher rates of unhealthy behaviors - like smoking, overeating, and unprotected sex, which result in infections, lung and heart disease and chemical addiction 2 - it also has direct effects on the body’s immune system and its ability to respond to infections.12

As this scientific body of knowledge has grown, it has become clear that child maltreatment is more than a social problem - child maltreatment is a medical problem that has serious personal, social and legal consequences - and pediatric health providers are well positioned as experts in growth and development to help lead the charge in research, policy and practice.

As a child abuse pediatrician working in a community challenged by high poverty rates and societal neglect, my daily mission is to help children and parents from many countries and ethnicities to feel comfortable to open up about their lives so that I can provide an accurate diagnosis and treatment. Knowing that doctors in the U.S. and abroad receive very little training on child maltreatment - even on topics as basic as genital anatomy 13,14,15,16 - my research has ranged from assessing interagency coordination on child sexual abuse in New York 17 to physician education on child sexual abuse in Malawi.18 While my research has helped provide evidence on the effectiveness of implementing best practices, I barely scraped the surface, and there is so much more research that could be done if there were greater access to funding.

I recently had the honor of being invited to evaluate research grant applications from across the United States addressing two different topics - teen dating violence, and the screening and treatment of suicidal patients in Emergency Departments. The applications that rose very quickly to the top among our expert panel of reviewers were those in which the lead investigators had already previously received large federal grants, and those who worked in medical centers with large infrastructures of support staff who could help write the 100-page proposals. For the vast majority of clinicians, whose primary responsibility is patient care, applying for grants like these, not to mention being awarded one, is almost impossible.

The World Health Organization and the U.S. Preventive Services Task Force each conducted a meta-analysis of the extant scientific literature on child maltreatment prevention, and they reached the same conclusion: prevention works.19,20 Programs that strengthen families - that promote safe, stable, nurturing relationships - are effective in primary and secondary prevention of child maltreatment, but these interventions need further dissemination, and there are many other interventions and questions that need to be researched. Funders must bring front-line experts to the table in order to provide the accurate information needed to set priorities, and to determine realistic, helpful metrics to assess outcomes.

As public health agencies, governments, foundations and philanthropists better understand brain development and exactly how adverse childhood experiences lead to so many long-term medical and mental health problems and costs to society, a shift in funding priorities can hopefully take hold this time. Advocates for children have known for centuries what scientists and economists have now found in clear terms with statistics: helping children and strengthening families is not only the right thing to do, it makes sense economically, and it makes the world a better place to live.


1- Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M. et al. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 14:245-258.

2- Washington State Family Policy Council (2012). Summary of ACE studies downloaded from - These statistics are a summary from more than 50 peer-reviewed scientific studies from the ACE cohort, which has followed over 17,000 adults over time to assess the long-term effects of adverse childhood experiences including: sexual abuse, physical abuse, emotional abuse and neglect, physical neglect, having parents who abused alcohol or drugs, or father who beat the mother, parents who separated or divorced, parents with mental illness, or a family member who was imprisoned. Data from countries all over the world demonstrate similar effects.

3- Shonkoff, J.P., Garner, A.S., The Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section On Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 129:e232-e246.

4- Compas, B.E. (2006). Psychobiological processes of stress and coping: implications for resilience in children and adolescents - comments on the papers of Romeo & McEwen and Fisher et al. Ann N Y Acad Sci. 1094:226-234.

5- Gunnar, M., Quevedo, K. (2007). The neurobiology of stress and development. Annu Rev Pschol. 58:145-173.

6- McEwen, B.S. (2007). Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev. 87:873-904.

7- Oberlander, T.F., Weinberg, J., Papsdorf, M., Grunau, R., Misri, S., Devin, A.M. (2008). Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses. Epigenetics. 3:97-106.

8- Brand, S.R., Engel, S.M., Canfield, R.L., Yehuda, R. (2006). The effect of maternal PTSD following in utero trauma exposure on behavior and temperament in the 9-month-old infant. Ann N.Y. Acad Sci. 1071:454-458.

9- Sedlak, A.J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., Greene, A., and Li, S. (2010). Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress, Executive Summary. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families.

10- Litrownik, A.J., Runyan, D.K., Bangdiwala, S.I., Margolis, B., Kotch, J.B. (2008). Importance of Early Neglect for Childhood Aggression. Pediatrics. 121:725-731.

11- McEwen, B.S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Ann N Y Acad Sci. 840:33-44.

12- Bierhaus, A., Wolf, J., Andrassy, M. et al. (2003). A mechanism converting psychological stress into mononuclear cell activation. Proc Natl Acad Sci U.S.A. 100:1920-1925.

13- Adams, J.A., & Wells, R. (1993). Normal versus abnormal genital findings in children: how well do examiners agree? Child Abuse & Neglect. 17:663-675.

14- Dubow, S. R., Giardino, A. P., Christian, C. W., & Johnson, C. F. (2005). Do pediatric chief residents recognize details of prepubertal female genital anatomy: a national survey. Child Abuse & Neglect. 29:195-205.

15- Heisler, K.W., Starling, S.P., Edwards, H., & Paulson, J.F. (2006). Child abuse training, comfort, and knowledge among emergency medicine, family medicine and pediatric residents. Medical Education Online, 11, Retrieved from

16- Lentsch, K. A., & Johnson, C. F. (2000). Do physicians have adequate knowledge of child sexual abuse? The results of two surveys of practicing physicians, 1986 and 1996. Child Maltreatment. 5:72-78.

17- Miller, A., Rubin, D., (2009). The contribution of children’s advocacy centers to criminal prosecutions of child sexual abuse. Child Abuse & Neglect: The International Journal. 33: 12-18.

18- Miller, A., Barlup-Toombs, K. (in press). Educating Physicians Internationally in the Diagnosis of Child Sexual Abuse: Evaluation of a Brief Educational Intervention in Malawi. Journal of Child Sexual Abuse.

19- Mikton, C., Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization. 87:353-361.

20- Selph, S.S., Bougatsos, C., Blazina, I., Nelson, H.D. (2013). Behavioral interventions and counseling to prevent child abuse and neglect: a systematic review to update the U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 158:179-190.