6

Direct and Indirect Costs of Violence

While no methodology exists to enumerate the full extent of the impact of violence, some costs can be estimated. These costs are roughly divided into direct costs, or those arising immediately or proximally to the violent event, and indirect costs, or those that result as a consequence, externality, or loss of opportunity. Direct costs are more readily quantifiable and tend to fall into traditional categories of medical and nonmedical costs and productivity costs. Indirect costs indicate impact beyond direct victims and perpetrators and also include indirect victims and often society at large. However, some costs can be categorized in either way, suggesting that a definitive line between the two does not truly exist.

The first paper is an overview of the costs of interpersonal violence around the world. This represents a comprehensive survey that includes a large number of data sources. It attempts to place the costs within a context by which comparisons across regions can be made.

The second paper discusses the costs and implications of elder abuse, an often-overlooked type of violence. Elder abuse, which can encompass more than just physical and psychological violence, is poised to have enormous impact as populations around the world age.

The third paper looks at a major risk factor for violence—firearms. The impact of gun-related violence extends beyond the home and immediate victims, but affects the neighborhood and community as well. This paper examines the indirect and more diffuse costs of such violence.

The fourth paper explores a similar concept of social costs by examining the contagious nature of violence. Violence does not occur in a vacuum, and often the undercurrent or environment of violence normalizes violent



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6 Direct and Indirect Costs of Violence While no methodology exists to enumerate the full extent of the impact of violence, some costs can be estimated. These costs are roughly divided into direct costs, or those arising immediately or proximally to the violent event, and indirect costs, or those that result as a consequence, external- ity, or loss of opportunity. Direct costs are more readily quantifiable and tend to fall into traditional categories of medical and nonmedical costs and productivity costs. Indirect costs indicate impact beyond direct victims and perpetrators and also include indirect victims and often society at large. However, some costs can be categorized in either way, suggesting that a definitive line between the two does not truly exist. The first paper is an overview of the costs of interpersonal violence around the world. This represents a comprehensive survey that includes a large number of data sources. It attempts to place the costs within a context by which comparisons across regions can be made. The second paper discusses the costs and implications of elder abuse, an often-overlooked type of violence. Elder abuse, which can encompass more than just physical and psychological violence, is poised to have enormous impact as populations around the world age. The third paper looks at a major risk factor for violence—firearms. The impact of gun-related violence extends beyond the home and immediate victims, but affects the neighborhood and community as well. This paper examines the indirect and more diffuse costs of such violence. The fourth paper explores a similar concept of social costs by examin- ing the contagious nature of violence. Violence does not occur in a vacuum, and often the undercurrent or environment of violence normalizes violent 33

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34 SOCIAL AND ECONOMIC COSTS OF VIOLENCE response in other settings. As well, witnessing or being a victim of violence can increase the risk of future violence. The final paper lays out the significant impact of violence at early stages of child development, by examining violence and its effects along the life span. Violence, resulting in traumatic stress, can have psychological and physiological effects on the brain and body, some of which can manifest much later in life. Mitigating these effects requires early intervention. THE COSTS OF INTERPERSONAL VIOLENCE— AN INTERNATIONAL REVIEW1 Hugh Richard Waters, Ph.D. Johns Hopkins Bloomberg School of Public Health Adnan Ali Hyder, M.D., M.P.H., Ph.D. Johns Hopkins Bloomberg School of Public Health Yogesh Rajkoti, Ph.D., M.Sc. Johns Hopkins Bloomberg School of Public Health Suprotik Basu, M.H.S. The World Bank Alexander Butchart, Ph.D., M.A. World Health Organization Abstract This article reviews evidence of the economic impact of interpersonal violence internationally. In the United States, estimates of the costs of inter- personal violence reach 3.3 percent of the gross domestic product (GDP). The public sector—and thus society in general—bears the majority of these costs. Interpersonal violence is defined to include violence between family members and intimate partners, as well as violence between acquaintances and strangers that is not intended to further the aims of any formally de- fined group or cause. Although these types of violence disproportionately affect poorer countries, there is a scarcity of studies of their economic im- pact in those countries. International comparisons are complicated by the calculation of economic losses based on forgone wages and income, thus undervaluing economic losses in poorer countries. 1 Reprinted from Waters, H. R., A. A. Hyder, Y. Rajkotia, S. Basu, and A. Butchart. 2005. The costs of interpersonal violence—An international review. Health Policy 73(3):303-315.

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35 DIRECT AND INDIRECT COSTS OF VIOLENCE Introduction and Methods This article systematically reviews peer-reviewed literature related to the economic consequences of interpersonal violence internationally. Al- though much of the available literature concerns high-income countries, vi- olence disproportionately affects low- and middle-income countries, where an estimated 90 percent of all violence-related deaths occur (Krug et al., 2002).2 As a result, the economic effects of violence are also likely to be proportionally more severe in poorer countries. This article defines interpersonal violence as violence between family members and intimates and violence between acquaintances and strangers that is not intended to further the aims of any formally defined group or cause. Self-directed violence, war, state-sponsored violence, and other col- lective violence are specifically excluded from these definitions. We conducted a comprehensive literature search to identify published estimates of the cost of interpersonal violence, using electronic databases, governmental and nongovernmental websites, and contacts with knowl- edgeable individuals working in the fields of violence prevention and eco- nomic evaluation. After initial electronic searches, additional sources were identified through the reference lists of collected articles and reports. The details of this search—including keywords used for electronic searching and experts consulted—are provided in the acknowledgments. The search was conducted without restrictions on the language of publication and included publication dates from January 1980 to September 2004. To categorize studies by type of interpersonal violence, we adapted the definitions of the most prevalent categories of interpersonal violence described in the 2002 World Report on Violence and Health, as shown in Table 6-1. Studies documenting the economic effects of interpersonal violence have used a broad range of categories of costs. We have divided cost cat- egories broadly into “direct” costs and benefits—those resulting directly from acts of violence or attempts to prevent them—and “indirect” costs and benefits. The most commonly cited direct costs are medical care and the costs of the judicial and penal systems (policing and incarceration). Indirect costs include the long-term effects of acts of violence on perpetrators and victims, such as lost wages and psychological costs, also referred to as pain and suffering (Hornick et al., 2002). We converted all monetary results to 2003 U.S. dollars to enable com- parisons and to adjust for inflation and varying exchange rates. Values 2 Countries are classified by income level using the following categories from the 2004 World Development Report (World Bank, 2004): low-income 5 $745 per capita or less; lower middle-income 5 $746 to $2,975; upper middle-income 5 $2,976 to $9,205; high-income 5 $9,206 or more.

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36 SOCIAL AND ECONOMIC COSTS OF VIOLENCE TABLE 6-1 Types of Interpersonal Violence Child abuse and neglect Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power Intimate partner violence Any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship Abuse of the elderly Act of commission or of omission, intentional or unintentional, of a physical nature; it may be psychological (involving emotional or verbal aggression), or it may involve financial or other material maltreatment Regardless of the type of abuse, it will certainly result in unnecessary suffering, injury, or pain; the loss or violation of human rights; and a decreased quality of life for the older person Sexual violence Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any persons regardless of their relationship to the victim, in any setting, including but not limited to home and work Youth violence Violence committed by or against people between the ages of 10 and 29 years Workplace violence Physical or psychological behavior directed against coworkers, including bullying, sexual harassment, threats, and intimidation SOURCE: Adapted from Krug et al., 2002. expressed in other currencies in original documents, and U.S. dollar values from previous years, have been converted to 2003 U.S. dollars using the U.S. consumer price index and applicable international exchange rates from the year of the original estimates. Costs expressed as a percentage of the GDP were calculated using the GDP from the year the costs were reported. Findings There are widely varying estimates of the cost of violence internation- ally, depending on the definitions used, the types of costs included, and the methodologies used. The U.S. Department of Justice (1994) reported estimated direct costs of violent crime to victims resulting from short-term medical expenses and work loss. These estimates were based on responses to the National Crime Victimization Survey (NCVS), an annual survey based on 100,000 interviews with crime victims. These costs amounted to

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37 DIRECT AND INDIRECT COSTS OF VIOLENCE $1.8 billion, 0.02 percent, of the U.S. GDP in 1994. When indirect costs are included, estimates of the costs of violence in the United States are sub- stantially higher. Miller et al. (1993) estimated an annual cost of intentional injuries of $84.1 billion in the United States for 1987-1990. Throughout the literature on the costs of violence, psychological costs greatly outweighed the direct costs of violence—partially explaining the wide variance in the estimates that are available. Miller et al. (2001) estimated that lost earnings, psychological costs, and the opportunity cost of victims’ time, in addition to the costs of polic- ing, incarceration, and life insurance in the State of Pennsylvania, equaled $14.2 billion. Separately, Miller et al. (1996) estimate a total annual cost to victims of personal crime in the United States—including domestic violence, sexual assault, rape, and child abuse—of $507 billion. This estimate, which includes psychological costs of pain and suffering, is equivalent to 6.5 per- cent of GDP, or $1,100 per person in the United States. Brand and Price (2000) estimated total costs from crime of $63.8 billion in England and Wales. Sixty-three percent of this amount was attributable to violence—in- cluding homicide, wounding, and sexual assault. This tally includes both direct costs such as police and judicial system costs and indirect costs that included forgone output and physical and emotional costs. Estimates from other high-income countries are more conservative. The Australian Institute of Criminology (2003) reported national annual costs for assault of $159 million, an estimate that did not include indirect costs and was based largely on the costs of incarcerating offenders. Similarly, the cost of homicide in Australia was calculated at $194 million per year, based on a cost per homicide of $602,000 (Walker, 1997). Fanslow et al. (1997) calculated the economic cost from homicide in New Zealand: when lost earnings, legal fees, incarceration, and policing were included, the cost per homicide was $829,000 for a total of $67.9 million. There are few documented estimates of the costs of violence in low- and medium-income countries. Additionally, comparisons with high-income countries are complicated by the fact that economic losses related to pro- ductivity tended to be undervalued in lower-income countries since these losses were typically based on forgone wages and income. For example, Phillips (1998) calculated the cost of homicides in the Western Cape Met- ropolitan Area in South Africa. Using a 4 percent rate to discount future productivity and opportunity costs, he calculated a cost averaging $15,319 per homicide, sharply lower than the United States, United Kingdom, Aus- tralian, and New Zealand estimates above. The Inter-American Development Bank (IDB) has spearheaded efforts to systematically document the costs of both interpersonal and collective violence in the Americas. Central America has been particularly affected. In 1995, El Salvador spent 6 percent of the gross national product (GNP) to

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38 SOCIAL AND ECONOMIC COSTS OF VIOLENCE TABLE 6-2 Costs of Social Violence in Latin America Country 1997 GDP Lost Due to Social Violence (%) Brazil 10.5 Colombia 24.7 El Salvador 24.9 Mexico 12.3 Peru 5.1 Venezuela 11.8 NOTE: Definition of violence includes collective violence (Buvinic et al., 1999). GDP 5 gross domestic product. control violence (Buvinic and Morrison, 1999). As part of the IDB’s work, Buvinic et al. (1999) reported estimates of economic losses due to social violence—including collective violence—in a variety of countries (see Table 6-2). These losses ranged from 5.1 percent of GDP in Peru to 24.9 percent in El Salvador, which was still in the throes of guerrilla war in the mid- 1990s when the data were generated. The estimates included lost earnings, the opportunity cost of time, policing, incarceration, judicial costs, forgone investments in human capital, and effects on investment. Child Abuse and Neglect The extent of child abuse and neglect is difficult to gauge since much if not most of it is unreported. The 2002 World Report on Violence and Health (WHO, 2002) estimates that the rates of homicide of children under 5 years of age were 2.2 per 100,000 for boys and 1.8 per 100,000 for girls in high-income countries. In low- and middle-income countries, the corre- sponding rates are 6.1 and 5.1 per 100,000, respectively, for boys and girls. In Africa, the rates are 17.9 per 100,000 for boys and 12.7 per 100,000 for girls (Krug et al., 2002). Many of the estimates of the costs of child abuse available in the literature are from the United States (see Table 6-3). The cost of child abuse ranges widely and depends on the mix of direct and indirect costs used to calculate it. Courtney (1999) calculated a figure of $14 billion for direct costs, including counseling and child welfare ser- vices resulting from child abuse in the United States. The U.S. Department of Health and Human Services (2001) calculated the costs of child abuse and maltreatment in Colorado to be $468 million—of which indirect costs represent 53 percent. There is a considerable range of estimates of individual-level treat- ment costs for child abuse, depending on the types of costs included. On

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39 DIRECT AND INDIRECT COSTS OF VIOLENCE TABLE 6-3 Costs of Child Abuse Total Study Location Cost Categories Included Annual Costs Study and Population (indirect costs in italics) (2001 US$) Courtney, 1999 United States, maltreated Direct medical (including $14.0 billion children and their families counseling) Evasovich et al., United States, Ohio Direct medical, legal fees $0.3 million; 1998 (4 counties), children (court costs, fines) $2,884 per child referred to social services for suspected child abuse (n 5 104) Forjuoh, 2000 United States, Pennsylvania, Direct medical $6.3 million; 1995, hospital discharge data $18,103 per (n 5 348 children) child HHS, 2001 United States, Colorado, Direct medical, legal $17.4 million 1995 services, incarceration, workers’ productivity, lost earnings, and opportunity cost of lost time Irazuzta et al., United States, West Virginia, Direct medical $0.6 million; 1997 1991-1994, pediatric ICU $42,518 per admissions (n 5 13) child Libby et al., Head trauma patients from Direct medical Mean charges of 2003 Colorado hospital discharge $4,232 more database, 1993-2000 than those with unintentional head trauma New and United States, Washington Direct medical $1.2 million; Berliner, 2000 State, 1994, mental $1,891 per child health treatment costs compensated by crime victims compensation program (n 5 608 children) Rovi et al., United States, national sample Direct medical Mean charges 2004 of inpatients through of $19,266 the healthcare costs and compared to utilization project, 1999 $9,513 for other hospitalized children Summers and United Kingdom, 1990, Direct medical 1990 GB£63,500 Molyneux, children hospitalized examinations only 1992 (n 5 181) Yodanis et al., United States, Washington Direct medical $9.1 million; 2000 State, randomly selected $17,356 per sample of women (n 5 child 1,225) enrolled in an HMO; 42.8 percent maltreated as children NOTE: HMO 5 health maintenance organization; ICU 5 intensive care unit.

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40 SOCIAL AND ECONOMIC COSTS OF VIOLENCE the high end, Irazuzta et al. (1997) calculated treatment costs per child of $42,518 based on daily hospital charges of $6,317 in a pediatric intensive care unit in Charlestown, West Virginia. Forjuoh (2000), working with discharge data from acute care hospitals in Pennsylvania, calculated a mean hospitalization cost of $18,103 per child abuse victim—comparable to a cost $19,266 per discharge found by Rovi (2004), working from a national survey of inpatients. Plontnick and Deppman (1999) calculated an average cost of $12,028 for hospitalizing an abused child for one week. Evasovich and Klein (1998) studied the costs of medical care and related legal fees for children admitted to the burns unit at the Children’s Hospital Medical Center in Akron, Ohio, and found costs totaling $13,781 per child. Public funds paid for 65 percent of these costs. New and Berliner (2000) examined claims paid by the Crime Victims Compensation pro- gram in Washington State and calculated mental health treatment costs of $2,921 per child, with counseling services costing between $70 and $90 per hour, exclusive of hospitalization or other healthcare costs. There are few estimates available of the cost of child abuse internationally. Mendonca et al. (2002) measured hospital costs due to violence against children and adolescents in Pernambuco State, Brazil. The mean cost of hospitaliza- tion for children and adolescents was $184. Violence against children and adolescents in greater metropolitan Recife, the principal city in the state, accounted for 65.1 percent of hospital admissions and 77.9 percent of hospital costs. Intimate Partner Violence The true extent of intimate partner violence is unknown. Surveys sug- gest a wide range in prevalence, but the results are difficult to compare given cultural differences and social taboos in responding to questions (see Table 6-4). In Paraguay and the Philippines, 10 percent of women surveyed reported being assaulted by an intimate partner (Heise et al., 1999), com- pared to 22 percent in the United States (Tjaden and Thoennes, 2000), 29 percent in Canada, and 34 percent in Egypt (El-Zanaty, 1996). Other stud- ies have shown that 3 percent or less of women in Australia, the United States, and Canada had been assaulted by a partner in the previous 12 months, compared to 27 percent of ever-partnered women in South Korea and 53 percent of currently married women in the West Bank and Gaza (Krug et al., 2002). There are complex methodological issues involved in measuring the economic impact of intimate partner violence. Many, if not most, incidents of intimate partner violence go unreported, and the effects of such abuse on investments in human capital and productivity inside and outside the home are difficult to estimate (El-Zanaty, 1996). Studies have documented

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41 DIRECT AND INDIRECT COSTS OF VIOLENCE TABLE 6-4 Costs of Intimate Partner Violence Cost Categories Total Study Location Included (indirect Annual Costs Study and Population costs in italics) (2001 US$) Coker et al., United States, Medicaid- Direct medical costs Mean difference 2004 eligible women in (physician, drug, and between high- Houston hospital) IPV and no-IPV women of $1,064 Day, 1995 Canada, data drawn Direct medical costs $1.2 billion from surveys (dental costs also), lost earnings and opportunity cost of time, other monetary costs, psychological costs Mansingh Jamaica, Kingston public Costs for treating $454,000 and hospital, 1991 victims of intimate Ramphal, partner violence, 1993 direct medical costs New and United States, Direct medical costs $3,087 per patient Berliner, Washington State, (mental health (median 15 2000 1994, 318 women; treatment costs) sessions) victims compensated by the crime victims compensation program Snively, New Zealand Direct medical costs, $3,087 per patient 1994 welfare, legal, policing (median 15 sessions) Stanko et United Kingdom, Public services only, $717,000 al., 1998 borough of Hackney, policing, legal, medical 1996 costs, other monetary costs (housing, refuge, social services) Wisner et United States, Direct medical costs $4,341 per patient al., 1999 Minnesota, 1992-1994, 126 victims of intimate partner violence in a large health plan NOTE: IPV 5 intimate partner violence. per-case direct treatment costs for intimate partner violence, but this type of study is only possible for those victims who have contact with the healthcare system. New and Berliner (2000) found that women who were compensated through the Crime Victims Compensation Program

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42 SOCIAL AND ECONOMIC COSTS OF VIOLENCE in Washington State averaged $3,087 for mental health treatment and counseling costs. Day (1995) comprehensively calculated the aggregate costs of vio- lence against women in Canada. Including healthcare costs, policing, legal fees, incarceration, lost earnings, and psychological costs, violence against women cost an estimated $1.2 billion. In these calculations, medical and dental visits are assigned a value of $67, a probable underestimate—so the total costs are likely to be higher than reported. As a percentage of GDP, estimates of the costs of intimate partner vio- lence are considerably higher in low- and middle-income countries than in high-income countries. Morrison and Orlando (1999) calculated the costs of domestic violence against women based on stratified random samples of women in Chile and Nicaragua. Based only on the lost productive capacity of these women, they extrapolated total costs of $1.73 billion in Chile and $32.7 million in Nicaragua—equivalent to 1.6 percent of GDP in Nicara- gua and 2 percent of GDP in Chile. Stanko et al. (1998) counted the costs of public services—including policing, court costs, medical care, and refuge—spent in the year 1996 on responses to domestic violence against women in the borough of Hackney in the United Kingdom. They estimated these costs to be $13.3 million for the borough, averaging $159 per household. Sexual Violence As with intimate partner violence, the costs of sexual assault are difficult to document systematically—given that many such assaults go unreported. As a result, most documented calculations are likely to be underestimates. Many of the published studies are based in the United States (see Table 6-5). The estimates vary widely, depending on the cost categories included and methods used. For example, Cohen (1988), using pain and suffering awards from more than 100,000 jury decisions in the United States, calcu- lated that the annual aggregate direct and indirect costs of rape were $14.9 billion—equivalent to 0.2 percent of GDP. In contrast, the U.S. Department of Justice (1994) calculated the eco- nomic losses of rape as $33 million, based on reported direct medical costs and lost earnings, though this estimate did not include psychological costs. For costs at the level of individual rape victims, Miller et al. (1993) used the NCVS to calculate a total cost of $85,000 per rape. Workplace Violence Violence at or related to the workplace extracts a significant economic toll (see Table 6-6), but studies of its magnitude are not well developed

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43 DIRECT AND INDIRECT COSTS OF VIOLENCE TABLE 6-5 Costs of Sexual Violence Cost Total Annual Study Location Categories Costs Study and Population Included (2001 US$) Cohen, 1988 United States, pain and Direct medical costs, Cost of rape, suffering data from lost earnings and $14.9 more than 100,000 opportunity costs of billion jury decisions time, psychological costs, other nonmonetary costs Miller et al., United States, NCVS, Direct medical costs, Costs per 1993 all victims of non- life insurance costs, rape, fatal physical and victim compensation $85,000 psychological injury, costs (jury awards), 1987-1990 employment and workers’ productivity, psychological costs, lost earnings, and opportunity costs of time U.S. Department United States, NCVS Direct medical costs, Cost of rape, of Justice, lost earnings, and $33 million 1994 opportunity cost of time and are hampered by measurement difficulties and nonstandardized meth- odologies. McCall and Horwitz (2004) found that in Oregon the rate of reported incidents of workplace violence was 1.86 per 10,000 employees annually, with female workers and those under age 35 experiencing the most violence. There is a wide range of estimates of how much interpersonal violence- related absenteeism, together with related medical care and productivity losses, costs employers and society in general. Internationally, a non-peer- reviewed report commissioned by the International Labor Organization (ILO) on the costs of violence and stress in work environments estimates that losses from stress and violence at work represent from 1 to 3.5 percent of GDP over a range of countries (Hoel et al., 2001). Biddle and Hartley (2002) studied the costs of homicides in the work- place in the United States and calculated an annual cost of approximately $970 million. This estimate included the lost earnings of victims extrapo- lated to the age of 67. Hashemi and Webster (1998) reviewed a random sample of nonfatal workplace violence claims filed with a large workers’ compensation insurance carrier. They calculated $26.5 million in annual costs to the insurer, based on 7,173 compensated claims, or $3,694 per

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73 DIRECT AND INDIRECT COSTS OF VIOLENCE (McEwen, 2007). An increase in one of those chemicals, cortisol, can have a dramatic impact on how memories are processed and stored (de Kloet et al., 2008). The production of cortisol and adrenaline (as well as noradrena- line) in the brain in a normal stress response leads to memory formation for events and places that signify danger. More specifically, elevated cor- tisol levels can strengthen the formation of memories of emotional events (McGaugh et al., 1996), block the ability to unlearn fear memories (Yang et al., 2007), and enhance the formation of memories of the surrounding context in which the fearful event occurred (Brinks et al., 2008). Interest- ingly, too much cortisol can also have the opposite effect and actually im- pair memory and learning in nonthreatening contexts (Roozendaal et al., 2009). Thus, the biological response to stress is intimately involved in both fear learning and fear unlearning. Persistent fear can distort how a child perceives and responds to threat. Fear learning typically takes place in specific contexts and results in those fears’ becoming associated with the places where the learning occurred. Children may also express fear in response to situations that are similar (not identical) to those initially learned or to situations that are similar to the contexts in which the original learning occurred. These are called “gen- eralized” fear responses, and they are thought to underlie the expression of later anxiety disorders, including PTSD (Davis, 2006; Grillon, 2002; Grillon and Morgan, 1999). Indeed, children who have had chronic and intense fearful experiences often lose the capacity to differentiate between threat and safety. This impairs their ability to learn and interact with oth- ers, because they frequently perceive threat in familiar social circumstances, such as in their home or neighborhood. These responses inhibit their ability to learn and often lead to serious anxiety disorders (Grillon et al., 1998; Reeb-Sutherland et al., 2009). Young children who have been exposed to traumatic circumstances also have difficulty identifying and responding to different expressions of emotions and, therefore, have trouble forming healthy relationships (Wismer Fries et al., 2005). These deficits lead to general problems with social interaction, such as understanding others’ facial expressions and emotions. For example, children raised in physically abusive households show heightened sensitivity (compared with nonabused children) to angry faces, which negatively affects their brain function and behavior (Pollak and Kistler, 2002; Pollak et al., 2000). Learning to identify anger—quickly and successfully—in order to avoid being harmed is a highly adaptive and appropriate response to an abusive environment. However, an increased tendency to assume someone is angry when his or her facial expression is ambiguous can be inappropriate and maladaptive in a typical, nonthreaten- ing social setting and even dangerous in unfamiliar social settings (Pollak, 2008). Thus, the extent to which children view the world as a hostile and

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74 SOCIAL AND ECONOMIC COSTS OF VIOLENCE threatening place can be viewed as both a logical adaptation to an abusive or violent environment and a potent risk factor for behavior problems in later childhood, adolescence, and adult life. Early exposure to intense or persistent fear-triggering events affects children’s ability to learn. There is extensive and growing scientific evidence that prolonged and/or excessive exposure to fear and states of anxiety can cause levels of stress that can impair early learning and adversely affect later performance in school, the workplace, and the community. Multiple studies in humans have documented problems in cognitive control and learning as a result of toxic stress (National Scientific Council on the Developing Child, 2005; Shonkoff et al., 2009). These findings have been strengthened by research evidence from nonhuman primates and rodents that is expanding our understanding of the brain mechanisms underlying these difficulties. The brain region in animals that appears highly vulnerable to adversity in this regard is the prefrontal cortex, which is the critical area for regulat- ing thought, emotions, and actions as well as for keeping information read- ily accessible during the process of active learning. For example, researchers have found that elevations of brain chemicals such as noradrenaline, an important neurotransmitter, can impair functions that are controlled by the prefrontal region by altering the activity of neurons in that area of the brain. In a related fashion, humans experiencing chronic stress have been shown to perform poorly on tasks related to prefrontal cortex functioning (such as working memory or shifting attention) and their ability to control their emotions is typically impaired (Arnsten, 2009). Implications for Policy and Practice Many policy makers, educators, and even medical professionals are unaware of the potentially significant, long-term risks to children of expo- sure to fear-provoking circumstances—including family violence—and lack information about the prevalence of these situations in their communities. This can lead to widespread misconceptions of how children experience and respond to fear. The scientific knowledge around fear and anxiety points to three im- portant implications: 1. Young children can perceive threat in their environment, but un- like adults, they do not have the cognitive or physical capacities to regulate their psychological response, reduce the threat, or remove themselves from the threatening situation. As a result, serious fear-triggering events such as family violence can have significant and long-lasting impacts on the developing child, beginning in infancy.

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75 DIRECT AND INDIRECT COSTS OF VIOLENCE 2. Children do not naturally outgrow early learned fear responses over time. If young children are exposed to persistent fear and excessive threat during particularly sensitive periods in the devel- opmental process, they may not develop healthy patterns of threat or stress regulation. When they occur, these disruptions do not naturally disappear. 3. Simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. Children who have been traumatized need to be in responsive and secure environments that restore their sense of safety, control, and predictability—and supportive interventions are needed to ensure the provision of these environments. As a result, it is important for policies and programs to take into account children’s developmental needs, beginning in early infancy, particularly focusing more attention on preventing persistent fear and anxiety. Children who live in violent homes or communities have been shown to have more behavior problems, greater evidence of PTSD, and increased physical symptoms such as headaches and stomach aches, as well as lower capacity for empathy and diminished self-esteem (Huth-Bocks et al., 2001). Programs focused on the reduction of domestic violence, substance abuse, neighborhood violence, and poverty are examples of the kinds of community-based services whose impacts could be enhanced by incorpo- rating targeted interventions to explicitly address the emotional needs of young children living under these conditions. When delivered effectively, such interventions could have a multiplier effect into the next generation by reducing both the individual and the societal costs of the negative de- velopmental effects of persistent fear, including mental health impairment, antisocial behavior, physical disease, and violent crime. REFERENCES Acierno, R., M. A. Hernandez, A. B. Amstadter, H. S. Resnick, K. Steve, W. Muzzy, and D. G. Kilpatrick. 2010. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public Health 100(2):292-297. Administration on Aging. 2011. Aging statistics. http://www.aoa.gov/aoaroot/aging_statistics/ index.aspx (accessed July 1, 2011). Arnsten, A. F. T. 2009. Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience 10(6):410-422. Australian Institute of Criminology. 2003. Australian crime: Facts and figures. Canberra: The Australian Government. Bandura, A. 1977. Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Bargh, J. A., and T. L. Chartrand. 1999. The unbearable automaticity of being. American Psychologist 54(7):462-479.

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