PREVALENCE and PSYCHOLOGICAL IMPACT of EXPOSURE to VIOLENCE AMONGST CHILDREN in KHAYELITSHA Dr

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PREVALENCE AND PSYCHOLOGICAL IMPACT OF EXPOSURE TO VIOLENCE AMONGST CHILDREN IN KHAYELITSHA Dr. Debra Kaminer, Department of Psychology and Child Guidance Clinic, University of Cape Town

INTRODUCTION Multiple data sources indicate that South African children grow up in a particularly dangerous context, when compared with their counterparts in other countries. The homicide rate in South Africa is five times the global average, and male youth are the most frequent victims (Seedat, van Niekerk, Jewkes, Suffla, & Ratele, 2009). In a national prevalence study, 30% of youth living in major metropolitan centres of South Africa had been victims of violent crime and 60% had witnessed incidents of intentional violence in their communities (Burton, 2006). Further, some studies report that South Africa has one of the highest incidences of rape worldwide (Jewkes & Abrahams, 2002), and an analysis of South African police statistics indicates that over 40% of all reported rapes, and half of all other sexual assaults, have been perpetrated against children (RAPCAN, 2012). Within this national context of high rates of youth victimization, the Western Cape has some of the highest levels of adolescent injury due to interpersonal violence. Cape Town has the highest rate of youth homicide in the country, at 76.4 per 100,000 males and 10.4 per 100,000 females (Burrows, Swart, & LaFlamme, 2009). In the Cape Town metropole, homicide is the second leading cause of death for children aged 10 to 14 years, and the leading cause of death for youths between the ages of 15 and 19 years (Groenewald et al., 2008). Further, 37% of youth in the Western Cape have experienced multiple criminal victimisations, which is a higher rate than that reported for youth in Gauteng, KwaZulu Natal, Free State, Eastern Cape and Northern Cape (Leoschut & Burton, 2006). In addition to these broader national and provincial figures, there is also some research data regarding children’s exposure to violence within the Khayelitsha community specifically. In addition, there is substantial media documentation of children’s exposure to violence in Khayelitsha, which is a valuable supplement to existing research findings in describing the lived experiences of young people in Khayelitsha. These sources of data are reviewed below.

1. CHILDREN’S EXPOSURE TO VIOLENCE IN KHAYELITSHA

1.1. Research studies An older study, conducted in the aftermath of South Africa’s first democratic elections and published in 1997, found that 95% of a sample of Khayelitsha children aged 10-16 years had witnessed community violence, and 56% had been victims of community violence (Ensink, Robertson, Zissis, & Leger, 1997). In more recent years, three studies have reported on rates of violence exposure amongst samples of children and youth from Khayelitsha. As will be demonstrated below, the findings of all three studies demonstrate that exposure to violence remains a common part of daily life for young people in this community.

Cluver, Gardner, and Operario (2008) assessed rates of violence exposure amongst 1025 children in Cape Town aged 10 – 19 years, of whom approximately two thirds lived in Khayelitsha and Macassar. Nearly half the sample (46%) had witnessed a stabbing, 32% had witnessed a shooting, and 29% had witnessed other forms of community violence (such as gang violence or seeing a corpse). With regard to direct victimization, 39% had been robbed and 13% had been assaulted in the community. Shields and colleagues (2008 and 2009) have reported on exposure to violence among primary school children aged 8 to 13 years at five Cape Town schools, including one from Khayelitsha. The sub-sample from Khayelitsha (47 children) comprises approximately one fifth of their total sample (247 children). All statistics reported for this study are for the total sample, as results were not disaggregated by school. The frequency of exposure to violence in the neighbourhood is reported below in Table 2. The majority of children (75%) have witnessed someone being badly beaten in the neighbourhood, more than a third (37%) had themselves been badly beaten in the neighbourhood, and 40% had been robbed. In addition, it is apparent that witnessing weapons related violence is very common in this sample of primary school children: almost two thirds (63%) have witnessed someone being threatened with a weapon, more than half (58%) have witnessed someone actually being attacked with a weapon, and 40% have witnessed a murder in their neighbourhood. Direct victimisation with a weapon was also reported by a substantial minority of this young sample: just under one third (31%) had been directly threatened with a weapon in their neighbourhood, nearly a quarter (24%) had been attacked with a weapon, and 22% reported that they had been shot at.

Table 1. Frequency of exposure to neighbourhood violence in Shields et al.’s (2008 and 2009) sample of primary school children (including 47 children from Khayelitsha)

NEIGHBOURHOOD EVENT FREQUENCY OF EXPOSURE Witnessed a serious beating in the neighbourhood 75% Experienced a serious beating in the neighbourhood 37% Robbed 40% Witnessed someone being threatened with a weapon 63% Witnessed someone being attacked with a weapon 58% Witnessed a murder 40% Directly threatened with a weapon 31% Directly attacked with a weapon 24% Directly threatened with a gun 29% Directly shot at 22%

In comparison with the results of this study, in a survey of a nationally representative sample of children aged 2 to 17 years in the United States only 5.3% had been robbed, 13% had witnessed someone being assaulted with a weapon, 5% had themselves been assaulted with a weapon and only 0.3% had witnessed a murder (Finkelhor, Ormrod, & Turner, 2007). The relative rarity of witnessed and direct community victimization amongst young people in this American sample highlights the disturbingly endemic nature of violence amongst the young children in Shield’s et al.’s study, where exposure to weapons related violence is the norm rather than the exception.

A third group of researchers (Weierstall et al., 2012) has recently conducted a study with 78 male youth offenders, including teenagers and young adults, residing in Khayelitsha and Gugulethu, attending a diversion programme run by a community-based organisation. Although this sample is not representative of all youth in these areas, and is obviously at higher risk than non-offending youth of being exposed to violent events, the degree to which they have witnessed violence in their neighborhoods further confirms the pervasive nature of violence in these communities. The frequency of witnessing different types of violence in this sample is summarised in Table 2. These results, presented at an international conference in 2012, are still being prepared for publication.

Frequency of witnessed community violence amongst 78 youth offenders in Gugulethu and Khayelitsha (Weierstall et al., 2012) EVENT FREQUENCY OF EXPOSURE Heard gun shots 97% Witnessed a beating in the neighbourhood 94% Witnessed a stabbing in the neighbourhood 86% Witnessed a shooting in the neighbourhood 77% Witnessed a dead body on the neighbourhood 80% Witnessed a murder in the neighbourhood 77%

1.2. Media documentation The media has provided further documentation that children in Khayelitsha are exposed to several specific forms of violence. This includes gang violence, vigilantism, rape and sexual abuse, and protest violence. Exposure to each of these forms of violence will be described in turn.

1.2.1. Gang violence During 2011 and 2012 several media reports highlighted the growth of gang violence amongst teenagers in Khayelitsha. In June 2011, West Cape News (see http://westcapenews.com/?p=3036) reported that parents and community leaders in Khayelitsha were increasingly concerned about gang related violence, which had been linked to 20 stabbings (two of these fatal) in the past month. For example, in Site B a 16 year old had been stabbed repeatedly by a group of about 50 members of the Vato-Sloko gang, while on his way home from soccer practice. The victim was hospitalised. The incident was witnessed by the victim’s mother. The article further reports that, according to the mother, she telephoned the police from her cellphone but they did not arrive at the crime scene. She then went to the Khayalitsha site B police station, where she was told that the police would come to take a statement from her son at the hospital, however they did not arrive. A spokesperson for the SAPS later stated that the SAPS had no knowledge of such an attack or of any gang activity in this area. At a community meeting later that week, parents reported that they had to lock their children inside their

3 homes at night, and that there were some areas that had become “no-go” areas. The article also includes an interview with a Grade 10 pupil at Bulumko High School, who was not able to write an exam paper that week because she had been beaten and threatened with being stabbed by Vata-Sloko gang members in E Section while on her way to school in the morning.

In March 2012, the New Age (see http://thenewage.co.za/45576-1011-53- Fatal_teenage_gang_fights_see_pupils_dropping_out_of_school) reported that fights between rival teenage gangs in Khayelitsha had resulted in the death of three school children, in the hospitalisation with serious injuries of two others, and in a spike in class absenteeism and school drops out due to school learners’ fears of being attacked on the way to school. According to the reporter, who visited two schools in Khayelitsha, up to six different gangs can be found in a school and gang members are as young as 12 or 13 years of age. Gang fights were reported to take place immediately outside the school premises when school ends. A Grade 9 pupil told the reporter that “Every day when the fights start I’m using a back door to escape. We live in fear of what is going to happen after school”.

In June 2012, an online article at allAfrica.com (see http://allafrica.com/stories/201206200201.html) reported the following: “Parents and residents of Harare 33 and 34 Section cheered as about 100 teenagers affiliated to the Vato- Slokos and the Madonsela gangs attacked each other with knives, pangas, sticks and stones. The teenagers, mostly still dressed in their school uniforms, waged a running battle through the streets for over two hours until police arrived, whereupon they scattered into surrounding streets. Eyewitnesses to the battle, this reporter among them, noted that at least five boys were injured. Some were bleeding from wounds to the head while others were stabbed. Groups of Vato-Slokos and Italians also clashed later on Tuesday afternoon in Site B in a battle that raged for about an hour…Residents reported that a group of girls stabbed another young woman in apparent gang-related violence on Monday. Harare resident Siphosethu Mduku said a group of girls attending Kwamfundo High, upon noticing another girl passing the school, rushed out and stabbed her.”

In July 1012, the Cape Argus reported that a 17 year old had been killed after being shot twice by gang members in Site D, on his way back from the funeral of a friend who had been fatally stabbed in gang violence two weeks earlier. The victim’s older brother reported that it was not safe to leave the house even during the day, and that rival gangs are holding the community hostage.

In September 2012, The Mail and Guardian also reported on the growth of gang violence in Khayelitsha, which had been linked to at least five teenage deaths in 2012 (see http://mg.co.za/article/2012-09-21-00-blood-sport-traps-cape-towns-teen-gangsters-in-a- spiral-of-violence). The article interviewed teenagers who have dropped out of school due to fear of being victimized by a rival gang, and reports that several local schools have closed temporarily due to gang violence on or near school property. Several of the teenagers interviewed in the article had either been stabbed multiple times or had witnessed several stabbings. A principal of a Khayelitsha school describes how teenagers from other schools jumped over the school fence to go “hunting” in his classrooms, and how a learner was stabbed at the school gates. The article further quotes a teen gang member describing gang killings as being like a soccer game in which rival gangs try to out-score each other.

The photographs below depict young people in Khayelitsha, some of whom appear to be on their way to school, showing gang membership signs.

From the New Age, March 2012

From the Mail and Guardian, September 2012

From West Cape News, June 2011

The above media stories illustrate the absence of safe spaces in the lives of children and adolescents in Khayelitsha, where gang violence permeates the neighbourhood and the schools. These reports confirm the findings of the research studies cited above, illustrating that exposure to life-threatening violence involving weapons, as either a witness or a victim, is part of the daily experience of many young people in Khayelitsha. These media reports also indicate that efforts to avoid these dangers significantly impair the ability of young people to participate in school or after-school activities.

1.2.2. Vigilantism Repeated incidents of vigilantism in Khayelitsha have been reported over the past two years, frequently resulting in the death of victims. An article in the New Age on 18th March 2013 (see http://www.thenewage.co.za/87792-1008-53-Call_for_action_on_mob_murders) reported that there had been 11 such murders in Khayelitsha in the past year. Victims had been either beaten or burned to death by a group of people who believed the person had perpetrated a crime, resulting in these murders being referred to in the popular media as ‘mob justice’. It is clear from media images that children have been both witnesses of, and participants in, this form of violence. The images below, published on the website for West Cape News in March 2012 (see http://westcapenews.com/?p=3929) show very young children witnessing the necklacing of three men accused of stealing.

In May 2011, The Sowetan (see http://www.sowetanlive.co.za/news/2011/05/30/police-save- suspect-from-mob-justice) reported on a separate incident of vigilantism in Khayelitsha, where a suspected thief was beaten and stoned to death by members of the community. The photograph below shows young children viewing the victim lying on the ground after the assault.

In September 2012, West Cape News (see http://westcapenews.com/?p=5144) published the following two photographs, showing very young children playing around the spot in a playground in Khayelitsha where a man had been burnt to death by necklacing a few days earlier. Evidence of the necklacing is still clearly visible on the ground.

Eyewitness News video footage published on Youtube in March 2012 (see http://www.youtube.com/watch?v=AtZClH8iDKk) features an interview with a child witness of a vigilante killing of a suspected cable thief in Harare, Khayelitsha. The child, who appears to be of primary school age, is standing with a group of other young children. He calmly and matter-of-factly gives a detailed description of the necklacing of the victim, and of the victim’s screams as he struggled against his attackers. Children’s involvement in vigilante attacks in Khayelitsha have not been restricted to witnessing. The following two photographs, published on IOLNEWS (see http://www.iol.co.za/news/south-africa/western-cape/khayelitsha-mob-justice-in-pictures- 1.1043282) show children participating in an assault on an alleged thief in Mandela Park, Khayelitsha, by kicking him and stamping on him as he lies on the ground. Although adults are present, no attempt is being made to prevent the children’s participation in the assault. The date of the assault is not specified in the report.

1.2.3. Sexual assault In addition to the above forms of violence, children in Khayelitsha, particularly young girls, are subject to sexual victimization, sexually motivated abductions and murder. In September 2010, the Sunday Times reported that a 4 year old was abducted from outside her Khayelitsha home, and was found wandering in the street three days later. She had been raped (see http://www.timeslive.co.za/local/2010/09/22/outrage-at-rape-of-4-year-old). In August 2012, the Cape Argus reported that a Khayelitsha man had been convicted of the kidnapping of 12 girls, the rape of 11 of these girls, and the murder of a 5 year old girl during 2010 and 2011 (see http://www.iol.co.za/capeargus/rapist-choked-crying-child-1.1367041). In December 2012, IOL reported that a 5 year old girl was abducted outside her home in the Green Point informal settlement in Khayelitsha (see http://www.iol.co.za/news/south-africa/western- cape/please-bring-back-my-nini-1.1445732). A few weeks later News24 reported that her body had been found a few houses away. She had been raped and killed (see http://www.news24.com/SouthAfrica/News/Missing-girls-body-found-in-shack-20130116).

1.2.4. Protest violence Service delivery protests in Khayelitsha have also involved interpersonal violence that is witnessed by children. In one incident, an off duty policeman was attacked and beaten on the head with a large rock by a group of protesters in Site C, Khayelitsha. In the photographs below, published by IOL in August 2009 (see http://www.iol.co.za/news/off-duty-cop-and- friend-attacked-in-khayelitsha-1.676428), a child witnesses the beating and a toddler stands nearby as the policeman lies unconscious on the ground after the attack.

In August 2012, IOL News published an online news article describing how protesters in Khayelitsha had stoned a bus, which then crashed into five dwellings, killing the driver and seriously injuring several residents (see http://www.iol.co.za/news/south-africa/horror-crash- after-protesters-stone-bus-1.1356460#.URn6TIs9aQY.gmail). The caption for the photograph below, which was published with the article, reads as follows: Thembeka Lamont and her son Lindokuhle at the crash site. They watched in horror as a bus ploughed through their Khayelitsha home with four family members still inside.

1.3. Summary The above sources of information indicate that children in Khayelitsha are exposed to violence in multiple domains, with few safe spaces that they can access. Research surveys have demonstrated that exposure to violence amongst children and youth in Khayelitsha is the norm rather than the exception, with very few children being exempt from violence exposure. Media reports and photographic evidence further illustrate that within the neighbourhoods and streets of the community, children witness gang violence, vigilante violence and protest-related violence on a regular basis. Gang warfare between teenagers in the streets and outside schools is common, frequently resulting in deaths and serious injury. Children have also witnessed the murder or serious injury of a number of suspected criminals in the context of what has been dubbed ‘mob justice’ or ‘vigilante attacks’. In addition, deaths and serious injury due to protest-related violence have been witnessed by young children. In addition to witnessing community violence, children in Khayelitsha are also victims of violence. Media reports indicate that many teenagers have been killed or seriously injured by weapons in the context of gang violence in the streets and in or outside schools. School grounds and access routes to school are experienced by many children as dangerous at a life- threatening level, resulting in school avoidance and drop-out. Furthermore, young children are also not safe outside their own dwellings, due to repeated instances of sexually-motivated child abductions. Not only are children in Khayelitsha frequently witnesses to and victims of violence, they are also involved in violence perpetration. Teenagers participate in frequently lethal gang violence, often involving knifes, pangas or other weapons, and view gang killings as a competitive game. While parents in the community have voiced deep concern about the danger posed to their children through gang violence, it is also apparent that violent behaviour is at times modelled to children by adults in public spaces, as evidenced by the active participation of young children in vigilante attacks perpetrated by groups of adults. Taken together, the above evidence indicates that for children in Khayelitsha, violence is more of a condition of living than a single specific event. In the words of American researcher Bruce Perry (1997), children in the Khayelitsha community are “incubated” in violence from an early age. Access to safe spaces, and to protection from danger, is limited, and children therefore have to find ways to adapt to multiple and ongong dangers. The

10 following section of the report will consider the psychological effects of growing up under conditions of continuous violence.

2. PSYCHOLOGICAL IMPACT OF VIOLENCE EXPOSURE Not all children will experience negative mental health outcomes as a result of exposure to violence. Many risk and protective factors play a role in determining a child’s capacity to withstand the impact of violent events, including individual personality factors, family factors, available social supports, and community resources (Kiser & Black, 2005; Masten & Narayan, 2012). However, several different forms of negative mental health outcomes have been documented amongst children in South Africa and elsewhere who have been exposed to violence. It appears that there are two different negative mental health trajectories for youth who are exposed to repeated violence, one that results in ‘internalising’ difficulties, such as feelings of fear, anxiety or depression, and another that results in ‘externalising’ difficulties, such as aggression and conduct disorders, though there may be some co-occurrence of these symptom types in some youth. In addition, there is evidence to suggest that exposure to violence reduces children’s school performance. These different outcomes are reviewed below. 2.1. PTSD and depression The most commonly reported psychological impact of exposure to violence amongst both adults and children is posttraumatic stress disorder (PTSD). This includes symptoms of re- experiencing traumatic events (through memories, intrusive images, nightmares, and anxiety reactions when confronted with reminders of the trauma), attempts to avoid reminders of the trauma (such as places similar to that where the trauma occurred), emotional numbing, and persistent physiological hyperarousal (being constantly on guard, over-reacting to potential threats, reduced ability to concentrate on tasks, sleep disturbances), all of which persist for longer than four weeks after the trauma and cause impairment in daily functioning at home, school, work or socially (APA, 2000). Symptoms of depression (low mood, feelings of hopelessness and worthlessness, reduced interest and pleasure in previously enjoyed activities, social withdrawal, appetite and sleep disturbances, and possibly suicidal feelings) frequently occur together with PTSD (Kessler et al., 1995). Several studies with school children in Cape Town have found that increased exposure to violence is associated with increased levels of PTSD and depression – that is, the more incidents of violence a child experiences, the more severe are their PTSD and depression symptoms (Cluver, Fincham, & Seedat, 2009; Fincham, Korthals Altes, Stein, & Seedat, 2009; Kaminer, Hardy, Heath, Mosdell, & Bawa, in press; Martin, Revington, & Seedat, 2012; Shields, Nadasen, & Pierce, 2008; Seedat, Nyamai, Njenga, Vythilingum, & Stein, 2004; Suliman et al., 2009; Ward, Martin, Theron, & Distiller, 2007). This is now a very robust finding, replicated across several studies, confirming that children in Cape Town who experience multiple exposures to violence are at higher risk of developing PTSD and depression than those who experience fewer exposures. Of these studies, at least three (Cluver et al., 2009; Shields, Nadasen, & Pierce, 2008; Suliman et al., 2009) have included children from schools in Khayelitsha. Further, findings suggest that both witnessing violence and being a direct victim are associated with an increased risk of depression, fear and anxiety (Shields et al., 2009; Ward et al., 2007).

The rate of PTSD in the general population in the United States is approximately 8% (Kessler et al., 1995). Existing studies with children in Khayelitsha have found far higher rates of PTSD. For example, Ensink et al.’s (1997) study found that 21.7% of children met the diagnostic criteria for PTSD. Suliman et al.’s (2009) more recent study (in which 17% of the total sample of 14 to 18 year olds lived in Khayelitsha) reported that 23.6% of the sample endorsed symptoms consistent with a PTSD diagnosis. Weierstall and colleagues’ (2012) study with male youth offenders from Khayelitsha and Gugulethu reported that 14% met criteria for PTSD. Even if children do not have full-blown PTSD, feelings of fear and vigilance to danger are pervasive amongst South Africa youth, affecting quality of life. In the national Youth Victimisation Study of 2005, approximately 28% of youth in South Africa cited murder as the thing they were most afraid of, while 20% cited rape or sexual assault (Burton, 2006). In the same survey, the Western Cape had the highest numbers of youth who report feeling afraid of criminals (70%), compared with other provinces (Leoschut & Burton, 2006). In a recent national Victims of Crime Survey (Statistics South Africa, 2011), 39% of participants stated that they did not allow their children to play in the neighborhood due to a fear of crime, and 34% did not allow their children to walk to school. The media reports in Section 1 above demonstrate that many children in Khayelitsha are themselves afraid to walk to school, and actively avoid school in order to keep themselves safe. The following case study illustrates the impact of community violence on PTSD and depression symptoms in children living in Khayelitsha. Nandi and Siya are siblings, 9 and 11 years old respectively, who were brought by their mother to the University of Cape Town’s Child Guidance Clinic in 2012. Their father had died of a chronic illness five years previously, and the three of them lived in a small ‘RDP house’ in Khayelitsha. Each day they commuted by public transport to Claremont where the children attended school and the mother worked as a domestic worker. Mother reported that in the past two years the family had experience the following events in Khayelitsha: on two occasions, the mother has been robbed by a group of youths at knifepoint while walking with the children from their home to the taxi rank in the early morning; on one occasion, their home has been broken into at night while they slept and several of their possessions were stolen; on several occasions, the bus on which they were travelling in Khayelitsha was stoned by protesters; and six weeks prior to their clinic visit their neighbour, a close friend of the mother and regular carer for the two children, was murdered by ‘gangsters’ in the road on her way to the taxi rank one morning. Since the murder of their neighbour, both children have become extremely tearful and fearful. They cry when they have to leave their home in the morning to walk to the taxi rank, as they are afraid that something will happen to them or their mother. Similarly, they cry when they travel back from school to Khayelitsha in the afternoon and beg their mother not to make them go back to their street where they feel unsafe, making her walk a circuitous route back to their house to avoid the spot where their neighbour was murdered. Both their teachers have reported to mother that the children appear tearful and distracted at school. Nandi, usually an engaged and strong student, has become withdrawn in class and has failed two recent tests. Both children struggle to fall asleep at night and wake frequently, being very vigilant to noises from the street. Siya has been asking his mother if he can carry a kitchen knife with him when they leave the house, to protect them. During the course of treatment at the clinic, options for addressing the family’s safety were explored, and the family were able to move out of their home to live on the property of the mother’s employer. As soon as they moved, the children’s symptoms remitted. Their school performance and sleeping returned to normal, they were no longer tearful, and no reported feeling fearful.

2.2. Aggression and the normalisation of violence For children who experience violence as part of their daily lives, aggressive behaviour may become normalised as an acceptable, appropriate and even honourable way to deal with conflicts and to achieve their goals (Burton, 2006; Perry, 1997). National statistics suggest that the process of the normalisation of violence and criminality is already entrenched among South African youth. In the Medical Research Council’s 2008 Youth Risk Behaviour Survey (Medical Research Council, 2008), 35% of male youth in the Western Cape carried some form of weapon, 22% carried a gun, and 34% carried a knife. These rates were higher than those for any other province. Further, nearly one in five male youth (19.8%) in the Western Cape reported that they were a member of a gang. In the national Youth Victimisation Survey of 2005, almost one in five children or adolescents had considered engaging in criminal acts, and a million youth admitted to already having committed a criminal act (Leoschut & Burton, 2006). The media images and stories from Khayelitsha reported in the previous section also testify to the normalisation of extreme violence as a way of dealing with disputes in the community, with children being both witness to and participants in vigilante attacks, gang violence and service delivery protest violence. Research in Western Cape schools has reported that direct exposure to trauma is associated with an increased risk of conduct problems among Grade 6 (Ward, Martin, Theron & Distiller, 2007) and Grade 7 (van der Merwe & Dawes, 2000) learners. In the study by Weierstall and colleagues (2012) with male youth offenders from Khayelitsha and Gugulethu specifically, increased episodes of witnessing community violence were associated with an increase in appetitive aggression. Appetitive aggression refers to aggression that is experienced as pleasurable and rewarding, rather than as strictly reactive to threats or as instrumental in achieving material goals. This implies that the more often boys in these communities witness acts of violence, the more likely they are to come to view violence as a source of pleasure and enjoyment rather than a source of threat or fear. This is likely to feed into an escalating cycle of violence over time within these communities. In addition to the development of a norm of violence as a source of entertainment and enjoyment, some American studies have suggested that youth who are chronically exposed to violence may develop a dissociation or emotional disengagement response as a way of coping (Fitzpatrick, 1993; Hill, Levermore, Twaite & Jones, 1996). While protective in some ways, this coping strategy may also increase the risk of violence and crime perpetration. A pattern of ‘terminal thinking’ has also been observed in chronically traumatised youth, whereby they are unable to envision any long-term future and become resigned to the belief that a violent death is inevitable (Garbarino, 1999). Emotional disengagement and terminal thinking may have a negative impact on children’s moral development, resulting in a lack of empathy and an absence of concern about the consequences of one’s actions towards others, which may in turn increase the risk of engaging in violent behaviour or criminality. Anecdotal observations reported to the UCT Child Guidance Clinic by schools and NGO service providers in high- violence communities in Cape Town suggest that dissociation and disengagement are common amongst children and adolescents. However, these responses have not yet been well documented in local research studies.

2.3 School performance In studies with children living in high-violence urban areas in the United States, exposure to repeated experiences of violence has been found to have a negative impact on various aspects of intellectual functioning, including verbal comprehension, working memory, processing speed and perceptual reasoning (Kira et al., 2012), and reading and maths achievement (Milam, Furr-Holdem, & Leaf, 2010). It is therefore likely that the presence of psychological symptoms related to trauma exposure reduce learning capacities. PTSD may impede children’s capacity to learn because they are preoccupied with identifying potential threats in their environment and with managing intrusive recollections of past traumas, making it difficult for them to concentrate and focus on schooling. Ford (2009) argues that, at a neurobiological level, the brains of children who grow up in violent environments are oriented towards survival rather than towards learning and exploration. There is an absence of local research on the relationship between violence exposure and school performance; however, there is no reason to expect that this relationship would be any different in South Africa than elsewhere in the world. While the South African education system faces many challenges that may contribute to poor school performance amongst learners in under- resourced settings, it is important to consider the additional role played by high levels of trauma exposure in impeding the school performance of learners in communities such as Khayelitsha.

2.4. At risk populations Some populations of children may be particularly vulnerable to the negative mental health impacts of violence, due to multiple stressors and limited support systems. In a sample of 1025 children that included participants from Khayelitsha, Cluver and colleagues (2009) found that children orphaned by AIDS were more likely to report symptoms of PTSD and had higher rates of clinical-level PTSD than both children orphaned by other causes and non- orphaned children, despite having similar rates of violence exposure. Children orphaned by AIDS are therefore a particularly vulnerable and at risk group within Khayelitsha, with regard to the possible impact of violence exposure upon their mental health. Violence exposure may further compound the psychological distress and survival hardships associated with AIDS- related bereavement. In addition, international studies have found that street children or homeless children are at a significantly higher risk for mental health problems such as PTSD, depression, suicidality and substance abuse than children who live with their families, due to the combination of increased exposure to violence and the constant insecurity of having to struggle to find food and shelter (Jones, Herrera , & de Benitez, 2007; Kidd & Carroll, 2007). There is little South African research on the psychological needs of street children, but one study from Gauteng supports international findings (Meyer, Madu, & Mako, 2002).

3. RECOMMENDATIONS There are several challenges to addressing the psychological impact of violence on children in Khayelitsha. The prevention or reduction of violence is of course the most important priority in attempting to address the high rates of violence exposure among children and adolescents in this community. At present most violence prevention programmes in South Africa are offered by a chronically under-funded and under-resourced non-governmental sector rather than by the state, although plans for a multi-sectoral governmental response to

violence reduction are well under way. Further, the early detection and containment of traumatic responses in children that could be offered by schools is hampered by the current dearth of posts for school-based psychologists and counsellors in the education system, and children living in high violence, low-income communities like Khayelitsha are therefore likely to be referred for intervention only once symptoms are impacting very severely on their functioning. Finally, tertiary level mental health services for children affected by trauma and violence are currently provided by an inadequately resourced state mental health service in which there is a paucity of psychologists and psychiatrists relative to the need (Lund et al., 2009). For example, the UCT Child Guidance Clinic is often unable to refer children from Khayelitsha to the state mental health system if they require more specialised psychiatric or psychological services, due to long waiting lists for these services. Intervention requires an emphasis on prevention and early identification wherever possible. There is a need for greater coordination and complementarity between the state and NGO sectors in addressing child and youth victimisation and for recognition that investment in both prevention and more clinical interventions now can greatly reduce the economic and societal burden of untreated childhood trauma in the long term. The creation of more posts for school-based counsellors would be an important step towards supporting children in Khayelitsha who have been affected by violence. Counsellors could rotate between schools rather than being based in only one school all week. In addition to some work with individual children, counsellors could offer training to teachers in early identification of traumatised children who should be referred to counselling, as well as group based interventions for learners aimed at enhancing their resilience, challenging norms of violence, and engaging them in active participation in violence prevention initiatives. In addition, improved state funding for the several NGOs in Khayelitsha that already offer counselling and support services for children would enhance existing community resources. Further, the development of more safe after-school spaces for Khayelitsha learners (whose parents often work long hours and are not available to supervise them after school) would be an important preventive strategy. Increased posts for mental health professionals at community mental health clinics would increase access to mental health support for those children most severely impacted by violence. Finally, it is vital that adults in the Khayelitsha community recognise the negative long-term consequences of modelling violent behaviour to children in their community. Psycho-education and public awareness initiatives, for example through community newspapers and radio stations, can contribute to this raising awareness. While there are realistic resource constraints which may impede the implementation of these recommendations, policy makers should hold in mind that as children grow up to become adults in their communities, the consequences of untreated trauma are likely to be passed on to the next generation of South African children, with growing societal and economic costs.

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