THE EFFECT OF FAMILY VIOLENCE ON CHILDREN'S ACADEMIC PERFORMANCE AND BEHAVIOR Johnnie Lassiter Dyson, MSW, ACSW Chicago, Illinois
Homicide perpetrated by an acquaintance or a close family member is the leading cause of death among blacks. Black children adversely affected by these violent occurrences suffer posttraumatic stress disorder. The purpose of this study is to illustrate how damage caused to black children from exposure to violence is reflected in behavior problems and poor school performance. Key words * family violence * children and school performance * posttraumatic stress disorder
Six students were referred from a combined seventh and eighth grade classroom of 33 students. Individual interviews with each of the six youngsters revealed histories of extensive family violence, including the murder of a close family member. Twice-weekly individual and group therapy sessions, tutoring, field trips, and home visits were provided with follow-up reports on behavior adjustments and school performance. Two case studies are presented to illustrate the effect of violence on academic performance and behavior. As exposure to family violence has a significant affect on learning and behavior problems in schools, Ms Dyson is a practicing Clinical Social Worker in Chicago, Illinois. Presented to the USA People to People Health-Mental Health Delegation to the People's Republic of China, June 4-21, 1989. Requests for reprints should be addressed to Ms Johnnie Lassiter Dyson, 7233 S. Luella Ave, Chicago, IL 60649.
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violence screening is essential in the diagnostic evaluation of children who experience school failure. The rate of violent crimes in the US, as compared with other Western countries, has dramatically increased within the past 20 years. Pynoss believes we are faced with an "epidemic of violence." This epidemic is even more dramatic among the black inner city population. According to Bell, in 1986 blacks accounted for 44% of murder victims in the US. Homicide accounts for 38% of the "excess death" in black men under age 45 years.3 Inner city children are exposed to violence at an early age. A Chicago survey of 539 second, fourth, sixth, and eighth grade children revealed 17% witnessed parents and other relatives fighting, 33% had seen someone shot, 31% observed a stabbing, and 84% had seen someone beaten up.4 Another survey of a Chicago elementary school revealed 4% of all fifth to eighth grade children aged I I to 15 years had seen someone shot, 31 % had seen a stabbing, and 22% had seen someone killed.5 Violent injury or death of a parent produces severe stress in children, altering their view of the world. Actual witnessing the act may produce acute posttraumatic distress disorder (PTSD) in children. i Feldman6 believes symptoms observed in PTSD can be understood from Kohut's "self-psychology" perspective. Pathologic behaviors that emerge when the "self" is exposed to extreme stress can be an attempt to maintain cohesion. Violent behavior by children exposed to violence often serves to prevent fragmentation of the self and so may not be a primary psychological 17
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configuration, but rather the only response available to prevent self-disintegration. Delinquency in young people exposed to extreme violence can be understood as an attempt to manage overwhelming anxiety. This response could explain the resistance to change and the cycle of repeated violence within families. With this understanding, treatment for these youngsters can often be successful. The inner city school from which the following case studies were taken is located in a run-down, all-black area abandoned by whites. Across the street from the school is a partially abandoned building alleged to be a "dope den," where a seventh grade student had recently been found dead from a drug overdose. This elementary school reportedly has one of the highest police arrest records of any of the city's public schools, including the high schools. The school serves a highly transient population and has an economic base below the poverty level. The children often lack impulse control, and teachers complain that 30% of their time is spent maintaining order. It is not uncommon for weapons to be discovered. The first six students referred for being a "disturbing influence," all from a single classroom, revealed a background of family violence-each child had suffered the loss of a close family member through murder. Although the case histories used in this study may seem extreme, they accurately reflect the chronically dysfunctional environment prevalent within this inner city community. Each of the six students was seen initially in individual sessions. As the pattern of family violence emerged, a group was formed to work on common concerns. Two case histories from the group will be presented for discussion.
CASE 1 David is a 15-year-old black eighth grade male referred for counseling by his teacher, who complained of repeated class disturbances. His first session was postponed because he was suspended from school for car theft. According to school records, he spent much of his day in halls or in the disciplinary office. He was described by teachers as perpetually having a smile on his face. Although viewed as a nervous reaction, this habit tended to intimidate. He allegedly belonged to a street gang. It was not uncommon, teachers reported, for his mother to appear at school looking for her son, who had not come home the previous evening. He was suspended on one such occasion for having come to school drunk. 18
He was described as illiterate. No one could recall having heard him read or having received written material from him. Teachers believed he behaved in a hostile, defiant manner to cover his lack of ability. A referral for learning disabilities had been initiated in his seventh grade year, but for reasons that were unclear, was never acted upon. David is the youngest child in a sibship of seven and was born in the inner city of Chicago. According to his mother, his father died in the county jail's infirmary of a chest and lung abscess, the result of years of heroin use. His mother recalled feeling overwhelmed by the loss of her husband, having experienced their relationship as loving, caring, and nurturing. With his death, she found herself suddenly faced with the burden of rearing seven children alone. Shortly after his father's death, one of David's uncles was killed, and on the night of his wake, a cousin was raped and strangled. Fewer than 2 years later, his oldest brother was killed-shot in the legs and left to bleed to death in an abandoned garage. Distraught by her son's brutal murder and fearing for the safety of her other children, his mother took the remaining children and fled to Arizona, where she remained in seclusion for approximately 2 years. During their 2-year exile, David received a limited and inconsistent education. Following the family's return to Chicago, David was placed in the third grade based only on his age, with no consideration being given to his readiness. His mother admitted to having been aware of his educational deficits, yet no apparent effort was made toward remediation. His mother stated that until recently he had been a "good child," easy going, pleasant, and obedient. During his seventh grade year (age 14), his mother noted the onset of real difficulties with him. Prior to that, he had been held back a grade due to poor academic performance. In seventh grade, he began to experience discipline problems. Most recently (eighth grade) he was held in juvenile detention for car theft. As this was his first encounter with the police, he was given probation. In our initial interview, David was defensive, guarded, and closed. He was distrustful and hostile. When he was told that these behaviors were understandable given his previous experiences with adults, and he felt accepted for who he was, he visibly relaxed. He appeared to sense a different response in this relationship, and a sincere rapport was established. He reported feelings of inadequacy in school, which were related to his lack of ability to comprehend school JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
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work. He also spoke openly about feeling disliked by his teachers because he is "bad." He felt that he was perceived as bad because of his street gang involvement. He reported that some years earlier, an older brother had been killed, and he suspected his brother's death was gang related. He was vaguely aware that this event was significant in his own subsequent gang involvement. Shortly after the initial interview, David was brought into the group of five other boys with similar experiences of losing a close family member through murder. Although he made attempts to participate in group discussions, his presence seemed to intimidate most of the other members. In the group session, he had a stern, fixed expression; his mouth was carved and controlled, and his eyes remained fixed and staring. He seemed compelled to resort to his "street demeanor," a composure in which softness, weakness, vulnerability, and concern for others are never shown. As his trust had been gained in the individual session, where he had allowed the softness of which he was capable to be observed, he was encouraged to share this side of himself in group. He was reassured that during the hour session, it would be okay to trust being himself. Within a few weeks, David merged into the group. He accepted the others and was accepted by them. He was always the first to be chosen for a team. He displayed a keen sense of mission, a drive to excel, and an openness to learn. He was supportive of the other boys, offering helpful suggestions. Although his teachers often complained of his annoying behavior in class, in the group he emerged as arbitrator of conflicts. Following a group outing to a pizza parlor, during which a waitress made insulting remarks to the boys, several group sessions were spent discussing their anger. They experienced intense rage and swore vows of revenge. The incident revealed the intense rage and vulnerability these youngsters feel. Violence, for them, seemed the only way to repair their injured self-esteem. Talking about their anger in the group as opposed to acting on it and beginning to understand their need for action was a new experience for these young men. Shortly thereafter, David's family moved from the school district. Unhappy about the prospect of losing him, the group members, on their own initiative, decided to circulate a petition to keep him in school. After secretly obtaining signatures from their classmates, the document was presented to their teacher. Despite this gallant effort, he was not JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
permitted to remain. However, a most remarkable outcome was observed in this process; for the first time, these young men were attempting to use methods other than violence to solve their problems.
CASE 2 Steve is a 15-year-old black eighth grade male, described as a "powder keg ready to explode." During our initial interview, he spoke of the murder of his mother, which had occurred fewer than 4 months previously. As he described in vivid detail the events that led to his mother's murder, his anger and rage permeated the room. His only solace was in thoughts of revenge. He thought only of the day when he would kill the woman who had killed his mother. He, his siblings, and adult members of his family witnessed his mother's murder. Although his primary caretaker had been his grandmother, he said he and his mother were "friends." "She was fun," he said. "She made us laugh a lot." Steve is a deeply serious young man with a tough exterior. He is feared by his peers and some adults. He stated that he had no friends, as he trusted no one. He had attended eight different public schools from kindergarten through eighth grade. He entered his present school in fifth grade. Each of his teachers reported a litany of unsatisfactory academic performance and disruptive behavior. His teachers had the impression that he was a bright child, as he could always answer questions verbally, but he would go into a rage if asked to write anything down. It was reported that he spent as much as 90% of his time in the discipline office. He had been in trouble for hitting kids, shooting cap bullets, and telling a security guard, "If you love your life, you better leave me alone." He was described as rude, hostile, aggressive, and defiant to all adult authority. He was described as a kid who had a perpetual chip on his shoulder. Steve is the third child in a sibship of four. His older sister left school at the age of 16, after a teenage pregnancy. His older brother, currently in high school, had recently suffered a gun shot wound to his neck. His younger sister, 10 years old, is repeating third grade in a special class for slow learners and is frequently suspended for fighting at school. He was raised, from birth, along with his siblings and numerous cousins, aunts and uncles by his maternal grandmother. His grandmother, a noble matriarch who had 18 children, 48 grandchildren, and 3 great-grandchildren, described a long chronically chaotic family history. 19
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The first death by violent means suffered by this family occurred when Steve's 28-year-old aunt, a prostitute, was shot, point blank, twice in the chest. His 38-year-old uncle was the next victim, shot with a shotgun in an attempted robbery. His 30-year-old aunt was shot, but not killed, by her jealous husband with a 38 caliber gun. His 33-year-old aunt committed suicide by a drug overdose. Steve's mother, 36 years old, died from gunshot wounds inflicted by a woman during a street fight. According to his grandmother, the hospital staff indicated that any chance to save her was lost when they were unable to find a vein to insert an IV. The grandmother remarked that her daughter had "shot dope" in the past and her veins had collapsed. The family was outraged at the light sentence her assailant received, 40 years with chance for parole in 10 years. During individual sessions, as he spoke of his mother and his aunt (who committed suicide), Steve would cry openly, sometimes needing to pace the floor as he talked. After several sessions, during which he had paced the floor, cried, and expressed anger and a need for revenge, he told of a recurrent dream that had left him frightened and upset. In the dream, he saw himself in the back seat of a large black car, seated between his mother and aunt. There was no driver behind the wheel, and the car was out of control going down a steep mountain road. In the dream, his mother and aunt were coaxing him to go with them. He told them repeatedly that he could not. He recalled saying to them, "Remember how bad we felt when you left us. Well, that's how bad grandma would feel if I left her."' He then found himself alone on top of a mountain, free of mother and aunt yet still in need of getting home safely. After telling the dream, he experienced relief from the intense anger and driving urge for revenge that had been a continual preoccupation. He became aware of feeling pride in his sense of importance to his grandmother, and he began to relate some positive happy memories of his mother. As memories of his aunt were shared, it became apparent that she, along with grandmother, served as a surrogate nurturing figure. As these sessions were quite intense, he was allowed to relax before returning to class. During the rest period, he played chess, a game he was eager to try and quick to learn. Following these sessions, Steve became more open and involved during the group discussions. He related what it meant to be a member of an organized street gang and was adamant in his depiction of the gang as organized "'for protection not for violence."' He also 20
spontaneously expressed an interest in improving his reading abilities. In response to his request, he was given a fairly complicated passage to read. He required assistance with every line, both in pronunciation of words and in understanding their meaning. However, when three days later he was asked questions about the passage, he was able to answer each question correctly without hesitation and elaborate on why he made one choice as opposed to another. His comprehension of the passage, his ability to recall detail and use inferences to arrive at a correct answer demonstrated his true intellectual ability. He had not mastered basic phonetics and lacked vocabulary skills, yet his intellectual capacity was clearly apparent. As the school year progressed, he began to settle down, was less agitated in his individual sessions, was supportive of members of the group, and became a model student in class. As graduation approached, he remarked that he felt sad about leaving this school. He graduated with numerous social honors, and the school gave him a standing ovation as he approached the podium to receive his awards.
DISCUSSION These cases, illustrate the extreme impact of violence on the lives of children. David's life was marred early by family tragedy. His mother's reaction to her older son's brutal killing-fleeing the city out of fear and remorse-was one of many negative events that affected this child's development. Formal education was irregular and inconsistent during his first 2 years of schooling. Placed in third grade based on age by persons with no knowledge of his previous experiences and with no consideration of his educational readiness, he had no chance for academic success. Steve's history, although extraordinary, is not exceptional. He lived in an extremely large extended family in which he was exposed to continuous violence. As statistics indicate, exposure to violence is more the rule than the exception among black inner city, children. Children exposed to violence suffer PTSD. Hyman7 identifies four maladaptive stress responses: 1. Resignation, acceptance of helplessness. 2. Impulsive acting out behaviors, loss of emotional control, quick to lose temper or attack others. 3. Avoidance of school and school-related activities, with emotional withdrawal and cognitive denial. 4. Passive-aggressive behaviors, common with underachieving children. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
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David and Steve, as well as other members of the group, responded with acting out and avoidance. These responses, which are distracting and disturbing, tend to gain attention from those in authority. However, children who exhibit characteristics of resignation and passive-aggressive behaviors have the same need to be reached. They also need to be taught that their behavior is a reaction to underlying issues that need to be addressed, not simply punished. Individuals with violent histories, especially if they also come from chaotic and deprived backgrounds, tend to be viewed as untreatable.6 However, psychological work with these youngsters proved useful and productive. Steve's ability to work through internal conflicts related to witnessing his mother's murder produced a marked change in his behavior. Four months following the tragic event, he was angry, agitated, and depressed. He openly vowed to avenge his mother's death. His affect during his early sessions was tense and determined. After several weeks of individual sessions, he shared his recurrent dream. Working through this dream helped to assuage his feelings of helplessness and his need for revenge8; a marked change in his affect was noted in subsequent sessions. In addition to this affective change, his behavior and his ability to attend to academic tasks improved markedly as well. Group therapy sessions were also beneficial for these children. They began to recognize and develop alternative modes of coping with life's stresses, whereas they had previously relied on violence and revenge. The group sessions also provided these young men with an experience of acceptance and a feeling of belongingproductive substitutes for a similar, although counterproductive, feeling which is derived from their participation in organized gang activity. For David, the benefit of the two forms of therapy were apparent as his ability to participate in the group was enhanced by his work in the individual sessions. The traditional therapeutic approaches (individual and group) contributed to the enhancement of self-esteem observed in both cases. Their experience of a caring therapeutic relationship, which enabled them to master acute events, gave them a general sense of potential mastery and provided an new way to build self-esteem. Unfortunately, counseling services are generally unavailable to children in inner city schools. Bell suggests that the medical community has been negligent in developing strategies and interventions to help families affected by violent crime.2 He further postulates that this negligence is most apparent in black JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
communities. Edstrom supports this posture in her description of the inequities observed in support services made available to an affluent Chicago suburban community verses the virtual absence of services, at times of crisis, to Chicago inner city school children.5 The cases of David and Steve, however, clearly demonstrate that when services are made available, inner city children can benefit from the same traditional psychotherapy offered middle class suburban youth. Inner city children may even gain more, as the psychotherapeutic process introduces the idea that as problems are talked about, feelings may change. This idea is often new to them. Dealing with the specific acute violent stresses, in both individual and group settings, had an affect on the general academic and behavioral responses of these students. Responding to the stress to which these youngsters were exposed, as opposed to labeling them as "bad" because of their reactions, activated previously untapped potential. FRr years, Steve's teachers had believed he was intellectually capable, but his behavioral difficulties had markedly interfered with his productivity. After working through his reactions to his mother's death, Steve's enhanced self-esteem was reflected in his improved academic performance. The experience at the pizza parlor points out the added stress that society places on inner city blacks; Pierce calls it "micro-aggression."9 Micro-aggression is the continuous, insidious, display of racially motivated hostility acted out in benign insensitivity. Micro-aggression generates added hostility to children's fragile self-esteem. By responding to their major stresses, new avenues for handling minor stresses were shown to these children. Steve's effort to justify his gang activity is similar to Solomon's description of second generation Holocaust survivors in which he recounts that "survivors and their children have a profound fear of being aggressive and a great need to justify any aggressiveness as temporary and purely defensive." 10 Steve's justification indicated that he was, at some level, uncomfortable with his own violent solutions. His responsiveness to the therapeutic intervention is further evidence of the capacity and desires of these children to cope with life more effectively when they are shown how to do so.
RECOMMENDATIONS 1. Accessible, intensive psychotherapy programs are needed on a wide scale within the black community, as these children do, in fact, benefit from insightorientated and supportive counseling. 21
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2. Psychotherapists should consider the effects of PTSD in working with this population. 3. Children with school failure or behavior problems should be assessed, in addition to routine diagnostic testing, for the occurrence of family violence. 4. Inequities in the distribution of public funds and services must be adjusted to provide the same quality service to inner city youth as that afforded their more affluent suburban neighbors. 5. Recreational and cultural enrichment programs are beneficial in that they provide exposures for these youngsters beyond the boundaries of their own community. These experiences may provide the motivation needed for them to better their circumstances. 6. Homicide perpetrated by acquaintances or family members is the leading cause of death among blacks. Rigorous research in the area of violence of blacks against blacks is, therefore, essential. Literature Cited 1. Pynoss RS, Eth S. Post Traumatic Stress Disorder in Children; Children Traumatized by Witnessing Acts of Personal Violence: Homicide, Rape, or Suicide Behavior. Washington, DC: American Psychiatric Press Inc; 1985:19-31.
22
2. Bell CC, Hildreth CJ, Jenkins EJ, Levi D. The need for victimization screening in a poor outpatient medical population. J Natl Med Assoc. 1988;80:853-860. 3. Nickens H. Report of the secretary's task force on black and minority health: a summary and presentation of health dates with regards to blacks. J Natl Med Assoc. 1986;78:577580. 4. Bell CC, Prothrow-Stith D, Smallwood CS, Murchison C. Black-on-black-homicide: the National Medical Association's Responsibilities. J Natl Med Assoc. 1986;78:139-141. 5. Edstrom K. Victims of violence: separate but unequal treatment. The Chicago Reporter. 1 988;1 7(9): 2. 6. Feldmann TB. Violence as a disintegration product of the self in posttraumatic stress disorder. Am J Psychother. 1 988;42:281 -288. 7. Hyman A, Zelikoff W, Clarke J. Psychological and physical abuse in the schools; a paradigm for understanding post-traumatic stress disorder in children and youth. Journal of Traumatic Stress. 1988;1 :243-266. 8. Pynoos RS, Eth S. Witness to violence: the child interview. American Academy of Child Psychiatry. 1 986;25:306-31 9. 9. Pierce CM. Offensive mechanisms: the vehicle for micro-aggression. In: Barabour FB, ed. The Black 70s. Boston, Mass: Porter Sargent Publications Inc; 1970. 10. Soloman Z, Kotter M, Mikulincer M. Combat-related posttraumatic stress disorder among second-generation Holocaust survivors: preliminary findings. Am J Psychiatry. 1 988;1 b45:865-869.
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Homicide perpetrated by an acquaintance or a close family member is the leading cause of death among blacks. Black children adversely affected by these violent occurrences suffer posttraumatic stress disorder. The purpose of this study is to illustrate how damage caused to black children from exposure to violence is reflected in behavior problems and poor school performance. Key words * family violence * children and school performance * posttraumatic stress disorder
Six students were referred from a combined seventh and eighth grade classroom of 33 students. Individual interviews with each of the six youngsters revealed histories of extensive family violence, including the murder of a close family member. Twice-weekly individual and group therapy sessions, tutoring, field trips, and home visits were provided with follow-up reports on behavior adjustments and school performance. Two case studies are presented to illustrate the effect of violence on academic performance and behavior. As exposure to family violence has a significant affect on learning and behavior problems in schools, Ms Dyson is a practicing Clinical Social Worker in Chicago, Illinois. Presented to the USA People to People Health-Mental Health Delegation to the People's Republic of China, June 4-21, 1989. Requests for reprints should be addressed to Ms Johnnie Lassiter Dyson, 7233 S. Luella Ave, Chicago, IL 60649.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
violence screening is essential in the diagnostic evaluation of children who experience school failure. The rate of violent crimes in the US, as compared with other Western countries, has dramatically increased within the past 20 years. Pynoss believes we are faced with an "epidemic of violence." This epidemic is even more dramatic among the black inner city population. According to Bell, in 1986 blacks accounted for 44% of murder victims in the US. Homicide accounts for 38% of the "excess death" in black men under age 45 years.3 Inner city children are exposed to violence at an early age. A Chicago survey of 539 second, fourth, sixth, and eighth grade children revealed 17% witnessed parents and other relatives fighting, 33% had seen someone shot, 31% observed a stabbing, and 84% had seen someone beaten up.4 Another survey of a Chicago elementary school revealed 4% of all fifth to eighth grade children aged I I to 15 years had seen someone shot, 31 % had seen a stabbing, and 22% had seen someone killed.5 Violent injury or death of a parent produces severe stress in children, altering their view of the world. Actual witnessing the act may produce acute posttraumatic distress disorder (PTSD) in children. i Feldman6 believes symptoms observed in PTSD can be understood from Kohut's "self-psychology" perspective. Pathologic behaviors that emerge when the "self" is exposed to extreme stress can be an attempt to maintain cohesion. Violent behavior by children exposed to violence often serves to prevent fragmentation of the self and so may not be a primary psychological 17
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configuration, but rather the only response available to prevent self-disintegration. Delinquency in young people exposed to extreme violence can be understood as an attempt to manage overwhelming anxiety. This response could explain the resistance to change and the cycle of repeated violence within families. With this understanding, treatment for these youngsters can often be successful. The inner city school from which the following case studies were taken is located in a run-down, all-black area abandoned by whites. Across the street from the school is a partially abandoned building alleged to be a "dope den," where a seventh grade student had recently been found dead from a drug overdose. This elementary school reportedly has one of the highest police arrest records of any of the city's public schools, including the high schools. The school serves a highly transient population and has an economic base below the poverty level. The children often lack impulse control, and teachers complain that 30% of their time is spent maintaining order. It is not uncommon for weapons to be discovered. The first six students referred for being a "disturbing influence," all from a single classroom, revealed a background of family violence-each child had suffered the loss of a close family member through murder. Although the case histories used in this study may seem extreme, they accurately reflect the chronically dysfunctional environment prevalent within this inner city community. Each of the six students was seen initially in individual sessions. As the pattern of family violence emerged, a group was formed to work on common concerns. Two case histories from the group will be presented for discussion.
CASE 1 David is a 15-year-old black eighth grade male referred for counseling by his teacher, who complained of repeated class disturbances. His first session was postponed because he was suspended from school for car theft. According to school records, he spent much of his day in halls or in the disciplinary office. He was described by teachers as perpetually having a smile on his face. Although viewed as a nervous reaction, this habit tended to intimidate. He allegedly belonged to a street gang. It was not uncommon, teachers reported, for his mother to appear at school looking for her son, who had not come home the previous evening. He was suspended on one such occasion for having come to school drunk. 18
He was described as illiterate. No one could recall having heard him read or having received written material from him. Teachers believed he behaved in a hostile, defiant manner to cover his lack of ability. A referral for learning disabilities had been initiated in his seventh grade year, but for reasons that were unclear, was never acted upon. David is the youngest child in a sibship of seven and was born in the inner city of Chicago. According to his mother, his father died in the county jail's infirmary of a chest and lung abscess, the result of years of heroin use. His mother recalled feeling overwhelmed by the loss of her husband, having experienced their relationship as loving, caring, and nurturing. With his death, she found herself suddenly faced with the burden of rearing seven children alone. Shortly after his father's death, one of David's uncles was killed, and on the night of his wake, a cousin was raped and strangled. Fewer than 2 years later, his oldest brother was killed-shot in the legs and left to bleed to death in an abandoned garage. Distraught by her son's brutal murder and fearing for the safety of her other children, his mother took the remaining children and fled to Arizona, where she remained in seclusion for approximately 2 years. During their 2-year exile, David received a limited and inconsistent education. Following the family's return to Chicago, David was placed in the third grade based only on his age, with no consideration being given to his readiness. His mother admitted to having been aware of his educational deficits, yet no apparent effort was made toward remediation. His mother stated that until recently he had been a "good child," easy going, pleasant, and obedient. During his seventh grade year (age 14), his mother noted the onset of real difficulties with him. Prior to that, he had been held back a grade due to poor academic performance. In seventh grade, he began to experience discipline problems. Most recently (eighth grade) he was held in juvenile detention for car theft. As this was his first encounter with the police, he was given probation. In our initial interview, David was defensive, guarded, and closed. He was distrustful and hostile. When he was told that these behaviors were understandable given his previous experiences with adults, and he felt accepted for who he was, he visibly relaxed. He appeared to sense a different response in this relationship, and a sincere rapport was established. He reported feelings of inadequacy in school, which were related to his lack of ability to comprehend school JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
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work. He also spoke openly about feeling disliked by his teachers because he is "bad." He felt that he was perceived as bad because of his street gang involvement. He reported that some years earlier, an older brother had been killed, and he suspected his brother's death was gang related. He was vaguely aware that this event was significant in his own subsequent gang involvement. Shortly after the initial interview, David was brought into the group of five other boys with similar experiences of losing a close family member through murder. Although he made attempts to participate in group discussions, his presence seemed to intimidate most of the other members. In the group session, he had a stern, fixed expression; his mouth was carved and controlled, and his eyes remained fixed and staring. He seemed compelled to resort to his "street demeanor," a composure in which softness, weakness, vulnerability, and concern for others are never shown. As his trust had been gained in the individual session, where he had allowed the softness of which he was capable to be observed, he was encouraged to share this side of himself in group. He was reassured that during the hour session, it would be okay to trust being himself. Within a few weeks, David merged into the group. He accepted the others and was accepted by them. He was always the first to be chosen for a team. He displayed a keen sense of mission, a drive to excel, and an openness to learn. He was supportive of the other boys, offering helpful suggestions. Although his teachers often complained of his annoying behavior in class, in the group he emerged as arbitrator of conflicts. Following a group outing to a pizza parlor, during which a waitress made insulting remarks to the boys, several group sessions were spent discussing their anger. They experienced intense rage and swore vows of revenge. The incident revealed the intense rage and vulnerability these youngsters feel. Violence, for them, seemed the only way to repair their injured self-esteem. Talking about their anger in the group as opposed to acting on it and beginning to understand their need for action was a new experience for these young men. Shortly thereafter, David's family moved from the school district. Unhappy about the prospect of losing him, the group members, on their own initiative, decided to circulate a petition to keep him in school. After secretly obtaining signatures from their classmates, the document was presented to their teacher. Despite this gallant effort, he was not JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
permitted to remain. However, a most remarkable outcome was observed in this process; for the first time, these young men were attempting to use methods other than violence to solve their problems.
CASE 2 Steve is a 15-year-old black eighth grade male, described as a "powder keg ready to explode." During our initial interview, he spoke of the murder of his mother, which had occurred fewer than 4 months previously. As he described in vivid detail the events that led to his mother's murder, his anger and rage permeated the room. His only solace was in thoughts of revenge. He thought only of the day when he would kill the woman who had killed his mother. He, his siblings, and adult members of his family witnessed his mother's murder. Although his primary caretaker had been his grandmother, he said he and his mother were "friends." "She was fun," he said. "She made us laugh a lot." Steve is a deeply serious young man with a tough exterior. He is feared by his peers and some adults. He stated that he had no friends, as he trusted no one. He had attended eight different public schools from kindergarten through eighth grade. He entered his present school in fifth grade. Each of his teachers reported a litany of unsatisfactory academic performance and disruptive behavior. His teachers had the impression that he was a bright child, as he could always answer questions verbally, but he would go into a rage if asked to write anything down. It was reported that he spent as much as 90% of his time in the discipline office. He had been in trouble for hitting kids, shooting cap bullets, and telling a security guard, "If you love your life, you better leave me alone." He was described as rude, hostile, aggressive, and defiant to all adult authority. He was described as a kid who had a perpetual chip on his shoulder. Steve is the third child in a sibship of four. His older sister left school at the age of 16, after a teenage pregnancy. His older brother, currently in high school, had recently suffered a gun shot wound to his neck. His younger sister, 10 years old, is repeating third grade in a special class for slow learners and is frequently suspended for fighting at school. He was raised, from birth, along with his siblings and numerous cousins, aunts and uncles by his maternal grandmother. His grandmother, a noble matriarch who had 18 children, 48 grandchildren, and 3 great-grandchildren, described a long chronically chaotic family history. 19
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The first death by violent means suffered by this family occurred when Steve's 28-year-old aunt, a prostitute, was shot, point blank, twice in the chest. His 38-year-old uncle was the next victim, shot with a shotgun in an attempted robbery. His 30-year-old aunt was shot, but not killed, by her jealous husband with a 38 caliber gun. His 33-year-old aunt committed suicide by a drug overdose. Steve's mother, 36 years old, died from gunshot wounds inflicted by a woman during a street fight. According to his grandmother, the hospital staff indicated that any chance to save her was lost when they were unable to find a vein to insert an IV. The grandmother remarked that her daughter had "shot dope" in the past and her veins had collapsed. The family was outraged at the light sentence her assailant received, 40 years with chance for parole in 10 years. During individual sessions, as he spoke of his mother and his aunt (who committed suicide), Steve would cry openly, sometimes needing to pace the floor as he talked. After several sessions, during which he had paced the floor, cried, and expressed anger and a need for revenge, he told of a recurrent dream that had left him frightened and upset. In the dream, he saw himself in the back seat of a large black car, seated between his mother and aunt. There was no driver behind the wheel, and the car was out of control going down a steep mountain road. In the dream, his mother and aunt were coaxing him to go with them. He told them repeatedly that he could not. He recalled saying to them, "Remember how bad we felt when you left us. Well, that's how bad grandma would feel if I left her."' He then found himself alone on top of a mountain, free of mother and aunt yet still in need of getting home safely. After telling the dream, he experienced relief from the intense anger and driving urge for revenge that had been a continual preoccupation. He became aware of feeling pride in his sense of importance to his grandmother, and he began to relate some positive happy memories of his mother. As memories of his aunt were shared, it became apparent that she, along with grandmother, served as a surrogate nurturing figure. As these sessions were quite intense, he was allowed to relax before returning to class. During the rest period, he played chess, a game he was eager to try and quick to learn. Following these sessions, Steve became more open and involved during the group discussions. He related what it meant to be a member of an organized street gang and was adamant in his depiction of the gang as organized "'for protection not for violence."' He also 20
spontaneously expressed an interest in improving his reading abilities. In response to his request, he was given a fairly complicated passage to read. He required assistance with every line, both in pronunciation of words and in understanding their meaning. However, when three days later he was asked questions about the passage, he was able to answer each question correctly without hesitation and elaborate on why he made one choice as opposed to another. His comprehension of the passage, his ability to recall detail and use inferences to arrive at a correct answer demonstrated his true intellectual ability. He had not mastered basic phonetics and lacked vocabulary skills, yet his intellectual capacity was clearly apparent. As the school year progressed, he began to settle down, was less agitated in his individual sessions, was supportive of members of the group, and became a model student in class. As graduation approached, he remarked that he felt sad about leaving this school. He graduated with numerous social honors, and the school gave him a standing ovation as he approached the podium to receive his awards.
DISCUSSION These cases, illustrate the extreme impact of violence on the lives of children. David's life was marred early by family tragedy. His mother's reaction to her older son's brutal killing-fleeing the city out of fear and remorse-was one of many negative events that affected this child's development. Formal education was irregular and inconsistent during his first 2 years of schooling. Placed in third grade based on age by persons with no knowledge of his previous experiences and with no consideration of his educational readiness, he had no chance for academic success. Steve's history, although extraordinary, is not exceptional. He lived in an extremely large extended family in which he was exposed to continuous violence. As statistics indicate, exposure to violence is more the rule than the exception among black inner city, children. Children exposed to violence suffer PTSD. Hyman7 identifies four maladaptive stress responses: 1. Resignation, acceptance of helplessness. 2. Impulsive acting out behaviors, loss of emotional control, quick to lose temper or attack others. 3. Avoidance of school and school-related activities, with emotional withdrawal and cognitive denial. 4. Passive-aggressive behaviors, common with underachieving children. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
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David and Steve, as well as other members of the group, responded with acting out and avoidance. These responses, which are distracting and disturbing, tend to gain attention from those in authority. However, children who exhibit characteristics of resignation and passive-aggressive behaviors have the same need to be reached. They also need to be taught that their behavior is a reaction to underlying issues that need to be addressed, not simply punished. Individuals with violent histories, especially if they also come from chaotic and deprived backgrounds, tend to be viewed as untreatable.6 However, psychological work with these youngsters proved useful and productive. Steve's ability to work through internal conflicts related to witnessing his mother's murder produced a marked change in his behavior. Four months following the tragic event, he was angry, agitated, and depressed. He openly vowed to avenge his mother's death. His affect during his early sessions was tense and determined. After several weeks of individual sessions, he shared his recurrent dream. Working through this dream helped to assuage his feelings of helplessness and his need for revenge8; a marked change in his affect was noted in subsequent sessions. In addition to this affective change, his behavior and his ability to attend to academic tasks improved markedly as well. Group therapy sessions were also beneficial for these children. They began to recognize and develop alternative modes of coping with life's stresses, whereas they had previously relied on violence and revenge. The group sessions also provided these young men with an experience of acceptance and a feeling of belongingproductive substitutes for a similar, although counterproductive, feeling which is derived from their participation in organized gang activity. For David, the benefit of the two forms of therapy were apparent as his ability to participate in the group was enhanced by his work in the individual sessions. The traditional therapeutic approaches (individual and group) contributed to the enhancement of self-esteem observed in both cases. Their experience of a caring therapeutic relationship, which enabled them to master acute events, gave them a general sense of potential mastery and provided an new way to build self-esteem. Unfortunately, counseling services are generally unavailable to children in inner city schools. Bell suggests that the medical community has been negligent in developing strategies and interventions to help families affected by violent crime.2 He further postulates that this negligence is most apparent in black JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 1
communities. Edstrom supports this posture in her description of the inequities observed in support services made available to an affluent Chicago suburban community verses the virtual absence of services, at times of crisis, to Chicago inner city school children.5 The cases of David and Steve, however, clearly demonstrate that when services are made available, inner city children can benefit from the same traditional psychotherapy offered middle class suburban youth. Inner city children may even gain more, as the psychotherapeutic process introduces the idea that as problems are talked about, feelings may change. This idea is often new to them. Dealing with the specific acute violent stresses, in both individual and group settings, had an affect on the general academic and behavioral responses of these students. Responding to the stress to which these youngsters were exposed, as opposed to labeling them as "bad" because of their reactions, activated previously untapped potential. FRr years, Steve's teachers had believed he was intellectually capable, but his behavioral difficulties had markedly interfered with his productivity. After working through his reactions to his mother's death, Steve's enhanced self-esteem was reflected in his improved academic performance. The experience at the pizza parlor points out the added stress that society places on inner city blacks; Pierce calls it "micro-aggression."9 Micro-aggression is the continuous, insidious, display of racially motivated hostility acted out in benign insensitivity. Micro-aggression generates added hostility to children's fragile self-esteem. By responding to their major stresses, new avenues for handling minor stresses were shown to these children. Steve's effort to justify his gang activity is similar to Solomon's description of second generation Holocaust survivors in which he recounts that "survivors and their children have a profound fear of being aggressive and a great need to justify any aggressiveness as temporary and purely defensive." 10 Steve's justification indicated that he was, at some level, uncomfortable with his own violent solutions. His responsiveness to the therapeutic intervention is further evidence of the capacity and desires of these children to cope with life more effectively when they are shown how to do so.
RECOMMENDATIONS 1. Accessible, intensive psychotherapy programs are needed on a wide scale within the black community, as these children do, in fact, benefit from insightorientated and supportive counseling. 21
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2. Psychotherapists should consider the effects of PTSD in working with this population. 3. Children with school failure or behavior problems should be assessed, in addition to routine diagnostic testing, for the occurrence of family violence. 4. Inequities in the distribution of public funds and services must be adjusted to provide the same quality service to inner city youth as that afforded their more affluent suburban neighbors. 5. Recreational and cultural enrichment programs are beneficial in that they provide exposures for these youngsters beyond the boundaries of their own community. These experiences may provide the motivation needed for them to better their circumstances. 6. Homicide perpetrated by acquaintances or family members is the leading cause of death among blacks. Rigorous research in the area of violence of blacks against blacks is, therefore, essential. Literature Cited 1. Pynoss RS, Eth S. Post Traumatic Stress Disorder in Children; Children Traumatized by Witnessing Acts of Personal Violence: Homicide, Rape, or Suicide Behavior. Washington, DC: American Psychiatric Press Inc; 1985:19-31.
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2. Bell CC, Hildreth CJ, Jenkins EJ, Levi D. The need for victimization screening in a poor outpatient medical population. J Natl Med Assoc. 1988;80:853-860. 3. Nickens H. Report of the secretary's task force on black and minority health: a summary and presentation of health dates with regards to blacks. J Natl Med Assoc. 1986;78:577580. 4. Bell CC, Prothrow-Stith D, Smallwood CS, Murchison C. Black-on-black-homicide: the National Medical Association's Responsibilities. J Natl Med Assoc. 1986;78:139-141. 5. Edstrom K. Victims of violence: separate but unequal treatment. The Chicago Reporter. 1 988;1 7(9): 2. 6. Feldmann TB. Violence as a disintegration product of the self in posttraumatic stress disorder. Am J Psychother. 1 988;42:281 -288. 7. Hyman A, Zelikoff W, Clarke J. Psychological and physical abuse in the schools; a paradigm for understanding post-traumatic stress disorder in children and youth. Journal of Traumatic Stress. 1988;1 :243-266. 8. Pynoos RS, Eth S. Witness to violence: the child interview. American Academy of Child Psychiatry. 1 986;25:306-31 9. 9. Pierce CM. Offensive mechanisms: the vehicle for micro-aggression. In: Barabour FB, ed. The Black 70s. Boston, Mass: Porter Sargent Publications Inc; 1970. 10. Soloman Z, Kotter M, Mikulincer M. Combat-related posttraumatic stress disorder among second-generation Holocaust survivors: preliminary findings. Am J Psychiatry. 1 988;1 b45:865-869.
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