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

2. 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

3. Overlap of Child Maltreatment and Domestic Violence One MillionTwo Million Maltreated30-60%Abused ChildrenWoman National Clearinghouse on Child Abuse and Neglect Information, 1998

4. 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.

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

6. 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

7. 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

8. 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

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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

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

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

22. 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

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

24. 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

25. 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

26. 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

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

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

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

36. TWO TRADITIONS Domestic Violence vsChild Abuse GrassrootsLegal mandate Empower abused womenProtect children Civil rights/feminist rootsSocial work roots Meet needs of womenMom fails to protect Abusive men accountableCourt decides accountability

37. 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

38. 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

39. 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.

40. 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

41. 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

42. 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

43. 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

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