Do we need to change the language of child abuse?

Part of the resistance to identifying traumatic childhood experience in patients centers on not knowing how to respond when the answer is Yes.  A good sentence to keep in mind is "Tell me how that has affected you later in life."  For instance, "I see on the Questionnaire that you were frequently beaten as a little girl.  Tell me how that has affected you later in life."  or "I see on the Questionnaire that your mother was a drug addict.  Can you tell me how that has affected you later in life."  

Yes, Jane, this is very important. While ACEs will always happen, people need the proper language to attach to them in order to prevent, minimize, recognize and then treat. Since there is now a board exam relating to the treatment of child abuse as it may be seen in hospital emergency rooms by doctors who may or may not have had training in medical school, I wonder what language is used by that test. And I wonder if there are now medical school classes in the treatment of child abuse and stress? 

Hi Jane,

I'm glad you brought this up as a forum topic. You're right; the word "abuse" is very loaded. As well as the criminal implications, many people do not want to identify themselves as having been abused; they feel ashamed by their caregiver's poor treatment of them. Shame has been shown to have a protective factor as well. When kids keep silent about the abuse, their abuser is less likely to incite further harm. Children often feel the abuse is their fault, which also keeps them silent in shame. Furthermore, many kids who are abused still love their parents and want to protect them. Keeping silent about abuse is one of the hardest habits to break, no matter how old a person is. Shame is thus very powerful in keeping the inter-generational transmission of ACEs going!

Perhaps it would help to make distinctions between different adverse childhood experiences based on best practices for treatment. I am currently training in sensorimotor psychotherapy, and we work with trauma based on the long-term impact on both psyche and soma. (For more information about sensorimotor psychotherapy, visit: http://www.sensorimotorpsychotherapy.org/home/index.html) Sensorimotor psychotherapy (and I suspect other modalities) identifies three types of "trauma-related tendencies," which are determined by what originally caused the trauma-related stress and defenses:

1) Trauma-related tendencies that result from overwhelming experiences (Big "T" traumas);

2) Maladaptive attachment-related tendencies, which result from such experiences as the non-abuse ACEs that involve early caregivers who caused emotional distress; and

3) Relational trauma, which results from having a dangerous caregiver (one who abuses) or even a "frightened" caregiver, such as a mother who is a victim of intimate partner violence.

I think this categorization can potentially lessen defensiveness and shame, since the focus is on the the body's natural defense responses and the importance of early attachment relationships for a healthy mind and body. I think it could  be a valuable schema for educating the public and parents on the causal relationship between ACEs and later life health problems in a way that is less focused on blame and more driven by identifying the conditions a growing infant and child needs in order to thrive. I have found with this schema there is less need to bring in moral judgment and more opportunities to educate about best practices for raising children.

The term "toxic stress" gets people in the door and listening. Everybody knows "stress." "Toxic" will get people thinking. And folks will be open to the new way of categorizing the three types of stress: positive, tolerable, and toxic: http://bit.ly/ri73ws.  Yes, "child abuse" is too loaded and repellant. Language and how we use it is key to changing things. Thought-provoking interview from language expert, Boroditsky here: http://bit.ly/w5y3KQ. Also worth knowing is how English is a very "blaming"/punitive language in how it is currently used. And it is reinforced virally throughout the social body via all forms of mass and social media. Reality-TV is the worst. As Slutkin said in his presentation (tiny.cc/Slutkin) modeling behaviors are picked up by our mirror neurons and locked in by social pressures. So important to understand this is how it works.

I totally agree with you. This has been a huge interest of mine! Also, terms like combating child abuse or fighting child abuse give exactly the wrong message.  This effort is about promoting peace and safety and non-violence, and when you use words like "fight", "combat", "target", etc., you give the opposite message,

Richard Aronson

Instead of "target" a population or a problem such as child abuse, use the words "serve" or "focus on" or "direct our efforts" at.

Instead of "combat" domestic violence, say "find creative, innovative, and positive ways" to make a positive impact on domestic violence.

Instead of "targeted case management" as a Medicaid benefit, say "focused care coordination". People don't want to be targeted at or managed or treated as cases.

Instead of focusing mostly on deficits and pathology and risks and what's wrong with people and communities, focus on their strengths, and their resilience.

Instead of always saying needs assessment, say needs and strengths assessment.

These are just a few: We need to get away from blaming the individual, to understanding how indicidual behavior is frequently an attempt to deal with an impossibly hard situation or experience. And thus, our language should reflect that.

 

Richard Aronson

These are all good points. Toxic stress is indeed less loaded than child abuse, Chris. As you point out, that's what Jack Shonkoff (Harvard Center on the Developing Child) is using as an easy way to understand all this.

Laura, your points made me realize that we have a lot of educating to do about what trauma is, especially since verbal abuse is right up there with sexual abuse by a family member has causing the most damage, according to Martin Teicher and Vincent Felitti.   

Richard -- have you identified any words besides peace, safety and non-violence? 

The more reporting I do on this, the more I see how we're stuck in blaming/punitive language, as you mention, Chris, which practically causes a knee-jerk reaction to rely on punishment rather than taking the time to think through a solution. It's nice to see organizations taking a different approach, such as the LA City Council in changing its policy on ticketing truant kids (that's in today's news roundup). 

Thanks for this excellent discussion - language is so important.  I think it's critical to remember that trauma refers to the response to an event or series of events.   The use of the term toxic stress does provide more universality further more it makes it more clear that there is a link to the biological impact of early adverse experiences and broadens the understanding of risk factors to include environmental and social factors, as well as the relational factors.

That's so interesting that you talk with parents about ACEs & resilience factors, Jim. What's been the response? Have some parents embraced it? Do any think it's ridiculous?

Jane, you bring up a very good point.  I think some of our high risk parents would respond better to "child trauma" instead of jumping to the defense when approached for "child abuse."  I wonder by changing the language if this would open some doors to getting parents to seek some help or be willing to participate in family reconciliation services.  I have a large poster in my office that lists the 10 ACE's along with attributes that build resilience to trump the ACE's in one's life. I have had some very meaningful conversations with parents as they identify their own ACE's by looking at the chart and then listening as I share with them how they can trump those ACE's by developing meaningful adult relationships for support.  I don't ask them to reveal their ACE's, I just ask them to look at the chart and share how many ACE's they have experienced in their lives. The problem is so overwhelming, I think we start with one parent at a time.  Thanks for all that you do Jane!   Jim

Very interesting, Kathy. So, exactly how do you talk with the adults? 

I appreciate your thorough thoughtfulness Jane.  Yes, I definitely think that changing the language to reflect the other things that harm children and their developing brains, such as the "trauma of family dysfunction," that are not, per se, criminal offenses, could help immeasurably in the efforts to educate and prevent childhood trauma.

When I think about my own family's dysfunction, even after the removal of the perpetrator, I know that the trauma did not end with his removal and has had long lasting effects on every one of us.

I would advocate for changing the terms "child abuse" to "child trauma" and certainly hope that it could make another step toward making this a healthier world for all children.

There are so many wonderful responses to this question. Several people pointed out that we have to keep in mind the parents' own trauma experiences. I think this is absolutely critical. And - we need to look at current cultural practices (including medical practices) that add to parents' trauma and create new trauma rather than alleviating it. We are missing so many opportunities to help parents and children.

 

To create a healthier world for children, we have to create a healthier world for parents. And we have to look not only at family dysfunction but at our culture's dysfunction (income inequality, racism, harmful maternity practices, societal hostility toward parents and children). 

 

I think this is a critical piece of the puzzle: adopting the “parental experience of child rearing” perspective, as explained by Alice van der Pas.  It takes a while to get used to this idea -- it's not about the actions the parents do that impact the child, it's about how the parents' world (including their own childhood experiences and current cultural experiences) impact their experience of raising a child. And that parental experience is expressed in the way the parent cares for the child, in emotional connection (or lack of connection), in tone of voice, physical care (tender or rough contact), in the parents' ability (or lack) to reflect on the child's experience (researchers call it mind-mindedness). I wrote about van der Pas' ideas in Thinking about Parenting:

Van der Pas offers a thorough rethinking of many myths about child rearing. Rather than categorizing children as either "at risk" or not, she asks us to recognize that children are put at risk when there are not adequate buffering processes [she uses the term moderating factors]. The first moderating factor is "a community which acknowledges the importance of parenting" and by "acknowledge" she means not only respect and encouragement but also concrete support, including economic support and also the nurturing of parents. As van der Pas emphasizes and strong research demonstrates, appropriate moderating factors such as interventions, support and services can improve a parent's well-being and nurturing behaviors.

 

And this:

Van der Pas notes about contextual factors including parents' relationship difficulties and poverty: "the 'risks' are risky only in so far as we do not 'buffer' them [with moderating factors]".

As Alice van der Pas says, in order for parents to nurture their children, they must themselves be nurtured; and she quotes anthropologist Sarah Hrdy: “Nurturing has to be teased out, reinforced, maintained. Nurturing itself needs to be nurtured.”7 In the Western world and among behavioral scientists, however, van der Pas observes widespread belief that parents themselves do not need to be nurtured. Also, many people think that a not-so-nurturing parent is a fixed contextual factor (or risk factor)--when in reality, and as shown by evidence-based research studies, appropriate and sufficient moderating factors (support, services, interventions) are likely to improve this parent's nurturing behaviors.

I think the van der Pas "parental experience" perspective would help change the conversation (including the words we use) about child abuse/neglect.

 

I recently read Dr. Felitti's 2003 article "The Origins of Addiction" (thanks to Kathy Brous, who wrote about this her on ACESConnection and on her blog). On page 10, Dr. Felitti writes about the importance of primary prevention and some of the barriers as well as potential avenues such as mass media.

 

A great example of a community public health prevention focused on parents:

In Madison, Wisconsin, the community achieved a drastic drop in the rate of preterm births among African Americans. Quoted in this New York Times article, the County health director, Dr. Schlenker, said "Pregnant women need to feel safe, cared for, and valued..."

 

For more on mother-friendly maternity care, see the Coalition for Improving Maternity Services

 

For a long time, I've been collecting resources related to parent support, and listening to parents talk about their struggles and what kinds of things help. Here are some thoughts and examples: 

 

Years ago there was a pilot study that placed social-emotional support staff in pediatrician's offices. These staffers saw parents at the time they came for well-baby checkups, and their role was to talk with the parents about many ACES issues (though this was before the ACES study). Funding ran out. I think I could find that study again if anyone is interested.

 

If we could emphasize a “growth mindset” for parents (as researcher Carol Dweck terms it as applied to children’s learning) I think it would have a powerful effect. As parents learn, they will share that knowledge with others.

 

A few examples: Most parents didn’t even consider homeschooling a few decades ago, they thought they were not qualified to “teach” their children. But as some people homeschooled, and learned more about how children learn, they gained confidence, they shared their experiences with others. Another example is breastfeeding, promoted by a grassroots nonprofit started by mothers – La Leche League…. And another example is home birth.

 

Via Facebook, parents are sharing their struggles to change their behavior and reduce stress for their children, and they are attracting tens of thousands of followers. Two examples:

The Orange Rhino (a mother who vowed to stop yelling)

The Hands-Free Revolution (a mother who vowed to stop being so perfectionist/busy when she realized how much stress she was causing for her young daughters). Here’s my review of her new book, Hands Free Mama.

 

And this mother writes about her philosophy of gentle parenting - Nurshable - with plenty of day-to-day experiences as illustrations of the challenges, struggles and successes. Others find inspiration here, a sense of community and shared struggle to be patient, loving, kind.

My organization, Family and Home Network, published a monthly journal for parents for 22 years. Now some of the articles are on our website. One of the most popular is “Learning from a Difficult Child” by Jeanne Faulconer. The comments illustrate how hungry parents are for understanding, for support and insight. Our capacity to follow through with the parents who comment is so limited. There is so much need.  

 

A parent support organization that does a great job in helping parents who want to do better with their relationship with their children is Hand-in-Hand Parenting. They offer webinars, telephone support, a blog, and informational articles – this one touches on parents’ ACES (without using ACES)… language here might be useful: “I swore I’d never say that! On being a parent”

 

On taking a public health approach to prevention, I highly recommend a book I just finished reading - “Join the Club” by Tina Rosenberg. This great review of the book explains the main points. The book includes a lot of information about the use of language, and the use of marketing techniques.

In our culture currently, we minimize the importance of parenting - parents don't feel respected or valued, many are isolated and struggle to find and maintain supportive relationships. In most communities, there is no place parents can gather. There is virtually no support for parent-child time together.

I think there are some hopeful things happening, but change is hard!  Thank you to everyone working on prevention and supporting parents and children.

Excellent points, Richard.

I think the issue of the language we use is a critical factor in our success in addressing childhood trauma. By talking about "abuse" and "abusers" we seem to be forgetting that, in most (if not all) cases, the parent (or "abuser") was him or herself traumatized as a child and is actually not in control when inflicting similar treatment on their own child. I think in our common useage, "abuse" may even imply active intent, and only a patholgically disturbed individual would plan on hurting his/her own child. That is not the population we are focused on.

This is one reason that in my work in Vermont I am focused (although not exclusively) on the adults. Traumatized adults are suffering tremendously, even as they inflict tremendous pain on their children. And so the cycle intensifies...

But to engage these adults and so interrupt that cycle, the language we use must be compassionate and inclusive, not stigmatizing and distancing.

To accomplish that, however, we have to deal with our own visceral reaction against the deeply disturbing concept that a parent is, in fact, hurting his/her own child. (That phrasing always catches me, as well. We react when anyone "big" picks on anyone "small," as we should. But we know at a very deep level that there is something even worse at work when a parent hurts their own child.)

The parallels here with the early work in domestic violence, which was largely focused on men battering women, and which tended to see the men as "bad" are obvious. I know in Vermont that domestic violence has come a very long way in addressing the men as victims themselves and providing treatment.

But that doesn't make what is essentially a paradigm-shift easy.

I work with parenting education, a still relatively new field, and and from the earliest days, it seemed the only way to get funder's attention was to talk about the prevention of child abuse and neglect.  And even prevention sounds better than "fighting or combatting".  In addition to words like peace, safety, and non-violence I'd also hope to think about going beyond the concept of prevention to promotion of healthy families.....not just keeping the worst from happening to children, but helping their parents to be nurturing and give them the best possible foundation for a healthy life. As obvious as this may be, many people still don't think beyond preventing child abuse.

That's one of many things I'm hoping to learn here and elsewhere! We're working on the issue of screening in primary care practice now, and this issue of addressing trauma with adults is an important part of the discussion. For example, we've talked about the fact that mandatory reporting, as necessary as it is, also creates a barrier since parents fear talking about what may be happening at home. We don't have any solutions, but we've talked about it!

I liked the example Jim Sporleder (below) gave in his post of having the chart of ACEs on the wall, and letting the patient start the discussion. And of course, Dr. Felitti's phrase of "how has [the trauma] effected your life?"

As we go forward bringing the entire issue of childhood trauma more to the fore, these are going to be critical points in our success, I think. How do we engage trauma survivors in discussion while taking care regarding "triggering" them, ensure their children are safe (if they have any), interupt the epigenetic cycle and get care for all involved? These are the kinds of issues that stop many groups from moving forward at all, I think. But of course, we have to move forward. It's unethical, given what we know today, to do anything else.

I think it may be advisable to use the term toxic stress in the context of other kinds of stress, so a person can distinguish all of the categories of stress.