Domestic Violence and the Link with Child Maltreatment

Domestic Violence and the Link with Child Maltreatment Rebecca R. S. Socolar, MD, MPH Associate Professor of Pediatrics and Social Medicine

Prevalence of Child Exposure to Domestic Violence • US 3. 3 to 10 million children exposed per year • North Carolina Over 39, 000 victims per year 27, 670 secondary victims, mostly child witnesses The Future of Children, 1999 NC Council for Women, 1998 -1999

Overlap of Child Maltreatment and Domestic Violence One Million Maltreated Children 30 -60% National Clearinghouse on Child Abuse and Neglect Information, 1998 Two Million Abused Woman

Types of Child Abuse • Physical-Act of commission; physical harm; punching, shaking, burning, kicking, etc. • Sexual-Act of commission; sexual acts for gratification of perpetrator • Neglect- Act of omission, failure to provide basic needs, healthcare, inadequate supervision, abandonment • Emotional-Commission/Omission; rejecting, isolating, terrorizing, corrupting, etc.

Prevalence of Substantiated Reports • Neglect-53% • Physical Abuse-25% [44 per 1000/yr 16 x higher than reported] • Sexual Abuse-14% [~25% of women, ~15% of men] • Emotional Abuse-5% • Other/Unknown-3%

Signs Of Child Abuse: • Injury of child with: -Differing historical accounts -Delay in seeking care -Unrelated adults seek care -Injury attributed to another child -Physical findings incompatible with developmental age -History incompatible with physical findings -Repeated unexplained injuries

Types of Domestic Violence • Physical -Inflicting or attempting to inflict physical injury and/or illness -Withholding access to resources necessary to maintain health • Sexual -Coercing or attempting to coerce sexual contact -Attempting to undermine the victim’s sexuality -AIN, 1994

Types of Domestic Violence (continued) • Psychological/Emotional -Instilling or attempting to instill fear -Isolating or attempting to isolate from friends, family, school, work -Undermining or attempting to undermine victim’s sense of self-worth • Economic -Making or attempting to make the victim financially dependent -AIN, 1994

Effects of Domestic Violence on Children • • Physical Injuries Neglect? Sexual Abuse? Psychological/Behavioral Effects

Prenatal Effects • • Fetal injury/demise Late prenatal care Pre-term labor Placental abruption

Cross-fire Injuries • Mechanism -<2 y. o. held in parents arms -Adolescent intervenes • Type of injury -Single location -50% contusions, 29% lacerations -Most minor Christian et al 1997

Physical Abuse of Child by Batterer • 33 -75% battered women report child abuse by batterer Stark and Fltcraft 1991 Bowker et al 1998 • 50% men who assaulted wives, abused a child Straus and Gelles 1985

Physical Abuse of Child by Batterer • May be using children to relay messages of power • May be more common when relationship ending • May be minimized as victims fear child taken away if abuse known • May be catalyst for victim to leave

Physical Abuse of Child by Victim • Battered women twice as likely to physically abuse child as non-battered women Straus and Gelles 1990 • 28% battered women physically abuse child Walker 1984

Physical Abuse of Child by Victim • Takes out anger on child • Views self as more in control of anger/punishment than partner • Harsh discipline to control child’s behavior for partner

Neglect and Domestic Violence • ? Prevalence? • Victim’s response -Gives all attention to batterer -Withdraws from family for self-protection • Perpetrator’s behavior -Denies access to medical care -Denies access to basic needs

Behavioral Effects of Violence on Children • Externalising Behaviors: -Aggressive -Delinquent -Acting Out/Anti-social behavior • Internalizing Behavior: -Withdraws -Anxious -Depressed • Poor performance - school, organized sports

Short-term Effects of Violence • 0 -5 years: -Sleep disturbances -Eating disturbances -Bed-wetting -Separation anxiety -Failure to thrive

Short-term Effects of Violence • 6 -12 years: -Eating disturbances -Somatic complaints -Fears of abandonment/loss of control -School failure/absenteeism -Depression

Short-term Effects of Violence • Adolescents: -Run away -Delinquency -Sexually precocious/pregnancy -Suicidal/Homicidal thoughts -Drug/Alcohol abuse -School failure/absenteeism

Long term Effects of Violence on Children • Child Abuse and/or Domestic Violence: -Learned helplessness -Low self-esteem -Depression -Somatic complaints -Delinquency and criminal behavior

Long term Effects of Violence on Children • Child Abuse: -CNS damage, long-term physical/developmental impairment • Domestic Violence: -Sons of batterers 10 x as likely to become wife batterers -Daughters of batterers; less likely to question dating violence, less likely to seek assistance when abused.

Mediators of Long-Term Effects of Witnessing • • • Severity of violence Chronicity of violence Child’s perception of his/her role Concurrent child abuse Age of child Gender of child Alternative adult role models Strong and positive attachments to mother Community supports Jaffe and Geffner 1998

Factors Associated with Domestic Violence and Child Abuse • • Similar for both types of family violence More life stressors Substance/Alcohol use Lower SES Neighborhood violence Poor maternal mental health History of severe physical punishment as a child ALL TYPES OF FAMILIES CAN BE INVOLVED Shipman et al 1999

PROFESSIONAL RESPONSE: DV Exposure First Recognized: • Legal system - criminal or civil court • CPS system - child abuse or DV investigation • Law Enforcement • Battered Women’s programs • Schools • Healthcare settings

SCREENING The Setting • • • Routine screening at regular intervals Screen when warning signs present Woman alone Confidentiality assured, as possible Professional, yet gentle, demeanor

SCREENING Issues • Important that screener is comfortable • Written vs. Verbal Rates of disclosure similar for both Canterino et al 1999 • What to ask

SCREENING What to Ask • Framing Basis of concern Routine screening • Emotionally or physically hurt by partner • Forced sexual activity • Issues of power, control, or fear

SCREENING What to Ask Example: We all have disagreements at home. What happens when you and your partner disagree? -Is there shouting, pushing, or shoving? Does anyone get hurt? -Has your partner ever threatened to hurt you or your children? -Do you ever feel afraid of your partner? -Has anyone forced you to have sex in the last few year? American Academy of Pediatrics

PROFESSIONAL RESPONSE: Recognize Warning Signs: Domestic Violence • Mother with signs of injury • Depressed or anxious mother • Failure to keep appointment • Reluctance to answer questions about home • Frequent office visits for complaints with no apparent basis • Child with behavioral effects associated with violence AAP 1998

PROFESSIONAL BARRIERS • • • Not MY problem Fear of offending parents Lack of training/knowledge Time constraints Powerlessness Lack of control Possible court involvement Reimbursement Cynicism Kuelbs 2000 Sugg and Inui 1992

ASSESS • Child’s safety • Mother’s safety -The most dangerous time is when mother leaves -No agency mandated to assure woman’s safety • Motivation to change/leave

SAFETY PLAN • Arrangements for transportation -Hiding set of car keys -Transportation with neighbor -Cell phone to call for help • Remove firearms, if safe • Secret signal to alert neighbor of trouble • Make copies of important documents, for quick escape • Limit arguments to safe locations -Not bathroom or kitchen -Rooms with two exits

COMMUNITY RESOURCES • • • Child protective services Battered women’s shelter Mental Health, Substance Use Legal/Law enforcement 1 -800 -799 -SAFE

TWO TRADITIONS Domestic Violence vs Grassroots Empower abused women Civil rights/feminist roots Meet needs of women Abusive men accountable Child Abuse Legal mandate Protect children Social work roots Mom fails to protect Court decides accountability

Two Critical Issues For Collaboration • Whether witnessing constitutes abuse or neglect—New policy has helped address this—Multiple Response System and When to Investigate witness of DV • Whether and when it is appropriate to remove a child from mother’s custody due to failure to protect

DSS Policy: When to Investigate If DV is the Only Allegation • Child is involved or present (within sight or sound) when violence occurs • Child exhibits behaviors that indicate fear or anxiety related to the violence • Presence of weapons to threaten or harm any family member • Increase in intensity or frequency of DV within the home

Amendment to G. S. 14 -33 Individuals who commit DV in presence of a minor must be placed on supervised probation in addition to any other punishment the court imposes. Punishment for a second or subsequent conviction of assault in the presence of a child: the perpetrator must be incarcerated for at least 30 days, in addition to other imposed punishment.

REPORTING • Mandated reporting of adult domestic violence in 5 states (CA, KY, NH, NM, RI) • Controversies: -Adults have right to control own lives -? Enhance child safety or deter battered women from getting care -Breach confidentiality -Insurance coverage denial -? Makes needed police protection more available

REPORTING DV North Carolina • Wounds, injuries, and illness caused by guns or knives • Any would causing “grave bodily harm” that appears to have resulted from a criminal act Must be reported to law enforcement by the treating physician North Carolina General Statute 90 -21. 20

REPORTING DV North Carolina Is Witness of DV a mandated report? • Not clearly delineated in law • It is injurious environment under neglect • Unclear how this in interpreted and managed by mandated reporters and DSS

Summary: • Witnessing domestic violence is common • Substantial overlap with child abuse • Deleterious effects on children are similar for child abuse and witnessing domestic violence • Professionals need to screen, know signs of family violence, and know community resources

Identifying and intervening on behalf of battered women may be one of the most effective means of preventing child abuse