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The Vortex of Violence How Children Adapt and Survive in a Violent World
Bruce D. Perry, M.D., Ph.D. Pre-Final DRAFT
This booklet is one in a series developed by the ChildTrauma Academy to assist parents, caregivers, teachers and various professionals working with maltreated and traumatized children. Adapted in part from: "Maltreated Children: Experience, Brain
Development and the Next Generation"
Childhood is a dangerous time. For centuries, children, the most vulnerable of our species, have struggled to survive this harsh world. For infants and children, survival is dependent upon adults, most typically, the nuclear family. It is in the family setting that the child is fed, clothed, sheltered, nurtured and educated, directly and indirectly, in the language, beliefs, and value systems of the culture. It is in the family setting in which the non-genetic ‘DNA’ of the culture is transmitted from generation to generation, allowing the amazing process of socio-cultural evolution. When the child’s development is characterized by structure, predictability, nurturing, and enriching emotional, social and cognitive experiences, a vulnerable and powerless infant can grow to become a happy, productive, insightful and caring member of society -- contributing to us all. Sadly, few families and communities can provide this idealized early life. Indeed, it is in the familial incubator that children are most frequently manipulated, coerced, degraded, inoculated with destructive beliefs and exposed to violence.
Infants and children depend upon adults for survival. It is in the family setting that the child is fed, clothed, sheltered, nurtured and educated. Unfortunately, it is in the familial incubator that children are most frequently manipulated, coerced, degraded, inoculated with destructive beliefs and exposed to violence. The home is the most violent place in America (Straus, 1974). In 1995, the FBI reported that 27% of all violent crime involves family on family violence, 48% involved acquaintances with the violence often occurring in the home (National Incident-Based Reporting System, Uniform Crime Reporting Program, 1999). Children are often the witnesses to, or victims of, these violent crimes. The major context for violence in America is the family (Straus, 1974). Intrafamilial abuse, neglect and domestic battery account for the majority of physical and emotional violence suffered by children in this country (see Koop et al., 1992; Horowitz et al., 1995; Carnegie Council on Adolescent Development, 1995; Perry, in press). Despite this, a majority of our entertainment, media and public policy efforts focus on community or predatory violence. Understanding the roots of community and predatory violence is impossible unless the effects of intrafamilial violence and the impact of abuse and neglect on the development of the child are examined. The adolescents and adults responsible for violence in the community developed these violent behaviors as a result of intrafamilial violence during childhood (O'Keefe, 1995; Myers et al., 1995; Mones, 1991; Hickey, 1991; Loeber et al., 1993; Lewis et al., 1989; Perry, 1998; Perry, 2000). Violent crime statistics, however, grossly underestimate the prevalence of violence in the home. It is likely that less than 5% of all domestic violence results in a criminal report. Intra-familial abuse and domestic battery account for the majority of physical and emotional violence suffered by children in this country (see Koop et al., 1992; Horowitz et al., 1995; Carnegie Council on Adolescent Development, 1995). This violence takes many forms. The child may witness the assault of her mother by father or boyfriend. The child may be the direct victim of violence - physical or emotional - from father, mother or even older siblings. Straus and Gelles (1996) have estimated that over 29 million children commit an act of violence against a sibling each year. The child may become the direct victim of the adult male if he or she tries to intervene and protect mother or sibling. While these all cause physical violence, an additional destructive element of this intra-familial toxicity is emotional violence - humiliation, coercion, degradation, and threat of abandonment or physical assault.
 Men commit most violence
against men. Men commit most violence committed against women. Women commit most violence
against children. Most violence committed by children is against other children. Children
commit most violence against pets. The intergenerational ‘cycle of violence’ is
well documented. This intergenerational ‘vortex of violence’ is not. Violent
behavior flows down a power differential. The majority of our violence initiatives and
examinations of violence focus on violence of a specific type -- violence committed
against voters (typically property owners). Indeed if one man hits another man (especially
one with a job), this is a felony - assault and battery, while the same physical violence
against a wife or a child is culturally sanctioned, often rationalized as
‘deserved’ or ‘discipline’. Prosecution of the former would proceed;
prosecution of the latter would never be pursued. Indeed the victim would often be openly
or tacitly ridiculed, and made to feel responsible -- "they deserved it."
The vortex of violence is fueled by the ‘conservation of violence’. When you are helpless, frustrated, humiliated and overwhelmed, it is common to bring this into your interactions with others. If the other is smaller and weaker, it is likely that the direction of frustration and violence will be from more powerful to least powerful. A typical flow of rage will start with a man frustrated and humiliated outside of the home. He will absorb this humiliation, modify some of it, and pass some on. At home, he will direct his anger and rage at his spouse -- she will absorb, modify and pass on. The overwhelmed and assaulted mother (usually when father leaves) will pass the humiliation and violence to the demanding children. These older children will absorb, modify and pass on -- to younger or weaker children. The child at the center of the vortex may have no human to ‘pass on’ to -- they will absorb, accumulate, wait until they are old enough, big enough, strong enough to hurt humans -- or they may pass on to animals. Children kill more cats than dogs do. Cruelty to animals is often a sign that a child has been exposed to violence or abuse. Living in this vortex of violence creates violent children. And what this process costs in robbed emotional, social, cognitive and physical is incalculable. Different individuals ‘absorb’ better -- and pass on less. Yet they pay one way or the other -- absorb and modify -- creating anxiety, depression, cognitive impairment -- and, often violence. It is the rare and strong person that can carry their trauma without having it spill into the next generation. For as many individuals that carry their pain, there are those that pass theirs on -- not to just one but to many. Violence of one person can leave a wake of destruction in the lives of hundreds.
In homes where no physical or emotional violence is present, children are still bathed in violent images; the average child spends more than three hours a day watching television. Television, videogames, music and film have become increasingly violent (Donnerstein et al., 1995). Huston and colleagues have estimated that the average 18 year old will have viewed 200,000 acts of violence on television (Huston, et al., 1992). Even with solid emotional, behavioral, cognitive and social anchors provided by a healthy home and community, this pervasive media violence increases aggression and antisocial behavior (Lewis et al., 1989; Myers et al., 1995; Mones, 1991; Hickey, 1991; Loeber et al., 1993; O'Keefe, 1995), contributes to a sense that the world is more dangerous than it is (Gerbner, 1992) and desensitizes children to future violence (Comstock and Paik, 1991). In children exposed to violence in the home, these media images of power and violence are major sources of ‘cultural’ values, reinforcing what they have seen modeled at home.
There has been a dramatic increase in juvenile violence over the last ten years. From 1986 to 1996 there was a 60% increase with juveniles now accounting for 19% of all violent crime (Snyder, 1997). Much of this is youth on youth violence. The violence in communities witnessed by youth has become so pervasive in some communities that in some studies, over half of all children surveyed had witnessed some form of violence in the year prior to the survey (Taylor et al., 1992; Richters & Martinez, 1993; Horowitz et al., 1995). The most heinous violence in schools has been widely publicized with the series of school shootings from 1992 to 1999. Yet the more common forms of school violence are intimidation, threat and simple assault. For thousands of children, school is not safe. It has been estimated that more than 250,000 students are attacked in school each month (Garrity, et al., 1994). For too many, school is a place of fear, dominated by the potential for harm and a sense of pervasive threat. The purpose of this paper is to describe how children survive in this ‘vortex’ of violence. Persisting threat results in persisting fear. Persisting fear and adaptations to the threat present in the vortex of violence alter the development of the child’s brain, resulting in changes in physical, emotional, behavioral, cognitive and social functioning. These changes in the developing child, in turn, contribute to the transgenerational cycle of violence as these young children become adolescents -- and finally, the adults that shape our society, the adults that choose and determine our cultural values, the adults that raise the next generation of children in a new intragenerational vortex of violence.
The majority of the initiatives dedicated to studying and intervening in violence have focused on violence committed by males. While men commit the vast majority of violence against women, the majority of direct violence to children takes place in the home The children who grow up to be violent in the streets are the products of this vortex of violence within the very environments entrusted to nurture, protect and educate them -- the home. These children are the products of their environments, adapted to living in a situation of pervasive threat, with all the expected adaptations in emotional, behavioral, cognitive, social and physiological functioning. The vortex of violence creates a pervasive sense of threat -- an incubator of terror -- for the developing child. The results are predictable. Children raised in the vortex of violence are much more likely to be violent (e.g., Loeber et al., 1993; Lewis et al., 1989; Koop et al., 1992; Hickey, 1991; Halperin et al., 1995). This is related to many factors, including modeling and learning that violent aggression is acceptable, even a preferable and honorable, solution to problems. Analysis of much of the violent behavior by children and adolescents today reveals a troubling degree of impulsive, reactive violence. This violence is often interpreted by the perpetrators as defensive (see Figure 4). "If I didn’t shoot him, he would have shot me." "I could tell that he was going to jump me -- he looked me in the eyes." "Listen, man, I just did him before he did me." These verbalizations reflect the persistence of a state of fear, literally, a persisting ‘fight or flight’ state which these adolescents are unable to get out of. The persistence of this originally adaptive internal state is due to growing up in a persistently threatening environment (Perry, 1994; Perry, 1996).
A growing body of evidence suggests that the developing brain organizes in response to the pattern, intensity and nature of sensory perceptual and affective experience of events during childhood (see Perry, 1993; 1994; Perry et al., 1995; Perry, 1998; 1999). Mediated by neurotransmitters and hormones, the stress responses can affect the development of the brain by altering neurogenesis, migration, synaptogenesis, and neurochemical differentiation (Lauder, 1988; for review Perry, 1994). Indeed, the developing brain is exquisitely sensitive to stress. For example, rats exposed to perinatal handling stress show major alterations in their stress response later in life (Plotsky and Meany, 1993). Such studies suggest that early exposure to consistent, daily stress can result in more adaptive later behavior and resiliency, while exposure to unpredictable stress can result in deficits. Predictability and control can make events much less destructive or traumatic. The human brain changes in a ‘use-dependent’ fashion (for review see Perry et al., 1995). Neural systems that are activated change in permanent ways, creating ‘internal’ representations -- literally, memories. The brain makes cognitive memories, emotional memories, motor-vestibular memories and state memories. The physiological hyperarousal state associated with fear and pervasive threat results in a brain that has created all of these memory types (i.e., cognitive, motor, emotional, state) and in doing so has adapted to a world characterized by unpredictability and danger. The brains of traumatized children develop to be hypervigilant and focused on non-verbal cues, potentially related to threat. These children are in a persisting state of arousal and, therefore, experience persisting anxiety. If during development, the threat response apparatus is required to be persistently active, a commensurate stress response apparatus in the central nervous system will develop in response to constant threat. These stress-response neural systems (and all functions they mediate) will be overactive and hypersensitive. It is highly adaptive for a child growing up in a violent, chaotic environment to be hypersensitive to external stimuli, to be hypervigilant, and to be in a persistent stress-response state. While these adaptive changes in the brain make a child better suited to sense, perceive and act on threat in their world these "survival tactics" ill-serve the child when the environment changes (e.g., in school, peer relationships: see Figs. 3 and 4).
These children are characterized by persisting physiological hyperarousal and hyperactivity (Perry, 1995a; Perry, et al., 1995). They are observed to have increased muscle tone, frequently a low grade increase in temperature, an increased startle response, profound sleep disturbances, affect regulation problems and generalized (or specific) anxiety (Kaufman, 1991; Ornitz et al., 1989; Perry, 1994a). In addition, our studies indicate that a significant portion of these children have abnormalities in cardiovascular regulation (Perry, 1994a; Perry et al., 1995b). Using continuous heart rate monitoring during clinical interviews, male, pre-adolescent children exposed to violence exhibited a mild tachycardia during non-intrusive interview and a marked tachycardia during interviews about specific exposure to trauma (n = 83; resting heart rate = 104; interview heart rate = 122). In comparison, females exposed to traumatic events tended to have normal or mild tachycardia that, during interviews about the traumatic event decreased (n =24; resting heart rate = 98; interview heart rate = 82). This gender difference was associated by differences in emotional and behavioral symptoms, with males exhibiting more ‘externalizing’ and females more ‘internalizing’ symptoms (Perry, et al., 1995b; Perry and Pollard, 1998). The implications of this for the violent youth are profound. First, any child in the vortex of violence will develop a persisting fear-response. There are marked gender differences in this response (Perry et al., 1995b; Perry, Pollard, Blakley, Baker, & Vigilante, 1995). Females more likely to dissociate and males more likely to display a classic "fight or flight" response. As a result, more males will develop the aggressive, impulsive, reactive and hyperactive symptom presentation. Males will more likely be violent outside the home and with women (George et al., 1979). This can be explained, in part, by the persistence of this "fight or flight" state -- and by the profound cognitive distortions that accompany this neurodevelopmental state. A young man with these characteristics, then, will very easily misinterpret a behavior as threatening and will, being more reactive, respond in a more impulsive and violent fashion. Literally, using the original (childhood) adaptive "fight or flight" response in a new context but, now, later in life, in a maladaptive fashion. In turn, the battered and overwhelmed woman will be more violent and abusive to her children. Women are more violent to children in the home than men. This may be due to the fact that men are often not in the home. It is also likely that when the direct object of their rage and violence can be the mother, it will be. If an older, typically male, child tries to defend the mother, the abusive paramour will be physically abusive to that child. But on the whole, the traumatized, unsupported and frustrated mother is more likely to be the perpetrator of emotional and physical abuse to children in the home.
There are profound clinical implications of the persisting arousal states in children. These children will have impaired capacities to benefit from social, emotional and cognitive experiences. This is explained by three key principles of brain functioning: 1) the brain changes in response to experience in a ‘use-dependent’ fashion; 2) the brain internalizes and stores information from any experience in a ‘state-dependent’ fashion and 3) the brain retrieves stored information in a state-dependent fashion. As described above, the brain changes in a use-dependent fashion. All parts of the brain can modify their functioning in response to specific patterns of activation -- or to chronic activation. These use-dependent changes in the brain result in changes in cognition (this, of course, is the basis for cognitive learning), emotional functioning (social learning), motor-vestibular functioning (e.g., the ability to write, type, ride a bike) and state-regulation capacity (e.g., resting heart rate). No part of the brain can change without being activated -- you can’t teach someone French while they are asleep or teach a child to ride a bike by talking with them. Mismatch between modality of teaching and the ‘receptive’ portions of a specific child’s brain occur frequently. This is particularly true when considering the learning experiences of the traumatized child -- sitting in a classroom in a persisting state of arousal and anxiety -- or dissociated. In either case, essentially unavailable to process efficiently the complex cognitive information being conveyed by the teacher. This principle, of course, extends to other kinds of ‘learning’ -- social and emotional. The traumatized child frequently has significant impairment in social and emotional functioning. These capabilities develop in response to experience -- experiences that these children often lack -- or fail at. Indeed, hypervigilant children frequently develop remarkable non-verbal skills in proportion to their verbal skills (street smarts). Indeed, often they over-read (misinterpret) non-verbal cues -- eye contact means threat, a friendly touch is interpreted as an antecedent to seduction and rape -- accurate in the world they came from but now, hopefully, out of context. During development, these children spent so much time in a low-level state of fear (mediated by brainstem and midbrain areas) that they were focusing consistently on non-verbal cues. In our clinic population, children raised in chronically traumatic environments demonstrate a prominent V-P split on IQ testing (n = 108; WISC Verbal = 8.2; WISC Performance = 10.4, Perry, in preparation). This is consistent with the clinical observations of teachers that these children are really smart but can’t learn easily. Often these children are labeled as learning disabled. These difficulties with cognitive organization contribute to a more primitive, less mature style of problem solving -- with violence often being employed as a "tool." This principle is critically important in understanding why a traumatized child -- in a persisting state of arousal -- can sit in a classroom and not learn. The brain of this child has different areas activated -- different parts of the brain ‘controlling’ his functioning. The capacity to internalize new verbal cognitive information depends upon having portions of the frontal and related cortical areas being activated -- which, in turn, requires a state of attentive calm. A state the traumatized child rarely achieves.
Children in a state of fear retrieve information from the world differently than children that feel calm (see Figures 1, 3 and 4). We all are familiar with ‘test’ anxiety. Imagine what life would be like if all experiences invoked the persisting emotion of anxiety. If a child has information stored in cortical areas but in the specific moment is very fearful, this information is inaccessible. In this regard, cognitively stored information does little good in the life-threatening moment. Simple didactic conflict-resolution models are doomed to fail unless they involve elements of role-playing. Imagine how much you would trust an Army that went through combat training by sitting in classroom -- or the E.R. physician about to run her first code after only leaning how to do that by reading a book. In the midst of most threatening experiences -- situations where violence often takes place -- the ‘problem-solving’ information in the cortex is not easily accessed. It is of interest to note that information learned in song, rhyme or rap is more easily recalled when in a state of high arousal. This is due, of course, to the fact that this information is stored in a different fashion than traditional verbal cognitive information.
How do you begin to help the traumatized child -- the child that has been living in the vortex of violence? The frustrating fact is that whether teacher, caseworker, mental health professional, pediatrician, police officer or any other caring adult, we often are unable to remove a child from the Vortex. We see the impact, we know the home, the community, the peer group, and the gang will stay the same. We know that for ‘24-7’ the child is in settings where we may have no control or impact. This need not be reason for despair -- motivation for outrage and action, yes -- but there is no reason for hopelessness. An amazing quality of the human brain is to create an image of the future. To make an internalization of a better place, a better way, a better life, a better world. This capacity is called hope. We can give children hope that not all adults are inattentive or abusive or unpredictable or violent. Some of the most influential people in any person’s life may be someone they have never even met. They have used that person to create an inner image to aspire to, to idealize, to idolize. Role models, mentors, and heroes -- all can provide critical formative experiences for children. And what are the qualities that we should introduce into our work to provide the experience for the children that can give them hope and the opportunity for change? The hallmarks of the transforming therapeutic interaction are safety, predictability and nurturance. The most ‘therapeutic’ interactions often come from people who have no training (or interest) in psychological or psychiatric labels, theories, treatments and the adult expectations of the child that go with these. In interacting with the child, respect, humor and flexibility can allow the child to be valued as what they are. Clinical principles for effective work with children have additional critical elements. One is helping the child understand what they feel and why they behave a certain way in given situations. Traumatized children frequently act impulsively and misunderstand why this has happened. They will often explain this (as will the adults around them) as the by-product of them being stupid, insensitive, bad, selfish, sick or damaged in some way. The false cognitions of the traumatized child need to be addressed and changed. A second important element of clinical work with traumatized children is educating the adults in the child’s world about the ways in which maltreated and traumatized children think, feel and behave. This can lead to understanding rather than rage. If a clinician can make the ten adults in the child’s life 5 percent more psychologically understanding, they can increase the number of neutral and positive experiences in the child’s life ten fold -- and decrease the number of negative experiences dramatically. The resulting impact is much more effective than 45 minutes a week in the clinicians office. There are many more important specific treatment aspects of working with these children that are beyond the scope of this paper. Yet even with optimal clinical ‘techniques’, treatment of maltreated children would overwhelm the entire mental health and child welfare community in this country. Today the number of children that would benefit from intervention far outstrips the meager resources our society has dedicated to maltreated children. At the end of the day -- and possibly at the end of our society -- we will have to focus on prevention.
What we are as adults is the product of the world we experienced as children. The way a society functions is a reflection of the childrearing practices of that society. Today, we reap what we have sown. Despite the well-documented critical nature of early life experiences, we dedicate few resources to this time of life. We do not educate our children about development, parenting or about the impact of neglect and trauma on children. As a society we put more value on requiring hours of formal training to drive a car than we do on any formal training in childrearing. In order to prevent the development of impulsive, predatory or violent children, we need to dedicate resources of time, energy and money to the complex problems related to child maltreatment. We need to understand the indelible relationship between early life experiences and cognitive, social, emotional, and physical health. Providing enriching cognitive, emotional, social and physical experiences in childhood could transform our culture. But before our society can choose to provide these experiences, it must be educated about what we now know regarding child development. Education of the public must be coupled with the continuing generation of data regarding both the impact of positive and negative experiences on the development of children. All of this must be paired with the implementation and testing of programs dedicated to enrich the lives of children and families and programs to provide early identification of, and proactive intervention for, at-risk children and families. The problems related to maltreatment of children are complex and they have complex impact on our society. Yet there are solutions to these problems. The choice to find solutions is up to us. If we choose, we have some control of our future. If we, as a society, continue to ignore the laws of biology, and the inevitable neurodevelopmental consequences of our current childrearing practices and policies, our potential as a humane society will remain unrealized. The future will hold sociocultural devolution -- the inevitable consequence of the competition for limited resources and the implementation of reactive, one-dimensional and short-term solutions.
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There are many other places to learn more about violence and children. A few starting places are listed below. ORGANIZATIONS and PROGRAMS Office of Juvenile Justice and Delinquency Prevention (OJJDP), Department of Justice The OJJDP is the division of the Justice Department dedicated to the shaping and enacting federal policy regarding the areas of juvenile justice. As it carries out this mission, the OJJDP is works with states and other non-government agencies and organizations to develop programs to prevent and control juvenile delinquency. The OJJDP website has a wealth of information regarding the prevalence of problems as well as the documentation of promising intervention programs. OJJDP has been a primary sponsor of the successful home-visitation models, the Safe Kids/Safe Streets project, Safe Start programs and the community policing initiatives taking place in many communities. OJJDP Parents and Teachers Against Violence in Education: Project NO SPANK. This is an advocacy organization that has documented and catalogued materials related to the issue of physical discipline. For any individual or group interested in reading about the research regarding the adverse impact of physical discipline and spanking, this is the site to start with. Remember, this is an advocacy organization; this site will clearly and strongly present their positions. Project No Spank New Haven Child Development-Community Policing Project: (CD-CP) This is an innovative program which is a collaborative project of the Yale Child Study Center, the New Haven Police Department, local schools and the Connecticut child protective services. This project is designed to provide the immediate mental health needs of child crime victims and witnesses. By creating special training opportunities, mental health providers and police officers share expertise and address the complex needs of children exposed to violence. This is an effective and unique program. The OJJDP is helping other communities create similar innovative collaboratives. CD-CP Program Family Violence Research Laboratory of University of New Hampshire This organization is a pioneer in conducting research and education in the area of domestic violence and violence in childhood. Since 1975, the Family Research Laboratory (FRL) has devoted itself primarily to understanding family violence and the impact of violence in families. This organization and its website are a highly recommended resource for quality research, reviews and thoughtful policy and practice recommendations. As public and professional interest in family violence has grown, so has the need for more reliable knowledge. The FRL has tried to fill that need in a variety of ways: through comprehensive literature reviews, new theories, and methodologically sound studies. Researchers at the FRL pioneered many of the techniques that have enabled social scientists to estimate directly the scope of family violence. These efforts have brought international recognition to the FRL. Family Research Laboratory BOOKS and Monographs Children in a Violent Society (J.D. Osofsky, Ed.) The Guilford Press, New York (1997) This edited volume is an excellent overview of various important aspects of the complex problems related to children and violence. Among the many contributors are pioneers in this area including Carl Bell, Joy Osofsky, Peter Fonagy, Steve Marans and Bob Pynoos. This is a recommended text for clinicians and academics interested in the effects of violence on children. Safe from the Start: Taking Action on Children Exposed to Violence, The Children Exposed to Violence Summit Action Plan (prepared by W.B. Jacobsen) U.S. Departments of Justice and Human and Health Services, (2000) This summary monograph is a useful introduction to the scope of problems facing children exposed to violence. This is a "white paper" product of the National Summit on Children Exposed to Violence in 1999. This three day working meeting brought together professionals and experts from a host of organizations and disciplines. The end result was a consensus on several areas of focus and on several principles of problem solving that should play a role in developing effective policy and practice to help children exposed to violence. Like most consensus products, this monograph restates many obvious points. The solutions are not detailed and reflect the interests of the participants. Despite the fact that there are literally thousands of academics, scholars and experts who did not participate in this summit, the end product is none-the-less a useful source of information. Some of the most useful elements of this monograph is a list of programs across the country that have been successful in addressing some aspect of children exposed to violence. These resources will be periodically updated and posted in a special section of the ChildTrauma Academy web site http://www.ChildTrauma.org. Visit this site for updates and for other resource materials about traumatic events and children.
Bruce Duncan Perry, M.D., Ph.D. Dr. Perry is the Medical Director, Provincial Programs in Children's Mental Health for the Alberta Mental Health Board. In addition he continues to lead the ChildTrauma Academy, a training and research institute founded in 1990. From 1992 to 2001, Dr. Perry served as the Thomas S. Trammell Research Professor of Child Psychiatry at Baylor College of Medicine and Chief of Psychiatry at Texas Children's Hospital in Houston, Texas.
About the the cover drawing: The Firing Squad. From of a drawing by a 12 year old Kosovar child witnessing the violence, chaos and destruction of war. Drawings by children exposed to traumatic events frequently include elements from the original trauma and are often re-enactment efforts.From the collection of Dr. Shoaib (Psychiatry resident at Baylor College of Medicine and a trainee at the ChildTrauma Academy in 1998) obtained during his work in Kosovar refugee camps in Albania in 1999. |
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