Systems of Care Among Children Exposed to Intimate Partner
Violence (IPV)
James M. DeCarli, MPA, MPH, CHESResearch Analyst III/Behavioral Sciences
Los Angeles County, Department of Public Health, Injury & Violence Prevention Program
Part I:Background on Intimate Partner Violence (IPV)Existing Child Protective Service (CPS) SystemMental Health Impact of Children Exposed to IPVProblems IdentifiedBarriers to ChangeIdeal System
Overview
Part II:Organizational Diagnosis of CPSCurrent System Revisited-Lessons LearnedRecommendationsEvaluation Plan
Overview
Background on IPV
IPV DEFINEDIntimate Partner Violence
Domestic ViolenceFamily ViolenceRelationship Violence
No uniform definition
A physical, sexual, or psychological harm to a person by a current or former partner or spouse (MMWR, 2005)
IPV Consists of:Physical violence Sexual violence Threats of physical or sexual violence
Perpetrator & Victim
Perpetrator: More often the husband, former husband, boyfriend, or ex-boyfriend (90%)Sometimes the abuser is female (10-40%)
Victim: MotherChild
Intimate Partner Violence (IPV)
Intimate Partner Violence (IPV) is a serious, preventable public health problem affecting more than 32 million Americans (Tjaden and Thoennes 2000)
5.3 million incidents of IPV occur each year among U.S. women ages 18 and older
3.2 million occur among men ages 18 and older
Cycle of Violence
Behavioral PhasesCycle of Violence
Repeated Cycles of Violence
Repeat stress: fear anxiety, PTSD, and depression in those exposed to IPV cycles. (Margarinos, 1997).
fMRI studies have linked abuse, PTSD and neuronal loss (DeBellis et al, 2000)
Those exposed to IPV share common behavioural outcomes of those observed who have hippocampal and amygdala lesions, such as impulsive behaviours, misperceived emotions, and aggression (Margarinos, 1997).
Health Effects of IPV Victimization
Increased mortality (CDC, 2000)30-40% women killed
Increased psychological and physical effects
Psychopathology
Depressive symptoms & disordersPosttraumatic stress disorder (PTSD)Anxiety symptoms & disordersLow self-esteemSubstance abuse disordersHopelessness & helplessnessSuicidal behavior
Physical Morbidity
Physical injuriesChronic body painSleep & appetite disturbancesMiscarriage or abortionDisfigurement or disabilityRecurrent vaginal infections (i.e. STD’s)Other Complaints (Cardiac, gynecological, etc.)
Childhood Exposure to IPV
3.3 million to 10 million in U.S. per year (Fantuzzo, 1999; Carlson, 1984)
Depending on:Specific definition of witnessing violence The source of interviewThe age of child included in the survey
Occurs when children sees, is aware of, or hear physical or verbal assaults or threats between their parents/dating partners or other family members, or observe its effects
Term Used to Describe Childhood Exposure to IPV
Child abuse and maltreatmentPhysical child abuseIncest and child sexual abusePsychological maltreatment
Verbal and emotional abuseChild neglectChild exposure to violence in the home
ParentsSiblingsOther family members
(National Center for Child Abuse and Neglect)
Childhood Exposure to IPV
Children observe IPV to varying degrees:Home Environment:
May see mothers use violence in self-defense or see both parents trading self-defense See parents occasionally slap, shove, and throw thingsSome see severe violence or threats, but the victim does not leave the home where not reported to police or public agencies
(Straus & Gelles, 1990)
A child’s experience with domestic violence
(Obtained with permission, Penn State, Milton S. Hershey Medical Center, College of Medicine)
Case Review: IPV-Related FatalityMother has custody of her 6yo child (from a former relationship)
Live-in boyfriend (had no past convictions-common)Boyfriend had moved out (request of the mother) Mother experienced 1-year of stalking/threats to kill mother and child (common)
Several months prior to the fatality the boyfriend broke down the door of the mothers house, as she would not let him in
Police were called
Mother failed to report (to protect him)
Police reported case to DCFS since child was present at the time and the mother refused to press charges or allow police know of his residence
DCFS ordered the mother to file restraining order or risk child removal
Mother filled restraining order
Case ReviewBoyfriend actions:
Violated the restraining order several timesThe mother did not report the boyfriend to protect his resident status
At times would become depressedMother allow him in her home due to his sadness
Continued to stalk and harass the mother
Finally the mother stopped all contacts with the ex-boyfriend and ordered him to stop calling and seeing her
The following incident occurred 2-days later
A Child’s 911 call during a domestic dispute
(Obtained with permission, Penn State, Milton S. Hershey Medical Center, College of Medicine)
Case Review Debriefing
Symptoms of Children Exposed to IPV
29 different studies of children who witnessed IPV
BehavioralEmotionalSocialCognitivePhysical
(Kolbo, Blakely, & Engleman, 1996)
Behavioral EffectsAggressionTantrums "acting out" ImmaturityTruancy and Delinquency
(Davies, 1991; Dodge, Pettit, & Bates, 1994; Graham-Bermann, 1996c; Hershorn & Rosenbaum, 1985; Hughes & Barad, 1983; Jouriles, Murphy, & O'Leary, 1989; Sternberg, Lamb, Greenbaum, Cicchetti, Dawud, Cortes, et al., 1993)
Emotional EffectsAnxietyAngerDepressionWithdrawal Low self-esteem
(Carlson, 1990; Davis & Carlson, 1987; Graham-Bermann, 1996c; Hughes, 1988; Jaffe, Wolfe, Wilson, & Zak, 1986)
Social Effects
Poor social skillsPeer rejectionInability to empathize with others
(Graham-Bermann, 1996c; Strassberg & Dodge, 1992)
Cognitive Effects
Language lagDevelopmental delaysPoor school performance
(Kerouac, Taggart, Lescop, & Fortin, 1986; Wildin, Williamson, & Wilson, 1991).
Physical Effects
Failure to thriveProblems sleepingEating problemsRegressive behaviorsPoor motor skills, and Psychosomatic symptoms (eczema, bed wetting, etc.)
(Jaffe, et al., 1990; Layzer, Goodson, & Delange, 1986)
Specific Signs & Symptoms by Age
Toddler/Preschooler (<5)
Aware of their environmentSleeping & Eating DisordersSomatic Complaints
StomachachesHeadaches
Separation Anxiety (clinging to mother/victim)Speech, motor skill & cognitive delaysDepression & anxietyDifficulty in expressing emotions-but anger
(National Resource Center on Domestic Violence, 2002)
Specific Signs & Symptoms by AgeChildhood (5-12)
Poor in School-Exhibit few options/low successSelf esteem limitations
Frequent mood swingsErratic attendanceInability to concentrate
Poor social skillsConflicts with classmates & teachers
Excel in School-Try to overcome & suppress family dysfunctionSeek approval by doing well in structured school environment
Perfect studentMaking many friends
However:Live with unpredictable home environmentsConflict-loving/hating their parentsExperience guilt, depression, sadness, powerlessnessUnable to relax/sleepSigns of PTSD
(National Resource Center on Domestic Violence, 2002)
Specific Signs & Symptoms by Age
Adolescence (13-17)
Eating difficulties resulting in anorexia, bulimia, or obesityAcademic difficulties-leading to dropping outFeeling powerless, fear, delinquency, substance abuse, suicideIntimate partner relationships
Without proper intervention-exhibit sex roles and communication patterns learned from dysfunctional home environment-contributing to the generational cycle of violence
(National Resource Center on Domestic Violence, 2002)
Reporting LawsIPVChild Abuse
CPS Case Report Process Community Professional Roles & ResponsibilityServices for Victims of IPV
Existing System
Reporting Law-IPVCalifornia Screening Law (1995)
Health and Professionals Code ξξ1233.5, 1259.5Requires screening protocols and practices for California’s licensed clinics and hospitals]
California Penal Code, Section 11160 mandates:That a healthcare professional call the local law enforcement agency by telephone immediately or as quickly as possibleBe familiar with their specific hospital, clinic, or HMO/PPO policies and procedures regarding reporting formsReporting forms must be completed and mailed to law enforcement within 48-hours
Reporting Law-Child AbuseCal Penal Code §§, 11 164-11174.3. The California Child Abuse and Neglect Reporting Act (CANRA):
Requires mandated reporters to report known or suspected instances of child abuse or neglect to law enforcement (includes “emotional maltreatment-child exposed to IPV)
Two reports are required:Report by telephone immediately to local law enforcementFile a written report within 36 hours of receiving information regarding the incident
CPS Case Report ProcessReport
Intake
InitialAssessment
Family Assessment
Case Planning
Case Management & Treatment
Evaluation of Family Progress
Case Closure
Referral
Stage 1: ReportMandated reporter, reports incident to CPS
Stage 2: IntakeDetermine appropriateness of the reportDoes the reported case meets agency guidelines for child maltreatment?How urgent is the referral? (i.e. high –risk respond immediately or within 24-hours)
Stage 3: Initial AssessmentCPS caseworker and law enforcement determine:
Validity of the child maltreatment reportAssess risk of maltreatmentDetermine safety of the child and need for further intervention
Medical, Mental health, and other community providers also involved
CPS Case Report Process
Stage 4: Family AssessmentCPS caseworker, community treatment providers, and family reach understanding on the most critical treatment needs to be addressed
Stage 5: Case PlanningCPS caseworker and other treatment providers develop a case plan with family members
Stage 6: Case Management & TreatmentImplementation of case plan-outcomes, goals, strategies to change the conditions and behaviors that results in child abuse and neglect
CPS Case Report Process
Stage 7: Evaluation & of Family ProgressCPS caseworker & other treatment providers evaluate and measure:
Changes in the family behaviors and conditions that led to child abuse and neglectMonitor the risk elimination/reductionDetermine when services are no longer necessary
Stage 8: Case ClosureBased upon evaluation identifying risk elimination, the CPS caseworker closes the case
CPS Case Report Process
Community Professional Roles & Responsibilities
ID/Report
Intake IntakeAssess
FamilyAssess
CasePlng
CaseMgt
Treatment EvalFamily Pgm
Case Closure
CPS
Healthcare
Mental Health
Education
Legal
Law Enf.
Support Services
Lead-Initiating actionProvides advising to support lead actionProvides input under specific function
Services for Victims of IPV
Women’s SheltersCriminal Justice System
Problems Identified with SystemLimited mental health services for children
CPS does not provide adequate (U.S. Advisory Board on Child Abuse and Neglect)
ProtectionTreatmentprevention
LA area High School surveys (National Child Traumatic Stress Network, 2004)Large percentage of significant trauma history, high levels of traumatic stress symptoms and impaired functionNever received assessment or treatment
Inadequate Screening (English, Edleson & Herrick, 2005; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004)Law Enforcement
Law enforcement leaders have questioned their own responses to children who are present when police respond to adult domestic assault reports (International Association of Chiefs of Police, 1997)
Lack of Screening ToolsFamily Worries Scale Graham-Bermann (1996) Children’s Perception of Interparental Conflict Scale (Grych, Seid, & Fincham, 1992)
Problems Identified with System
Inadequate Investigation (English, Edleson & Herrick, 2005; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004)
Criminal justice systemJuvenile and family courts struggle to understand and assess the significance of child exposure when making decisions concerning custody and visitation (Jaffe, Lemon & Poisson, 2003; Kernic, Monary-Ernsdorff, Koepsell & Holt, 2005).
Barriers to Change(Provider)
Lack of education and training (Rodriguez, 1999; Sugg, 1992, 1999)
A belief that patient will be offended by screening (Sugg, 1992, 1999)
Personal discomfort from having a personal history of exposure to abuse and interpersonal violence (Sugg, 1992)
Belief and/or experience that patients will not disclose intimate partner violence (Rodriguez, 1999; Gerbert, 1999)
Lack of time to screen and respond (Rodriguez, 1999; Gerbert, 1999; Sugg 1992)
Belief of a "medical" model of care-provider does not include addressing intimate partner violence (Warshaw, 1989; Parsons, 1995; Warshaw, 1996)
Barriers to Change(Patient)
Perpetrator directly preventing access to care (McCauley, 1998)
Socioeconomic barriers to accessing care (Rodriguez 1996)
Low self-esteem and a feeling of shame (McCauley, 1998; Rodriguez 1996; Gerbert 1996)
Fear of retaliation from perpetrator (McCauley, 1998; Gerbert 1999; Gerbert, 1996)
Sense of family responsibilities and fear of loss of custody (Rodriguez 1996)
Provider appearing too busy or treating the patient negatively (Plitchta 1996; McCauley 1998; Sugg 1999, Gerbert 1996)
Fear of consequences of mandatory reporting or police involvement (Rodriguez 1996)
Barriers to Change(Institutional)
Lack of training of healthcare personnelmultiple research issues, including a remarkably large number of crucial unanswered questions;lack of uniform or standard definitions used in the field of intimate partner violence research;lack of funding for research on violence, especially violence against women;lack of societal resources for treatment and prevention of intimate partner violence for both victims and perpetrators; numerous legal issues, including mandatory healthcare reporting laws that do not require patient consent, insurance discrimination against victims and survivors of intimate partner violence, lack of privacy protections of the medical records of victims/survivors of intimate partner violence, lack of legal requirements for education about violence for licensure of medical personnel, and lack of legal incentives for development of healthcare-based programs; lack of sufficient diagnostic and procedural codes for violence; lack of reimbursement for intimate partner violence-related services; lack of financial and other support for development of violence screening and treatment programs. Enhancement of screening and treatment by providers and healthcare systems may require a number of different, concurrent approaches that directly address provider, patient, and institutional barriers.
Ideal System
Improved mental health services for childrenDeveloped & evaluated screening tool for exposure to violenceProvider/schools/faith groups trained Community Awareness on IPV ImprovedImproved Access to Care
Part II
Organizational Diagnosis of CPS SystemCurrent System Revisited-Lessons LearnedRecommendationsEvaluation Plan
Organizational Diagnosis of CPS System
ProviderLaw EnforcementDV ShelterSchoolChild Abuse Hotline
Current System Revisited-Lessons Learned
Gaps:ProblemsBarriers to Change
Recommendations
Improved mental health services for childrenDeveloped & evaluated screening tool for exposure to violenceProvider/schools/faith groups trained Community Awareness on IPV ImprovedImproved Access to Care
Summary
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