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Silent victims: a decade later.

The article by Purugganan et al in this issue of the Journal (J Dev Behav Pediatr 24:424–430, 2003) adds to the growing body of knowledge about the dimensions of child exposure to violence; specifically issues of proximity, type of violence, gender, age of child, and relationship between witness and victim. The issue of proximity was addressed initially in the seminal work of Pynoos et al on a Los Angeles playground shooting in 1984, which was the first systematic collection of data on children’s exposure to danger. This study found strong evidence that acute posttraumatic stress disorder (PTSD) symptoms occur in school-aged children but with diminished intensity depending on the child’s physical proximity to the event. Another significant factor in how children are affected is the type of violence experienced. For example, among children aged 14 to 20 years in Los Angeles, 31% reported physical abuse by a parent, 19% and 25% reported witnessing minor and severe acts of interparental violence. In this same group, approximately 45% of males and 37% of females reported witnessing a stabbing or a shooting in their communities, and 49% of males and 40% of females reported witnessing a stabbing at school. Multiple studies have found that males are more likely than females to be victims of and witnesses to violent acts, but thismay differ by age, and that most violencewitnessed is committed by persons familiar to the witness (families, friends, and acquaintances rather than strangers). Ten years ago our team coauthored a commentary titled ‘‘Silent Victims: Children Who Witness Violence,’’ which was followed by a study and another commentary on children who witness domestic violence. These articles derived from clinical observations supported by seminal research at a time of escalating community violence and growing awareness of domestic violence. Our goal was to communicate to pediatric clinicians the potential deleterious effects of witnessing violent events, potentially life-altering events with effects on school functioning and emotional and social development, even when children were not physically harmed. Since that early work, there has been steadily growing concern about the high prevalence and consequences of witnessing violence and other traumatic events. The impact of these events on the development and physical and mental health of children during their life-course is considerable. Recent research has documented harmful consequences of exposure to traumatic events on brain development. In recognition of this considerable public health problem, the federal government has committed resources to combat this problem. The Justice Department, through the Office for Juvenile Justice and Delinquency Programs, has funded 11 urban, rural, and tribal communities across the country to establish integrated systems to identify and intervene with young children exposed to violence. This funding has improved the delivery of high-quality care to young children (and their families) who are at risk of exposure to community and domestic violence. The Center for Mental Health Services, Substance Abuse Mental Health Services Administration, and U.S. Department of Health and Human Services have established the National Child Traumatic Stress Network, which consists of 37 clinical and research centers dispersed around the nation devoted to advancing the quality of interventions for traumatized children. By 2004, the network (funded at >30 million dollars per year) will include more than 50 sites working collaboratively to address the issues of child trauma in our nation. This year, the National Institutes of Health developed a specific Program Announcement to generate methodologically sound data on children’s exposure to violence with the goal of informing clinical care programs and policy. These initiatives are promising in their scope and research potential. However, as pediatric clinicians, we have a long way to go to generate and apply information within pediatric settings about the impact on children of witnessing violence—domestic, community, or in the media. At times it seems that as clinicians, our response is similar to the parent who denies that his or her child witnessed domestic violence (‘‘he didn’t hear anything’’) when the child was in the next room. We must not be passive bystanders. By denying the effects of the almost daily barrage of violence on children in their homes, on the streets, through the newspapers, and, increasingly, in their classrooms, we and society at large seem to be engaged in a conspiracy of silence as we avoid mention of things too horrible to fathom. What do we know about the consequences of witnessing violence for children and adolescents? PTSD, which can be characterized by exposure to a traumatic event with resultant re-experiencing of the event (frightening dreams and reenactment through play), numbing of responsiveness, and experiencing symptoms of increased arousal, is found in 25% to 50% of children witnessing significant violence, with the higher prevalence occurring in response to witnessing maternal assault. Beyond full criteria for PTSD,