DR RAOUL GOLDBERG, BSC (MED), MB CHB, CEDH (HOM), practises anthroposophical medicine in his general family practice in Cape Town. He has been a school doctor in the Waldorf school movement for many years and has lectured widely on many subjects related to child development and health. His work is inspired by the knowledge that the foundations for a healthy life are laid down in childhood.

shades of violence in children and adolescents part 2

Part 2 in this series examines further ‘shades’ or forms of violence, as well as the nature of violence, appreciating that this mechanism is not only destructive but also protective. Violence and vulnerability are indeed intertwined.

Self injury seems to be on the increase among adolescents and young adults and is three times more common in females than males. It usually begins between 14 and 16 years of age but may persist well into adulthood. In American high schools and colleges, 12 – 14% of students have engaged in self injury at some point, and 40 – 60% of psychiatric hospitalised adolescents have actively engaged in such activity.1-3 This does not include culturally sanctioned behaviours like tattooing and body piercing but intentional and repetitive behaviour aimed at harming one’s body and resulting in physical injury. This self mutilation is done through cutting, scratching, burning, pinching, skin picking or hurting oneself in some other way. This form of self injury is classified as impulsive self injury that tends to be psychologically motivated. It is a classic addictive behaviour that fulfills all the criteria for addictive disorders. Self injurers are dependent on the self injury in the same way that a heroine junky is hooked on heroine. It is essentially the best way they know how to control their painful emotions. It may also be a means of self-expression: I need your help/Are you interested in me?/Is your love really unconditional?/I am in control/This is who I am/I hate myself and deserve to be hurt/This is my way of punishing you.

Major self-injury tends to be more dramatic and life threatening and usually occurs in psychotic or drug-induced states of mind. Injuries such as self castration and limb amputation are fortunately rare and isolated events.

Stereotypic self-injury refers to repetitive and self-stimulating behaviours such as head banging, hair pulling and self biting and is associated with infant or childhood syndromes such as autism and mental retardation.

Compulsive self-injury is repetitive, habitual behaviour such as nail biting, hair pulling and skin picking that usually causes minor and superficial injury commonly seen in Tourette’s syndrome and body dysmorphic disorder. Nail biting, hair twirling, cuticle picking or scab or blemish picking is a non-injurious, compulsive habit-driven activity that usually does not interfere with normal life.

Cutting is the most common form of self mutilation and occurs in about 4% of hospitalised psychiatric patients. Most commonly, fine cuts are made on the wrists, arms, thighs or legs with a razor blade, knife or broken glass. Less commonly the chest, abdomen and genitals are injured. Frequency may vary from several times a day to a single episode. Cutters give different reasons for injuring themselves: it relieves them from overwhelming negative emotions and tensions such as guilt, frustration, anger, anxiety, sadness, jealousy, loneliness; it is a way of reducing the pain and numbing themselves to the inner discomfort; or they are giving expression to the way they feel, namely self hatred, guilt, self punishment; or it allows them to feel something again when they have been feeling numb and empty. The cutter is either trying to free herself from her suffering by getting away from her body (‘cutting is like being high or taking a pain killer’) or she is trying to connect more strongly with her unfeeling body (‘I need to feel something/I feel alive again’). There is a frequent association with substance abuse, sexual abuse, eating disorders, mood disorders and attempted suicide.

The suicide rate among adolescents has risen dramatically in many countries, increasing 3 – 4-fold over the past 30 years. Suicide is the third leading cause of death in the USA for individuals aged between 15 and 24 years and second among white males in this age group. Currently the rate is 13.6 per 100 000 boys and 3.6 per 100 000 girls. Below 14 years the rate is 1 per
100 000 whereas between 15 and 19 years the rate is 10 per 100 000. In children younger than 14 years, suicide attempts are at least 50 times more common than successful suicides, whereas between 15 and 19 years the rate of attempts is about 15 times greater than suicide completions.

In stressful situations many children have suicidal thoughts and make suicidal threats. Most of these are innocent melancholic outbursts and relatively few go on to attempt or complete suicide. How can we tell which children are at risk? Previous suicide attempts, mood disorders together with substance abuse and a history of aggressive behaviour are high-risk factors. Impulsive adolescents with conduct disorders are prone to suicide during conflict situations. Other high-risk factors include despair, hopelessness and social withdrawal, poor problem-solving skills, depression (especially in girls), perceived failure in high achievers and perfectionists, conflicts, arguments, fear of punishment, broken romances, rejection, humiliation, pregnancy, school difficulties, bereavement, and separation compounded with substance use in psychiatrically disturbed and vulnerable adolescents. Highly publicised suicides as well as television programmes and movies depicting the suicide of teenagers have been found to increase adolescent suicides (the ‘Werther syndrome’ after the central character in Goethe’s novel, The Sorrows of Young Werther, who kills himself). Adolescents who engage in self injury are also at risk since 50 – 90% of individuals who self injure also engage in suicidal behaviour.

When aggressive and violent behaviour becomes repetitive, habitual and compulsive and brings relief to emotional discomfort, the addictive process swings into action. Violence becomes another means, a false substitute to address unfulfilled needs that lead to inner pain and discomfort. Thus animal cruelty, hostile defiant behaviour, bullying, constant fighting and the various kinds of self injury can all be used addictively to try to relieve pain caused by an original need that was never addressed.

We tend to only think of violence in the psychosocial dimension as an aggressive and offensive mechanism, not realising that violence is a double-edged sword that guards and protects as much as it attacks and destroys. Observe the human biological phenomena, both in the healthy and diseased condition, and you will understand more clearly the nature of violence from this perspective.

The human organism includes biological systems whose primary function is destruction and breakdown in service of the integrity and homeostasis of the whole. The three main systems that carry out this function are as follows.

The immune system is a highly complex and efficient defence system present throughout the body comprising chemical, cellular and biological components whose function it is to destroy any threatening foreign elements. The stomach acid and digestive enzymes of the pancreas and intestinal tract and the bile of the gall bladder are highly destructive substances that violently destroy all biological foreign agents such as bacteria, viruses, fungi and other parasites. The bacterial flora co-operate in defence mechanisms. Mucous secretions lining the surfaces of all hollow organs trap bacteria and destroy them chemically. The lymphocytes are white blood cells that eliminate foreign organisms either by ingestion or by the production of protein substances called antibodies, which like missiles, attack and destroy viruses. Specific lymphocytes are known as natural killer cells on account of their superior destructive abilities.

The digestive system, through its sophisticated system of chemical substances (stomach acid, pancreatic and intestinal enzymes and bile secretion), liquidising muscular action of the stomach and intestine and intestinal bacterial flora, is designed to actively and completely destroy the foreign nature of mineral, plant or animal food substances and to transform it into a form that can serve the human organism. These food substances are completely stripped of their natural energetic qualities in order that the neutral substance may be reformed into nutrients that carry the human energetic signature.

Programmed cell destruction. Every cell in the body is equipped with tiny storage granules called lysosomes that contain powerful degradative substances. These may be secreted and utilised within the cell to regulate cellular metabolism, maintaining the fine balance between anabolism (cellular build-up) and catabolism (cellular breakdown). Senescent or damaged cells destined for destruction are eliminated in this intracellular way as well as by other mechanisms such as destruction within the spleen or shedding of old cells on surface linings.

When healthy homeostatic mechanisms are disturbed by intrusions or deficiencies of one kind or another, a variety of destructive phenomena on the human biological level can be recognised. Some of these are as follows.

 As a result of heightened stress levels and weakened mucous protection, the stomach produces excessive acid which may erode the lining causing ulceration of the stomach. In some cases it may be violent enough to cause perforation leading to death.

 This is a healthy defensive reaction of the tissues caused by some toxic provocation. For instance a thorn, a sting, bacteria or some poison will elicit a tissue response whereby defensive agents (chemical, immunological) in the fluid or blood system are mobilised to eliminate the biological violator. In the process, however, the body’s tissues can be severely damaged. Think of a boil that breaks down causing severe pain and lack of function for days until healing occurs.

Auto-immune illnesses.
 It may happen that the cause of the provocation comes not from outside as in the above case of the boil caused by a thorn, but from the inside, from the tissues themselves.

Something tells the defence system to turn on itself and attack its own tissues.
 For instance, in rheumatoid arthritis the cartilage of the joint becomes the target of an attack causing serious disability. This appears to be the biological equivalent of the psychological entity of self injury. In our time this category of illnesses is becoming increasingly frequent among children and will be discussed in more depth in a later article.

 This phenomenon expresses the opposite activity. Instead of hypervigilance leading to self destruction, we have the loss of self care and self surveillance whereby the immune system no longer recognises potential dangers and does nothing to remove injurious agents. Eventually the tissue cells are modified to the degree that they take on an autonomy of their own, growing wherever they wish and causing death and destruction in their wake.

When we seek to understand the nature of violence, it is most helpful to look at our own experience of this phenomenon. What reality lies behind all acts of violence? Recall how you felt when you lost your temper, verbally abused someone or committed any other act of aggression. It may feel as if one is trying to defend oneself against something that is in one’s way, irritating or attacking one from the outside. Try and re-live the event and experience how you felt just before your aggressive outburst. Awareness will reveal that you were probably feeling hurt in some way. To be sure it was the dog that was in your way or the mess on the table that set things off, but in reality it triggered off an abuser inside of you that causes hurt. With awareness one can easily feel the hurt person inside; however it is not usual to know the one who is hurting you. If one does not check things out by looking inside, one will end up justifying one’s actions, blaming the other person for offending one and perhaps feeling guilty at one’s behaviour. When one realises, however, that the aggression is invariably a reaction to the hurt or violation projected outwardly, the situation looks very different.

Suddenly one is in a position to understand why one acted in this way and to deal constructively with the deeper cause of the aggression.

If we now look from the position of our own original experience at all the above characterisations of different shades of aggression and violence in childhood and adolescence, we shall see that they are all different reactions to an inner soul experience of hurt and violation. An introverted child will more likely experience the inner hurt and violation inwardly and project it towards himself; the extroverted child however often projects this inner experience outwardly in acts of violence towards others. The 2-year-old child who cannot get her way, experiences inner frustration and hurt at being blocked by an external will when her unbridled will is needing to express itself. The environment of disruptive children or adolescents will invariably present with external or internal factors that have led to inner soul hurt and violation, e.g. a violent and abusive father. The teenager addicted to violent behaviour is compulsively dependent on the violence to temporarily soothe the continuous feeling of hurt that lives inside him.

Violence and vulnerability would therefore appear to be inextricably bound up with one another. It is this connection that can help us to understand the nature of violence and to manage it correctly and effectively. Part 3 in the next issue of the Journal will examine the origin of violence, and Part 4 will look at an approach to its management.

1.    McVey-Nobel M, et al. When your child is cutting. A parent’s guide to helping children overcome self-injury. Oakland, Calif.: New Harbinger Publications, 2006.
2.    Favazza A. The coming of age of self-mutilation.  Journal of Nervous and Mental Disease 1998; 186: 259-268.
3.    DiClement R, et al. Prevalence and correlates of cutting behavior.  Journal of the American Academy of Child and Adolescent Psychiatry 1991;
30: 735-739.