Repercussions of family violence : oral history of adolescents

Rev Bras Enferm. 2020;73(1): e20180228 http://dx.doi.org/10.1590/0034-7167-2018-0228 7 of ABSTRACT Objective: To know the repercussions of the experience of family violence from the oral history of adolescents. Method: Qualitative study based on the Oral History method, conducted from interviews with adolescents enrolled in a public school in Salvador, State of Bahia, Brazil. The data were systematized according to the thematic analysis and supported by theoretical references on family violence and adolescence. Results: Family violence implies physical illness associated with the damage caused by physical aggression and somatization of violent events, as well as compromising mental health, provoking feelings of deep sadness, self-injury behavior and suicidal ideation. All of these factors impair interpersonal relationships, school performance, as well as making them more vulnerable to alcohol intake. Final Considerations: The study indicates signs suggestive of grievance, from which the professionals should proceed the investigation in order to refute or confirm the experience of the phenomenon, as well as intervene in the cases. Descriptors: Violence; Violence in the Family; Child Violence; Adolescents; Health Care.


INTRODUCTION
Family violence against children and adolescents is a worldwide reality that consists of any violent act committed by any member of the family, even without consanguineous bonds, against another member under the age of 18 years old. Defined based on family and affective relationships established between those involved, and not by the physical space in which it occurs, this phenomenon is predominantly manifested through physical, sexual, psychological and negligence forms (1) .
A study conducted in Quebec, Canada with 1400 adolescents showed that most were victims of family violence during their lives, of whom 82% were victims of more than one form of victimization (2) . In Brazil, a study conducted in the South region, from medical records of children and adolescents attended at the Reference Center Specialized in Social Assistance (RCSSA), also shows that the main complaints were related to family violence, with the prevalence of sexual, physical and psychological violence (3) . Another national study conducted from anonymous reports of violations of rights against children and adolescents confirms that they experience psychological, physical and sexual violence, also warning of neglect (4) . In all studies, the main perpetrators of maltreatment were relatives or other people with close relationship (2)(3)(4) .
This is what a Brazilian study conducted with children and adolescents attended in the health service due to the consequences of violence confirms when revealing that more than 70% of the aggressors are considered people from the affective bond, such as father, mother, stepfather, spouse, ex-spouse, boyfriend, ex-boyfriend, brother, and friend/acquaintance. It also found a predominance (64.6%) of events occurred in the victims' home, while 18.2% occur on the public settings, 4.9% at school, 1.1% at a bar and 11.1% in other places (5) . Thus, it is possible to notice that it is precisely in the family environment, which should be synonymous with security and protection, that most cases of child and youth violence occur.
In this reality, the fact of naturalization of family violence is aggravated (6)(7) , which can be ratified when a study carried out in 12 cities in different regions of Brazil reveals that, although many adolescents state that they live in hostile environments and with frequent situations of violence, few perceive themselves in this situation (7) . This invisibility may be associated with the historical conception that violence constitutes an authorized, appropriate and common educational resource, being a culturally accepted practice (8) and, therefore, socially reproduced.
In the context presented, it is possible to notice the importance of training professionals to investigate family violence, especially those who work in spaces of greater proximity to the adolescent population (9) . A study conducted with health professionals and family members ratifies this need for greater capacity to approach violence cases, since the interviewees denoted a fragile support network (10) .
Considering the relevance of professionals to recognize violence situations early, we believe that the knowledge about the repercussions of this complaint may direct the process of qualification to identify them. This will favor proper health care of victims and perhaps the prevention of the phenomenon, contributing to children and adolescents to enjoy a life free of violence. Thus, we chose the following research question: What are the repercussions of the experience of family violence for adolescents? We delimited as object of study: The repercussions of family violence for adolescents.

OBJECTIVE
To know the repercussions of the experience of family violence from the oral history of adolescents.

Ethical aspects
This study was approved by the Research Ethics Committee of the Nursing School in the Federal University of Bahia, complying with the norms established by Resolution 466/2012 from the National Health Council, namely: the right to decide whether or not to participate in the study; to give up at any phase without any harm, to have their identity preserved, for which fictitious names are used. When they agreed to participate in the study, they were asked to sign the Informed Consent Form by the legal guardian and the Term of Assent by the adolescent.

Theoretical-methodological reference and type of study
This is a qualitative approach research, based on the Oral History method. This method allows individuals to express their experiences, favoring the understanding of social relationships (11) , and thus, a more subjective view of the repercussions of the phenomena. In this study, the oral testimony of the adolescents constitutes the core of the investigation, favoring qualitative interpretations about family violence and its repercussions in the lives of those who experience it.

Scenario of the study
The scenario of the study is a public elementary school located in a peripheral district in the city Salvador, Bahia, Brazil.

Data source
The participants were: eight adolescents with a history of family violence identified by a matrix study entitled "University and public school: seeking strategies to face factors that interfere in the teaching/learning process", with funding from the Foundation for Research Support of the State of Bahia (FAPESB). In order to include the adolescents, the following criteria were defined: being an adolescent, age group from 10 to 19 years old, as recommended by the Ministry of Health, and experiencing or who had already experienced family violence.
The approximation with the adolescents was favored by the Community and Society Curricular Action (CSCA) entitled "Interdisciplinary and transdisciplinary approach to health problems related to violence", which is part of the curricular structure of undergraduate courses of the Federal University of Bahia. Throughout the year 2014, educational and reflective workshops on topics related to adolescence were developed, such as: sexuality; bullying; and drugs.

Data collection and organization
Data collection occurred from March to May 2015, from interviews conducted based on the Oral History of the adolescents focusing on the experience of family violence. The interviews were conducted in a private room and recorded with the support of a digital recorder. Then, the steps proposed by the method of Oral History were followed: transcription, phase in which all the oral content was converted to the written form, with the support of the Microsoft Word program; textualization, stage in which the narratives were placed in the first person singular, with questions and repetitive terms being supplied, obeying the logical structuring required for a written text, from which the central ideas of the speeches were identified; and transcriaction, a more subjective intervention process in the text, with the complementation of insinuated words and description of moments of emotion and/or significant silences, aiming to interpret what was said and recorded. Finally, the finished text was validated by each adolescent (11) .
The results were categorized from the perspective of the thematic analysis of content, obeying the classification of the constituent elements, followed by regrouping according to the analogy. To identify the units of analysis, the interviews were exhaustively read, and the ideas of meanings were grouped through content similarity (12) .
It is also worth mentioning that the data organization phase was carried out with the support of the NVIVO10 software, which allows the importation of texts, data archiving, coding and managing categories; in addition to create relationships between documents, including images and videos (13) .

Data analysis
The decomposition of the speeches favored the construction of the following categories: repercussions for physical health; repercussions on mental health; social repercussions. Supporting the thematic categories, the NVIVO10 software also allowed the elaboration of the "cloud of words", whose representation highlights the words most often mentioned by the adolescents (13) .

RESULTS
Among the adolescents in the study, five of them were girls and three of them were boys, aged between 12 and 18 years old. Concerning the people they live with, half of them reported they were living with their biological parents and siblings; and the other half, with other members of the family, such as grandparents, uncles and aunts. Based on the narrative universe of orality of adolescents with a history of family violence, the study reveals that this experience has repercussions for physical and mental health, as well as damage for social development. These repercussions were grouped from the following categories:

Repercussions for physical health
The speeches point to visible marks caused by physical aggression, which cause damage to the integrity of the adolescents, such as bruises resulting from punches. The study also indicates the physical illness associated with the somatization of any form of violence experienced that prompts the triggering of clinical complaints, such as headache.

Repercussions on mental health
The study revealed the psychic suffering to which adolescents with a history of family violence are vulnerable. The reports indicate the appearance of depressive symptoms manifested by deep sadness, the behavior of self-injury, as well as by suicidal ideation:

Social Repercussions
The orality of the adolescents shows that the experience of family violence negatively impacts their social life, affecting interpersonal relationships, impairing school performance and vulnerability to alcohol use: The repercussions of family violence, revealed in the illustrated categories, are supported by the "cloud of words" (Figure 1), whose words express the essence of the central ideas of the study.
This reality directs to the need to investigate family violence, even if complaints and signs do not indicate associated pathology. As a somatization of the violent event, we can mention headache, identified in our study through Agata's Oral History, which associates pathology with the fights she presents at home. This situation interferes with their school achievements, a situation corroborated by all the adolescents interviewed.
The impairment of school performance is also related to recurrent memories of the stressful situation. Therefore, the adolescents have difficulties in concentrating during classes, which reflects their poor school performance and, consequently, flunk, as evidenced by Berilo ' s speech. In consonance with our result, a study on the theme points that children and adolescents experiencing family violence tend to have low school performance and difficulties in learning and concentrating during classes (17) .
In international scenario, studies also highlight learning deficit as a consequence of domestic violence (18)(19) . Intellectual impairments in maltreatment victims in childhood and adolescence have serious consequences, since there is evidence that cognitive issues influence academic and work performance throughout life. In addition, children and adolescents with learning difficulties also tend to have difficulties in socializing, such as abilities to ask for help or to request attention in an appropriate way (19) .
Another repercussion of family violence experience for adolescents' health revealed by the study refers to psychological suffering. The group investigated had depressive symptoms , anxiety, anguish, apathy and disinterest in living, culminating in thoughts of death and risk behavior related to self-injury caused by cutting themselves. Corroborating, national and international studies which indicate the occurrence of emotional and mental disorders in young people submitted to traumatic events, with a higher occurrence for depressive disorders (20)(21) .
Regarding the behavior of self-injury or cutting, the physical pain caused by cutting indicates possibility of, even temporarily, reduction of emotional pain caused by violence, as corroborated by Cristal's report, an adolescent who believes that this conduct is a mechanism to soften sadness and alleviate sentimental pain. Although studies point to non-suicidal intention when cutting, the repetitive behavior of self-injury can indicate diagnosis of mental disorders and develop a suicidal potential (22) .
The relationship between mental suffering and self-harm behavior was also reported in a study whose objective was to describe factors associated with the practice of self-mutilation, revealing its association with depression and Post Traumatic Stress Disorder (PTSD) (23) . PTSD is manifested in an associated way with a traumatic event that causes anguish, persistent mood changes, social isolation and psychological suffering (2) . A study conducted in Wales indicates that the exposure to traumatic events in childhood, including family violence, negatively affects mental health throughout the life (24) .
It is also verified that the impairment of mental health triggers other problems, mainly social ones. Isolation, for instance, was an event unveiled in our study and corroborated by a study conducted in South Africa (25) . The difficulty in satisfactorily building interpersonal relationships was also identified in a study conducted with children and adolescents victims of domestic violence, attended in Reference Centers Specialized in Social

DISCUSSION
The oral history reveals the experience of physical violence and its marks on the adolescents' bodies, such as bruises, excoriations, injuries, loss of skin integrity. Research that deals with the damage of violence to the physical health of children and adolescents has showed that health professionals daily witness cases of bruises, such as belt marks, buckles, fingers; lesions on the skin and mucous; contusions and abrasions on face, lips, arms, back and buttocks (14) . Other studies point to fractures in adolescents, drawing attention to the increase in femur fractures due to the violence experienced (14)(15) . Considering that physical injuries on the body favor the suspicion of grievance, the study indicates the importance of health professionals to investigate the experience of family violence when they see visible marks.
Health professionals should be aware not only of the marks resulting from physical aggression, but also of other clinical complaints that indicate violence, since regardless of the violence expression form, it can be transferred to the body. A study conducted with 1850 adolescents from the western province of Sri Lanka revealed that gastrointestinal diseases, presented by many of them, were somatized due to sexual, psychological and/ or physical violence experience (16) . Assistance (RCSSA) from a Brazilian city (26) . Signs such as cold and distant relationship with friends, not talking or playing, shyness, introversion, retreat and distancing from socializing were cited by Brazilian teachers as indicative that the child or adolescent has gone through some kind of family problem, which indicates the importance of education professionals to be alert to the way their students interacts with each other (27) .
For the adolescents, the symptoms of physical and mental illness presented in this study showed to be a vulnerable element to alcohol use, result ratified by international studies (28)(29) . A study conducted in Brazil also shows the association between family violence and the usage of psychoactive substances, evidencing that among people who related using drugs, more than half reported at least one violent event in their childhood (30) . Another Brazilian study indicates that adolescents who drink alcoholic beverages are more likely to be involved in situations of violence and accidents, since abusive consumption of this substance disinhibits individuals' behavior, as well as reduces self-preservation care and impulse control (31) .
Considering the magnitude of the phenomenon, a closer articulation between health sector and schools is necessary, being pertinent actions of health education with relatives, teachers and students in order to prevent and identify cases of violence, as well as refer to treatment situations that need care, as in case of self-mutilation that requires psychological monitoring. It is important to emphasize that the Statute of Child and Adolescent (SCA) establishes that it is mandatory for health and education professionals to notify and refer suspected or confirmed cases of family violence against children and adolescents (32) . This notification must be conducted three times, so that one is filed in the service; another is sent to the municipal sector responsible for the Epidemiological Surveillance of Non-communicable Diseases and Aggravations (NCDA) and the last one to the Guardianship Council and/or competent authorities. Ministry of Health also alerts that children and adolescents with suspected or confirmed cases of any kind of abuse should be referred to health services, to social assistance services (RCSSA) and other bodies of the Guarantee System Rights of Children and Adolescent (33) .
These actions can be implemented through Health in School Program (HSP), instituted in 2007 aiming to establish a partnership between health and education sectors in prevention and confronting of vulnerabilities that affect adolescents, among them: family violence (34) . Specifically regarding school scenario, it is essential to promote spaces of trust in order to strengthen the bond between teachers, employees and adolescents, so they feel confident about telling them their stories. Facing the damage caused by the experience of family violence for children and adolescents and their habitual coexistence with school employees, it is urgent to re-signify the identity of the professional educator anchored in the biopsychosocial development of the individual, favoring the development of his/her cognitive, emotional and intellectual capacity, in order to provide the full exercise of their potential.
For this, the educator must be prepared during his/her academic training to commit primarily to the well-being of children Considering that one of the premises of the school institution is education for citizenship, it is essential that conditions are ensured for children and adolescents to exercise their potential, increasing their chances of being what they want, which is jeopardized due to their experience of violence.

Limitations of the study
Adolescents who experience family violence were identified in 2014 from a quantitative study also included in the matrix project, however, the interviews were only conducted in the following year. For this reason, part of the sample was lost due to the absence of the student in the period of data collection, either due to change of schools (adolescents who attended freshman year in 2014, needed to change schools in the following year, since the school does not have a full high school education) or due to unknown reasons.

Contributions to the area of nursing, health or public policy
The study contributes by pointing signs suggestive of grievance, from which professionals should proceed the investigation in order to refute or confirm the experience of the phenomenon. Professionals who work in the areas of education and health are essential in this process because they have greater access to children and adolescents.
It is important to emphasize the need for curriculum in undergraduate courses and continuing education spaces to address the issue, training professionals to identify signs suggestive of experiencing violence, since as we have seen in this study, it does not always leave visible marks. A sensitive look at family and school context, resuming adolescent's history focusing on behavior changes, is valuable to recognize grievance.

FINAL CONSIDERATIONS
From the oral history of adolescents, the study showed that the experience of family violence leaves, in addition to corporal marks, important sequels that affect human development. It revealed that experiencing the phenomenon raises constant recalls of the event, continuous sadness and disinterest in living, elements that indicate a depressive scenario. This context is related to social isolation, alcohol use and poor school performance, situations that affect the full development of adolescents' potential and limits, consequently, personal and professional achievements.
Considering that our study points to the commitment on physical, mental and social health, we believe that the experience of family violence affects the future of these adolescents. Noting that the potential of an adult is based on respect for their needs as a developing person, it urges strategies that favor experiences of family relationships based on respect and harmony, in order to ensure a healthy and violence-free childhood and adolescence.