Contents lists available at ScienceDirectChildren and Yout

Contents lists available at ScienceDirect
Children and Youth Services Review
journal homepage: www.elsevier.com/locate/childyouth
Service needs of children exposed to domestic violence:
Qualitative findings
from a statewide survey of domestic violence agencies☆
Kristen A. Berg1, Anna E. Bender, Kylie E. Evans, Megan R.
Holmes⁎ , Alexis P. Davis2,
Alyssa L. Scaggs, Jennifer A. King
Center on Trauma and Adversity at the Jack, Joseph and Morton
Mandel School of Applied Social Sciences, Case Wester n
Reserve University, United States
A R T I C L E I N F O
Keywords:
Intimate partner violence
Child maltreatment
Family violence
Intervention
Trauma-informed care
A B S T R A C T
Objective: Each year, more than 6% of all U.S. children are
exposed to domestic violence and require inter-
vention services from agencies that serve affected families.
Previous research has examined detrimental biop-

sychosocial consequences of domestic violence exposure during
childhood and the importance of effective
prevention and intervention services for this population.
However, less research has explored diverse inter-
vention professionals’ own perspectives on the needs of the
domestic violence-exposed children they serve.
Method: This study employed an inductive approach to thematic
analysis to investigate intervention profes-
sionals’ reflections and advice regarding the service, policy,
and research needs as well as overall strategies to
better protect children exposed to domestic violence.
Results: Respondents articulated four primary themes of (a)
building general education and awareness of the
effects of domestic violence exposure on children; (b) the need
for trauma-informed care; (c) the salience of
cultural humility in serving affected families; and (d) essential
collaboration across service domains.
Respondents discussed these themes in the context of four key
systems of care: the clinical or therapy, family,
school, and judicial systems.
Conclusions: Future research should integrate the voices of
affected children and families as well as examine
models for effectively implementing these recommendations
into practice settings.
1. Introduction
More than a quarter of children are projected to witness
domestic
violence (also known as intimate partner violence) in the United
States
by the time they reach age 18, with an estimated 6.4% of all
children
exposed each year (Finkelhor, Turner, Ormrod, Hamby, &
Kracke,
2009). Domestic violence exposure induces substantial

economic
burden nationwide, incurring over $55 billion in aggregate
lifetime
costs, including increased healthcare spending, increased crime,
and
reduced labor market productivity (Holmes, Richter, Votruba,
Berg, &
Bender, 2018). Children who have been exposed to domestic
violence
are at higher risk for a range of behavioral and mental health
problems
compared with non-exposed children (e.g., Fong, Hawes, &
Allen, 2019;
Kitzmann, Gaylord, Holt, & Kenny, 2003; Vu, Jouriles,
McDonald, &
Rosenfield, 2016; Wood & Sommers, 2011).
A variety of social service agencies, domestic violence service
pro-
viders, and other systems of care provide essential services to
families
impacted by domestic violence. While a growing body of
literature has
examined service gaps and practitioner perspectives from
domestic
violence service agencies specifically, less research has
examined do-
mestic violence-specific agencies in tandem with those that
frequently
collaborate with domestic violence agencies to address systemic
service
gaps and/or provide other necessary treatment for trauma. Our
study
contributes to building this knowledge by surveying such
agencies

https://doi.org/10.1016/j.childyouth.2020.105414
Received 13 April 2020; Received in revised form 24 August
2020; Accepted 24 August 2020
☆ Funded through The HealthPath Foundation of Ohio. The
contents of this publication do not necessarily reflect the views
or policies of the funders. This
information is in the public domain. Readers are encouraged to
copy and share it, but please credit the authors. Funded through
The HealthPath Foundation of Ohio.
The contents of this publication do not necessarily reflect the
views or policies of the funders. This information is in the
public domain. Readers are encouraged to
copy and share it, but please credit the authors.
⁎ Corresponding author at: Mandel School of Applied Social
Sciences, Case Western Reserve University, 10900 Euclid Ave.,
Cleveland, OH 44106-7164, United
States.
E-mail address: [email protected] (M.R. Holmes).
1 Present affiliation: Center for Health Care Research and
Policy, The MetroHealth System, 2500 MetroHealth Dr.,
Cleveland, OH 44109, United States.
2 Present affiliation: Florida Policy Institute, 1001 N Orange
Ave., Orlando, FL 32801, United States.
Children and Youth Services Review 118 (2020) 105414
Available online 28 August 2020
0190-7409/ © 2020 Elsevier Ltd. All rights reserved.
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across the state of Ohio to generate an assessment, from
providers' own
perspectives, regarding gaps in service provision and policies
crucial to
promoting resilience among families and children exposed to
domestic
violence.
1.1. Prevalence
Domestic violence (DV) refers to physical violence, sexual
violence,
stalking, and/or psychological aggression perpetrated by a
current or
former intimate partner (Centers for Disease Control and
Prevention,
2016). The CDC’s National Intimate Partner and Sexual
Violence Survey
(NISVS) estimates that more than 10 million adults each year in
the
United States are physically assaulted by current or former
intimate
partners, with more than 1 in 4 women (27.3%) and more than 1
in 10
men (11.5%) victimized by DV at least once in their lives
(Breiding
et al., 2014). Research suggests that DV is more prevalent

among
couples with children, placing children at risk for both direct
and in-
direct witnessing of violence (McDonald, Jouriles, Ramisetty-
Mikler,
Caetano, & Green, 2006). Children who witness DV may see or
hear the
violence, attempt to intervene in or stop the violence, or
perceive the
aftermath of violence such as notice bruising or tension within
the
household (Cross, Mathews, Tonmyr, Scott, & Ouimet, 2012).
In the
state of Ohio, the current study’s site, an estimated 163,000
children are
exposed to DV annually and 657,000 before the age of 18 (U.S.
Census
Bureau, 2015).
1.2. Negative effects of childhood domestic violence exposure
Children’s exposure to DV has been linked to a number of
deleter-
ious outcomes across a range of developmental domains. DV
exposure
has predicted more internalizing (e.g., anxiety and depressive
symp-
toms) and externalizing (e.g., hyperactivity and aggression)
behaviors
in youth, social and emotional impairments, poorer cognitive
outcomes,
and impaired physiological functioning due to hyper-activated
stress
responses (Koolick et al., 2016; Perkins & Graham-Bermann,
2012;
Saltzman, Holden, Holahan, 2005; Vu, Jouriles et al., 2016).

Affected
youth also demonstrate higher rates of bullying and dating
violence as
both perpetrators and victims (Choi & Temple, 2016; Jouriles,
Mueller,
Rosenfield, McDonald, & Dodson, 2012; Moretti, Obsuth,
Odgers, &
Reebye, 2006; Voisin & Hong, 2012). These negative sequelae
have
been observed across developmental stages from infancy to
adoles-
cence, with DV-exposed youth exhibiting poorer outcomes
compared
with their nonexposed counterparts (Howell, Barnes, Miller, &
Graham-
Bermann, 2016).
The detrimental effects of children’s witnessing DV have been
lar-
gely conceptualized by developmental traumatology and
emotional
security models. Witnessing the assault of a caregiver at the
hands of
another caregiver is particularly threatening to children’s sense
of
safety and well-being. DV signals caregivers’ distress and
unhappiness,
the possibility of family dissolution, and/or the possibility of a
care-
giver’s serious harm or death (Davies et al., 2002). Witnessing
threat to
the integrity or life of a caregiver destabilizes a child’s
foundational
sense of stability integral to emotional well-being, dysregulates
chil-
dren’s stress response systems over time, and increases risk of

post-
traumatic stress symptomatology (Davies & Martin, 2013; De
Bellis &
Zisk, 2014). Such trauma can impair children’s developing
brains and
physiologies, increasing vulnerability to adverse behavioral,
physical,
cognitive, and socioemotional functioning (De Bellis, 2001; De
Bellis &
Zisk, 2014).
1.3. Co-occurrence of child maltreatment and domestic violence
Children who witness DV are also at increased risk of poly-
victimization (i.e., experiencing multiple forms of victimization
such as
DV exposure with child abuse and/or neglect; Finkelhor,
Turner,
Hamby, & Ormrod, 2011). A national survey found that 33.9%
of youth
who witnessed DV during the past year were also maltreated
during the
same time period, compared with 8.6% of youth who reported
only
child maltreatment (Hamby, Finkelhor, Turner, & Ormrod,
2010). In
the state of Ohio, approximately 4 in 10 DV-exposed children
also ex-
perience maltreatment. The Ohio Department of Job and Family
Services (2016) reported that 39,401 cases in State Fiscal Year
2014—or 43% of all child maltreatment cases—had a notation
of
“Concern of Domestic Violence.”
Considering the high rate of co-occurrence, child welfare

workers,
DV service providers, and law enforcement personnel are all
critical in
identifying and serving children. However, studies of these
providers’
perceived knowledge and competence at addressing co-
occurring mal-
treatment and DV have found discrepancies. For example,
research has
found that DV service providers and child welfare personnel
were more
likely to identify and address DV exposure and child
maltreatment,
respectively, with limited skills and training around identifying
their
co-occurrence (Coulter & Mercado-Crespo, 2015; Hazen et al.,
2007;
Kohl, Barth, Hazen, & Landsverk, 2005). Such evidence
suggests com-
partmentalized provider training focused on intervention
services for
families who are, statistically, likely to be dually affected.
1.4. Complex needs of families who experience domestic
violence
Families affected by DV, and often co-occurring child
maltreatment,
experience complex needs consequent of multiple interrelated
family
traumas. Adults and children exposed to DV are likely to
present with
symptoms of complex trauma or impairments across regulatory
and
interpersonal domains (Cook et al., 2017; Pill, Day, & Mildred,
2017).

Symptoms of complex trauma, spanning from emotional
dysregulation
to cognitive and physical difficulties, manifest in unique
presentations
not necessarily aligned clearly with diagnostic criteria and
require more
individualized treatment (Cook et al., 2017; Pill et al., 2017;
van der
Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). DV-
affected fa-
milies tend to also experience substance use (Afifi, Henriksen,
Asmundson, & Sareen, 2012; Macy, Giattina, Parish, & Crosby,
2010),
homelessness (Pavao, Alvarez, Baumrind, Induni, & Kimerling,
2007),
and interruptions in children’s education (Kiesel, Piescher, &
Edleson,
2016). Each of these concerns reflects another domain of
service pro-
vision in a complex web of presenting needs; however, the
ability of
agencies to offer such multigenerational and comprehensive
services
requires additional staffing, training, and logistical
considerations.
1.5. Service systems that interface with families affected by
domestic
violence
Such complex needs demand collaborative, interactive, and co-
ordinated systems of care. Historically, DV agencies were
established to
provide advocacy and wraparound services (e.g., crisis care,
safe
shelter, legal interventions, counseling) for affected families

(Macy
et al., 2010a; Panzer, Philip, & Hayward, 2000; Zweig & Burt,
2007).
However, in the aftermath of a DV incident, families may also
interface
with law enforcement, child welfare, school, or medical
systems. Re-
cognizing the need for a cross-system collaborative response,
the
seminal Greenbook practice guidelines were published in 1999
by the
National Council of Juvenile and Family Court Judges
(NCJFCJ), urging
the field to reduce service fragmentation and coordinate system
re-
sponses to children dually exposed to DV and maltreatment
(Schechter
& Edleson, 1999). Several cooperative response models have
since been
implemented, including the Safe Start Initiative (Kracke &
Cohen,
2008), Handle with Care programs (Bushinski, 2018),
coordinated
community response teams (Banks, Dutch, & Wang, 2008), and
Family
Justice Centers (Murray, Wyche, & Johnson, 2020). Despite the
colla-
borative progress of these initiatives, research documents a
history of
divergent philosophies and service approaches across agencies
involved
(Gordon, 1988; Humphreys & Absler, 2011; McKay, 1994). For
ex-
ample, child welfare approaches often identify the child as the
victim

K.A. Berg, et al. Children and Youth Services Review 118
(2020) 105414
2
and the non-offending caregiver as implicitly culpable. In
contrast, DV
agencies primarily focus on the non-offending caregiver as the
victim.
The paradigm differences reflected in these two systems, as
well as
other networks of care, complicate collaborative efforts that
would best
promote family safety and healing from trauma (Appel & Kim-
Appel,
2006; Holmes, Bender, Crampton, Voith, & Prince, 2019).
1.5.1. Challenges faced by service providers
In addition to challenges to creating and enacting a
collaborative
model of care, providers face multiple other barriers to
effectively
identifying and serving families affected by DV. Providers
report in-
adequate training and skills around inclusively serving
subpopulations
(based on race/ethnicity, sexual orientation, urbanicity,
disability
status, immigrant status, etc.), rendering those affected families
under-
served (Helfrich & Simpson, 2006; Lehrner & Allen, 2009;
Messing,
Ward-Lasher, Thaller, & Bagwell-Gray, 2015). Families have

also re-
ported barriers to engagement such as fear and distrust of the
child
welfare, legal, and justice systems (Alaggia, Regehr, & Jenney,
2012;
Baker, Cook, & Norris, 2003; Lichenstein & Johnson, 2009).
When fa-
milies do engage with services, providers articulate limitations
around
enacting trauma-informed practices—those grounded in
recognizing
and responding to the cognitive, psychological, socioemotional,
and
physical consequences of trauma (Leitch, 2017)—to most
effectively
mitigate the effects of DV exposure (Laing, Irwin, & Toivonen,
2012;
Trevillion et al., 2012). Furthermore, providers report
challenges
around funding to continually meet the needs of families and
offer
ongoing training and education for staff (Stover & Lent, 2014).
1.6. Current study
While there is research that examines collaborative approaches
to
serving families affected by DV, to the authors’ knowledge, no
study has
synthesized open-ended responses both from diverse
professionals who
directly serve families who have experienced DV, and more
peripheral
service systems that interface with those primary agencies.
Additionally, this study explored perspectives of providers
across an

entire state, illuminating and assessing the needs of families and
service
providers across diverse communities. This study employed an
in-
ductive approach to thematic analysis to explore the following
research
questions across one state: (a) What do providers experience as
the most
prevalent service needs for children and youth exposed to
domestic
violence? (b) What do providers experience as the most
prevalent
policy needs for children and youth exposed to domestic
violence? (c)
What do providers experience as the most prevalent research
needs for
children and youth exposed to domestic violence? (d) What do
provi-
ders report are the best strategies for protecting children and
youth
exposed to domestic violence? and (e) What do providers report
are the
best strategies for reducing the negative effects of domestic
violence
exposure for children and youth?
2. Method
An electronic statewide survey that solicited open-ended
responses
was conducted to engage directors of Ohio-based agencies
providing
services for children exposed to DV. The purpose of the survey
was to
examine how DV-exposed children were being served by
agencies (e.g.,

types and delivery format of services offered, ages of children
served,
which evidence-based or promising programs were offered) and
to seek
information and ideas on how to better serve this population.
Data were
collected over a 4-month time period in 2016. This study was
approved
by the Institutional Review Board of a private Midwestern
university.
2.1. Participants and setting
The Shelter and Program Referral List on the Ohio Domestic
Violence Network website
(http://www.odvn.org/survivor/shelter.
html) was first used to locate relevant agencies in the state that
pro-
vided DV services, resulting in a list of 205 agencies. After
removing
duplicate agencies that were listed in more than one county, a
total of
75 agencies were included as the initial sample. Using an
internet-based
search, agency directors’ contact information was identified.
From
October 2016 to November 2016, directors were contacted by
the re-
search team via postal letter, email, and telephone and invited
to
complete the electronic Qualtrics survey (survey items
described
below). In November 2016, to maximize participation,
outstanding
respondents were invited to participate in a short-version form

of the
survey. All agencies invited to participate in the survey were
sent
weekly reminder emails.
Two particular questions on the survey requested that directors
list
(a) other agencies to which they referred children or youth who
needed
services not provided by their agency and (b) other agencies
within
their communities that provided trauma services to children or
youth
that they had not listed. Through November 2016, responses to
these
questions yielded an additional 47 agencies, which resulted in a
total of
122 agencies across the state that could potentially provide
services for
youth affected by DV. Of the 122 agencies, 17 were excluded
due to the
study researchers being either unable to identify the agency
itself or
being unable to find sufficient contact information with which
to ex-
tend an invitation to participate in the survey, resulting in a
total
sample of 105 agencies that were asked to complete the survey.
Out of
those, 59 completed the entire survey (56.2%), 19 completed a
portion
of the survey (18.1%), 5 declined or refused to complete the
survey
(4.8%), and 22 did not respond to the study team’s calls or
emails re-
garding the survey (20.9%). A total of 78 respondents (74.3%)

either
completed or partially completed the survey. Among those, 44
(41.9%)
provided qualitative responses to at least one of the survey’s
open-
ended questions and those data were used to synthesize the
results
presented in this study.
2.2. Survey items
The survey included questions about whether agencies offered
ser-
vices for children and their non-offending caregivers, whether
the
agency was able to meet the current demands for children or
youth
exposed to DV, whether respondents considered their agency to
be
trauma-informed, the types of services the agencies provided,
and the
specific evidence-based or promising programs used with
children and
youth. In addition, agencies were asked to respond via
extended, open-
ended response to the following questions: As the state of Ohio
assesses
statewide needs as they relate to DV-exposed children or youth,
(a)
what recommendation would you make about where to focus
particular
attention in terms of need related to services?; (b) what
recommenda-
tion would you make about where to focus particular attention
in terms
of need related to policy?; (c) what recommendation would you

make
about where to focus particular attention in terms of need
related to
research?; (d) What do you think needs to be done to better
protect
children or youth who are exposed to DV?; and (e) What ideas
do you
have about reducing negative effects of DV on Ohio's children
or youth?
A total of 44 agency respondents offered responses to at least
one of
these extended questions.
2.3. Analysis approach
All extended text responses from agencies were downloaded
from
the electronic survey as text files and then uploaded into NVivo
qua-
litative data analysis computer software, version 11.4.2.
Agencies’
collective set of responses were inductively coded by two
doctoral-level
research assistants using Braun and Clarke’s (2006) approach to
the-
matic analysis in order to examine both the semantic and
conceptual
patterning across agency participants’ responses. The coders in-
dependently first analyzed verbatim responses with a
combination of in
vivo and open coding in order to inventory the range of
individual
(2020) 105414

3
http://www.odvn.org/survivor/shelter.html
http://www.odvn.org/survivor/shelter.html
concepts expressed by participants. Separately, the coders then
sorted
the in vivo and open codes into emergent categories by
conceptual si-
milarity and then organized those emergent categories into
broader,
internally cohesive themes. The coders then reconvened to
review,
compare, and combine their two resulting coding schemes and
re-
conciled conceptual discrepancies. This generated one cohesive
the-
matic scheme by which participants’ responses to the extended
response
survey questions were classified and organized, as discussed
below.
3. Findings
3.1. Descriptives
Table 1 provides descriptive information about the 44 agency
pro-
viders in the current study. The total number of children
reported to
have received services in the State Fiscal Year 2016 was
85,213. Of
note, because some children interact with multiple systems, it is
pos-
sible that some children may have been double counted using

the four
sources of data. Because data were de-identified, it is not
possible to
know the extent of possible double counting.
The majority of the sample (47.7%) identified themselves as ex-
ecutive directors while 4.6% self-identified as clinical directors
and
9.1% specifically as DV program directors or coordinators. Just
over
18% reported as other directors (e.g., visitation director, shelter
di-
rector, child advocacy center director), and almost 7% reported
as other
coordinators (e.g., advocacy coordinator, general coordinator).
Another
7% self-identified as other professionals such as administrative
assistant
or legal advocate. Approximately 45.4% of agencies reported
that in
addition to offering services for children, they also offered
services to
support the non-offending caregivers who were parenting the
children.
Over 60% indicated being able to meet current demands for DV-
ex-
posed youth to a large or very large extent, though 20%
reported
meeting children’s needs at a small or very small extent. In
total, 84% of
respondents considered their agencies to be trauma-informed
and 59%
indicated their agencies to be using at least one evidence-based
or
promising intervention or prevention program.

3.2. Thematic analysis findings
Across extended response survey questions, agency providers
of-
fered four key recommendations to: (a) build general education
and
awareness surrounding the consequences of children’s exposure
to IPV;
(b) implement a trauma-informed care framework across child-
serving
systems; (c) integrate culturally-humble practices across and
within
systems; and (d) collaborate across systems. Providers made
these re-
commendations in reference to four primary contexts of the
clinical or
therapy system (i.e., any behavioral or mental health services
for DV-
exposed children), family system (i.e., any points of
intervention for the
family as a whole, such as parenting classes, counseling or
support for
non-offending parents, or visitation services), school system
(i.e., sup-
portive services for DV-exposed children in educational settings
and
schoolwide prevention or intervention curricula), and judicial
system
(i.e., child welfare services as well as family and criminal court
sys-
tems). Table 2 displays an abbreviated summary of key study
findings.
3.2.1. Education
Providers (43%) discussed the importance of promoting general

education and awareness for service providers, school
personnel, par-
ents, and the broader community on how children are affected
by
witnessing DV. Advice for better protecting DV-exposed
children in-
cluded suggestions such as requiring annual trauma-focused
training
and continuing education credits for all professionals working
with
children affected by trauma. Responses particularly emphasized
the
importance of providing general education and awareness within
the
family system surrounding DV and its detrimental effects on
children.
As one provider suggested, “the best way to protect the child is
to
educate the parent about the effects of domestic violence on
their
children.” Another provider qualified, however, that such
information
should be carefully and thoughtfully delivered to parents in
order to be
accessible and thus useful:
Increase education available to parents about domestic violence
and
how it really relates to their children, but in an engaging way,
as most
of the information that is delivered today is still targeted toward
victim-
blaming and is unreceptive to the parent.
Other providers highlighted opportunities for schools to

integrate
socioemotional health-focused curricula to promote early
education,
starting in childhood, about healthy relationship dynamics.
Some of-
fered examples of curriculum content, including: healthy
relationship
skills, general emotion coping skills, ways through which to
identify
and express emotions healthily both in the self and in others,
emotional
intelligence, meditation and mindfulness, safe dating behaviors,
and
sex-positive and enthusiastic consent-focused sexual health
education.
Alluding to the preventive capacity of socioemotional education
on
children’s current and later relationships, one provider
suggested that
schools could offer “education for children beginning in
elementary
school regarding healthy relationships.” Another detailed:
Teach more social and emotional skills in school instead of just
academic topics, [and] cover healthy relationship skills, sexual
health,
etc. Include different coping skills built into the curriculum.
Some
Table 1
Characteristics of comprising study agencies (n = 44).
N %
Respondent job responsibility a

Executive Director 21 47.7
Clinical Director 2 4.6
DV Program Director or Coordinator 4 9.1
Other Director 8 18.2
Other Coordinator 3 6.8
Other 3 6.8
Missing 6 13.6
Services also offered to non-offending parent
Yes 20 45.4
No 2 4.5
No answer 22 50.0
Extent to which able to meet current demands for DV-exposed
children
Very small extent 3 6.8
Small extent 6 13.6
Moderate extent 7 15.9
Large extent 16 37.2
Very large extent 11 25.0
No answer 1 2.3
Would expand service area or services if additional funding
were
available
Yes 39 88.6
No 5 11.4
No answer 0 0
Consider agency to be trauma-informed
Yes 37 84.1
No 6 13.6
No answer 1 2.3

Types of services offered
Individual counseling for children
Age birth to 2 4 9.1
Age 3 to 5 9 20.4
Age 6 to 12 10 22.7
Age 13 to 18 13 29.6
Community outreach 24 54.6
Safety planning 24 54.6
Material resources (transportation, children's clothing, food,
etc.) 23 52.3
Uses at least 1 evidence-based or promising intervention or
prevention program
No 2 4.5
Yes 26 59.1
No answer 16 36.4
a Multiple respondents reported more than one job
responsibility, rendering
these categories (with the exception of “missing”) not mutually-
exclusive.
(2020) 105414
4
schools have implemented meditation rooms instead of
detention halls
with great results.
Beyond the family and school systems, multiple responses

called for
broad community-wide education. For example, one provider
suggested
that the state unroll a “public health campaign, to the same level
as
[those about] drugs and smoking, about the impact of violence
on
children in Ohio.” Another articulated the crucial role of such
education
in “taking away the belief that only certain people are affected
by do-
mestic violence and trauma.”
Providers spoke to the role of active research and its
dissemination
in promoting education and awareness of the long-term effects
of DV,
and intervention and prevention knowledge for professionals
working
with affected families. Providers offered specific research topic
ques-
tions of interest such as “What [should] relationships with
fathers who
batter mothers look like?” or “What is the correlation between
domestic
violence and issues with child learning?” Continued research
related to
the Adverse Childhood Experiences (ACEs) study (Felitti et al.,
1998)
and work by professionals like Dr. Bruce Perry (2009) were
additionally
recommended, as was ensuring the accessibility of such
research:
Staff working in this field need to be well-informed and
educated on

the effects of all forms of violence and trauma on children and
families
they serve. Therefore, continued research is vital to keeping
new and
cutting-edge information on the effects of violence in the
forefront of
their minds as they are treating the children and families.
Additionally,
continued research is needed to find and refine best evidence -
based
practices to treat and care for those who have experienced
violence and
trauma.
3.2.2. Trauma-informed care
Providers (36%) repeatedly discussed the need for trauma-
informed
care across domains of training, policy, and direct services with
which
DV-exposed children and families interface. The school system
was
identified as a particularly crucial context of meaningful
intervention to
ameliorate the negative effects of DV exposure on children. For
in-
stance, one provider proposed “Have a trauma specialist
assigned to a
school district that can come to the school when an issue
presents and
help the school staff to better serve the child.” Another
suggested
trauma education for all school personnel interacting with
children:
In the schools, I think there needs to be more education about

children and the effects of domestic violence and how that
appears in
the institution. A better understanding of trauma for those allied
pro-
fessionals could lead to a more trauma-informed approach in the
classroom.
Providers’ highlighted the need for all-encompassing trauma-in-
formed approaches extended to the judicial system. For
instance, one
provider reported how challenges in collaborating with child
welfare
workers limit the entities’ joint capacities to effectively and
sensitively
address the needs of clients:
Children's Services is not a solid collaborative partner. Our
philo-
sophy and processes are often in opposition, especially related
to
trauma-informed approaches and from a family advocacy and
victim's
rights' perspective (especially right of parenting under VAWA
[the
Violence Against Women Act]), which poses additional conflict
and
barriers to collaboration. Further, unaccompanied youth seeking
ser-
vices including shelter and advocacy are not allowed to remain
in our
services due to Children's Services’ approach through their
operation of
the local Child Advocacy Center.

Solution
s for these partnerships will
help extend services and remove current barriers.
Providers underscored the need for trauma-informed policies in
the
court and justice system, particularly among child welfare
workers and
in family and criminal court. Broad recommendations were
made to
increase the enforcement of DV statutes and, more specifically,
for court
officials to adopt a trauma-informed approach to visitation
decision-
making by considering how witnessing DV affects children’s
overall
well-being. One provider elaborated on how trauma-informed
policy
would also support more valid and thorough investigations and
inter-
ventions with DV-affected families in the child welfare system:

Child Welfare does not protect children! Children are ‘terrible’
witnesses to the crimes committed against them. Trauma
symptoms,
rather than explicit disclosures, need to be taken into
consideration
when investigating child sexual abuse or domestic violence
cases.
Providers additionally warned that the neglect of children’s
agency
and rights within the justice system may compound the trauma
of
witnessing violence. One explained:
I think children need to have more rights. It seems that parents
have
rights and children have almost none. When children are
removed from
Table 2
Key qualitative findings from respondent agencies (n = 44).
Theme Meaning Evidence
1. Education Responsive and empathic education is needed to

help caregivers
understand the effects that witnessing DV has on children. All
children would benefit from schools integrating education about
socioemotional health into their curricula. Furthermore, general
education and awareness of how witnessing violence affects
children is needed for broader society.
“Increase education available to parents about domestic
violence and how it
really relates to their children, but in an engaging way, as most
of the
information that is delivered today is still targeted toward
victim-blaming and
is unreceptive to the parent.”
“The best way to protect the child is to educate the parent about
the effects of
domestic violence on their children.”
2. Trauma-Informed
Care
Stakeholders in the court and justice systems, educators, school
personnel, and other allied professionals should adopt policies
that
work to mitigate DV-exposed children’s trauma and consciously

avoid re-traumatizing them. Professionals– particularly
educators–
should receive regular training to recognize trauma symptoms
and
understand the psychological, cognitive, and social effects of
children’s trauma.
“Have a trauma specialist assigned to a school district that can
come to the
school when an issue presents and help the school staff to better
serve the
child.”
“…Teach those who interact with children to know the signs of
trauma at every
developmental stage” and to provide “more information and
education about
the long-term effects of trauma on children and their
development—cognitively and psychologically.”
3. Cultural Humility Child-serving systems must infuse other-
oriented approaches into
all levels of service provision that recognize how characteristics
of
family and community culture affect experiences of DV and
trauma.

This includes building awareness of the ways in which cultural
identity and historical experiences can influence family
interactions
with systems of care.
“Focus should not just be on what services to offer. It should be
on making sure
the services provided are culturally competent and trauma-
informed.”
[there is need for] “mental health counselors for Deaf children
exposed to
trauma …”
4. Collaboration There remains ongoing need for the various
service systems (e.g.,
education, child welfare, criminal justice, DV advocacy) caring
for
children and families affected by domestic violence to work
jointly
and synergistically to best address children’s and families’
needs.
“Intimate partner violence [domestic violence] collaborative
approaches will
help assure victims who are parents that the common goal is to

ensure their
right of parenting, support the family, protect the children, and
reduce the risk
of child removal until it is proven as the last resort and as a
temporary measure
with input from the victim/parent. There is still too much to
lose and therefore
victims do not come forward, allowing children to be exposed to
violence
longer.”
(2020) 105414
5
the home, reunification is always the plan. There are times
when
children are removed from the home and then returned only to
be re-
moved again. This is too much trauma for the children and
sends a
message that their feelings do not matter. This is the same when

talking
about children participating in the court process and being abl e
to ex-
press their feelings and wishes.
Another provider echoed concern for how DV-traumatized youth
may be treated in the justice system and the long-term effects of
court
decisions made without regard for how trauma and traumatic
stress
affect children over time:
Domestic violence programs for youth who are charged [need
to]
recognize that many youths who are charged with domestic
violence
are defending the family against a batterer or are lashing back at
a
batterer. Too often, the adult who is also charged in the incident
has his
charge reduced or dismissed and the child is adjudicated.
At the intersection of trauma-informed care and education
advice,
providers described the importance of disseminating

information about
trauma-informed care principles through training and education
ma-
terials. Providers emphasized the need to “teach those who
interact
with children to know the signs of trauma at every
developmental
stage” and to provide “more information and education about
the long-
term effects of trauma on children and their development—
cognitively
and psychologically.”
3.2.3. Cultural humility
Other providers (20%) articulated the importance of cultural hu-
mility, defined as ongoing, other-oriented approaches to
providing
services that are mindful both that cultural factors affect an
individual’s
experience surrounding DV, and that culture is fluid and
subjective
(Tervalon & Murray-García, 1998). For example, one individual
de-
scribed a gap in services for children in the Deaf community,

reporting
unmet need for “mental health counselors for Deaf children
exposed to
trauma, with certification in EMDR [Eye Movement
Desensitization and
Reprocessing] and play therapy, sand tray therapy and other
expressive
therapies.” One provider differentiated between the mere
presence of
services versus those that integrate culturally humble and
trauma-in-
formed approaches, advising “Focus should not just be on what
services
to offer. It should be on making sure the services provided are
culturally
competent and trauma-informed.” Providers relatedly called for
re-
search to examine “cultural aspects and competency” such as
better
identifying service barriers faced by members of the Deaf
community,
the importance of linguistic translation and interpretation
services
(including sign language and closed-captioning) in DV–related
care and

educational materials, and effective services for trauma-exposed
chil-
dren with developmental disabilities and other special needs.
3.2.4. Collaboration
A smaller portion of providers (14%) identified the need for
colla-
boration across service systems tasked with addressing the
needs of
children exposed to DV. For instance, speaking to joint efforts
between
law enforcement and clinical services, one provider suggested
the
creation of Child Advocacy Centers with forensic investigators
in every
county across the state. For another, specific policies could be
made to
legally ensure that children are guaranteed school-based
services de-
spite relocation from their home districts to DV shelters:
“[Enforce]
strict guidelines and sanctions for school systems that will not
provide
services for children who have moved out of their home city to

a shelter
due to domestic violence.” Advocating for stronger
collaboration with
DV-affected families, an additional provider described barriers
that
preclude victims of DV from coming forward, thus promoting
extended
exposure of children to the violence:
Intimate partner violence [domestic violence] collaborative ap-
proaches will help assure victims who are parents that the
common goal
is to ensure their right of parenting, support the family, protect
the
children, and reduce the risk of child removal until it is proven
as the
last resort and as a temporary measure with input from the
victim/
parent. There is still too much to lose and therefore victims do
not come
forward, allowing children to be exposed to violence longer.
4. Discussion

4.1. Practice and policy implications
In the present study, professionals serving DV-exposed children
across the state of Ohio provided the following policy, service,
and
research recommendation: targeted education initiatives focused
on the
consequences of child exposure to DV, implementation of a
trauma-
informed care framework across child-serving systems,
integration of
culturally-humble practices at all system levels, and cross-
system col-
laboration. Building from these themes, providers specified that
these
recommendations be integrated across four distinct systems: the
clin-
ical/therapy system, the family system, the school system, and
the ju-
dicial system.
4.1.1. Increasing education and policy around the effects of
domestic
violence, ACEs, and trauma-informed care

More than 40% of agency providers in this study articulated the
importance of bolstering community knowledge about the effect
of
violence exposure and adverse childhood experiences (ACEs) on
chil-
dren’s development. Aligned with this recommendation, there
are
several examples across the United States where
multidisciplinary
education initiatives on ACEs and child violence exposure have
been
linked with policy enhancements and improved outcomes for
youth
(Forsadt, Cooper, & Andrews, 2015; Kagi & Regala, 2012; Ko
et al.,
2008; Purewal et al., 2016). For example, Washington State has
im-
plemented statewide legislation to facilitate ACEs educational
training
and awareness programs for helping professionals across several
sec-
tors, including social work, education, law enforcement,
medicine, and
the judicial system (Kagi & Regala, 2012). This policy-level
approach to

statewide ACEs education has resulted in trauma-informed
adjustments
to juvenile court policies and offender treatment, increased
levels of
protected funding for family-based home intervention services,
and
higher levels of cross-system collaboration.
In addition to recommending multidisciplinary ACEs education
in-
itiatives, providers in the present study also advocated for
integration of
trauma-informed care at all system levels. Trauma-informed
care (TIC)
is an orientation to service delivery that recognizes the
cognitive, so-
cial-emotional, behavioral, and neurodevelopmental impact of
trauma
on individual and community well-being (Leitch, 2017). At both
the
agency and individual/clinical level, the TIC model emphasizes
a col-
laborative approach to clients’ engagement with systems and
promotes
client safety, empowerment, and resilience. Although models of

TIC
vary, one common component of a trauma-informed approach
with
children and families is the implementation of processes and
policies
that support routine screening for traumatic exposures and
related re-
actions or symptoms to identify exposed children and intervene
as
early, and as comprehensively, as possible. Exposure to DV,
especially
early in life, can create a complex and idiosyncratic symptom
picture
that requires comprehensive screening and assessment in order
to drive
individualized, effective intervention. Consequently, many
researchers
and practitioners across sectors advocate for universal early and
routine
screenings for childhood exposure to violence in pediatric and
other
primary healthcare settings (Thackeray, Hibbard, & Dowd,
2010).
Although the comprehensive and cross-discipline nature of TIC

has
led to widespread appeal among service providers, challenges to
TIC
implementation remain, including difficulties operationalizing
and as-
sessing the success of TIC in practice settings and agencies’
limited
funding and resources for implementation. As the vast majority
of
providers in this study indicated that they consider their
agencies to be
trauma informed, it is worthwhile to note that as of yet there is
no
uniform definition or understanding of what exactly this means
and
how it manifests in practice.
(2020) 105414
6
Despite these challenges, however, evidence indicates that TIC

ap-
proaches have been effective in improving youth outcomes
across sys-
tems, including the child welfare system (Lang, Campbell,
Shanley,
Crusto, & Connell, 2016), schools (Dorado, Martinez,
McArthur, &
Leibovitz, 2016), inpatient psychiatric settings (Azeem, Auila,
Rammerth, Binsfeld, & Jones, 2011), pediatric primary care
settings
(Purewal et al., 2016), and juvenile justice settings (Ford &
Blaustein,
2013). One potential starting point for agencies seeking to adopt
a TIC
approach is to explore the model programs and assessment re-
commendations advanced by the National Child Traumatic
Stress Net-
work (NCTSN) and replicate those that align with the agency’s
re-
sources and staff capabilities (Ko et al., 2008).
Finally, some respondents emphasized the need for cultural
humi-
lity within DV service provision for individuals such as those
within the

Deaf community, the developmental disability and other special
needs
communities, and those whose primary language is not English.
These
findings align with growing calls for intersectional approaches
to the
specific study of children’s exposure to DV (Crenshaw, 1993;
Etherington & Baker, 2018). For instance, Rizo and colleagues,
in their
review on DV and developmental disability, note the absence of
services
tailored to DV-exposed children with intellectual disabilities
(Rizo, Kim,
Dababnah, & Garbarino, 2020). Sullivan (2009) had similarly
noted, a
decade prior, that while research has explored myriad violence
ex-
posures of children with disabilities, few studies have examined
ex-
posure to DV among children with disabilities. Although
research has
examined the discrete identities, or positionalities, of children
exposed
to DV, far less inquiry has investigated the intersectionality of
multiple

positionalities. Pivoting from a focus on individual identities to
inter-
sectionality may render programs and services for DV-exposed
children
more successful by continually tending to culturally nuanced
intra-
personal and family dynamics that affect how trauma is
experienced,
cognitively and emotionally processed, and thus best intervened
upon.
4.1.2. Adopting paradigms of cross-system collaboration
Respondents underscored the need for improved collaboration
across systems to best serve families affected by DV. In
response to
nearly all questions, respondents emphasized the need to
cultivate or
improve collaborations across service systems interfacing with
DV-ex-
posed children and families. Of specific concern was bridging
gaps
between the judicial (i.e., family court, child welfare) and DV
service
systems. As noted previously, nearly half of Ohio children

exposed to
DV also experience child maltreatment (Ohio Department of Job
and
Family Services, 2016). Awareness of the need for effective
collabora-
tion between these two systems garnered attention following the
pub-
lication of the Greenbook, also known as “Effective
Intervention in
Domestic Violence and Child Maltreatment: Guidelines and
Practice”
(National Council of Juvenile and Family Court Judges,
Schechter, &
Edleson, 1999). The Greenbook provides important, actionable
practice
guidelines around staff training, assessment, safety planning,
and of-
fender accountability to reduce fragmentation of services at the
inter-
section of the child welfare system, DV service system, and the
judicial
systems to improve care for children and families affected by
DV. Al-
though the Greenbook has shaped the development and
implementa-

tion of successful demonstration projects across multiple sites,
the ex-
periences of respondents detailed here underscore the need for
further
implementation of these collaborative practices (Banks,
Landsverk, &
Wang, 2008; Malik, Ward, Janczewski, 2008). The findings
from our
study, together with a recent review of research and literature
(Holmes
et al., 2019), underscore that much progress remains–despite the
Greenbook being published over 20 years ago– in actually oper-
ationalizing concepts of system collaboration in practice. Our
findings
illuminate areas that remain for further development and
innovation,
all of which provide an informative foundation for supporting
com-
munities in building system collaborations.
Other models of collaborative prevention and intervention pro-
grams exist. The Centers for Disease Control funded, for
example,
community coordinated response sites (CCRs) with the two-fold

aim of
both preventing DV and providing intervention services
following a DV
incident (Klevens, Baker, Shelley, & Ingram, 2008). CCRs
engage in
prevention activities through education campaigns about the
scope and
causes of DV, training professionals around effective screening,
and
disseminating information about DV–related policies and
services
(Klevens et al., 2008). CCRs also strive to improve intervention
services
by developing substantial and comprehensive cross-systems
collabor-
ations—implementing comprehensive information-sharing
agreements,
embedding DV units within law enforcement or child welfare
entities,
and providing cross-training across service sectors (Klevens et
al.,
2008).
As alluded to by participants in this study, the implications for
such

a robust cross-system collaborations are notable. Research from
Washington’s Family Policy Council found that areas with
collaborative
community networks exhibited reduced levels of individual
ACEs, as
well as social and community problems, compared with regions
that did
not establish collaborative community networks (Hall, Porter,
Longhi,
Becker-Green, & Dreyfus, 2012). To best serve children and
families
affected by DV, continued efforts to build these cross-systems
colla-
borations are required.
Another such cross-system collaboration initiative specifically
in
Ohio is the Linking Systems of Care for Children and Youth
Project
(Linking Systems), a federal demonstration project currently
funded in
Montana, Virginia, Illinois, and Ohio. One primary objective of
Linking
Systems is to “build capacity within communities to meet the
needs of

youth exposed to violence” (Office for Victims of Crime, 2017).
The
Ohio project site, having entered the demonstration project in
2018, is
working to build capacity through multidisciplinary statewide
work
groups, creation of a trauma-informed care resource directory,
and
development of a child violence exposure screening tool.
Conducting a
statewide needs assessment and gap analysis was an essential
first step
in the Ohio Linking Systems project, as the results ensured
appropriate
allocation of resources, evidence-informed decision-making,
and col-
laboration from survivors and stakeholders in both rural and
urban
areas of the state and from those with historically and
philosophically
diverging approaches to service provision.
Other collaborations demonstrate the potential utility of person-
or
family-centered data-sharing frameworks to best care for

vulnerable
children and families. For example, the Los Angeles County
Department
of Health Services houses a countywide pilot program titled
Whole
Person Care aimed at integrating public health and social
services data
for vulnerable residents who interact with multiple service
systems
(justice, housing, behavioral health, etc.). By building an
information
technology infrastructure that merges data at the level of person
or
family, real-time information is shared across multiple service
systems
to minimize gaps in communication across those systems and
provide
real-time care for clients (Armstrong, Elson, & Weir, 2019).
Such
person-centered data-sharing initiatives could demonstrate
utility for
families and children affected by DV who would likely benefit
from
more seamless coordination between, for example, housing
authority,

child welfare, family court, and education systems. Concerns
about
sharing data about a victim, for example, across agencies who
may also
be working with the perpetrator are notable and warranted.
However,
existing information-sharing programs have been successfully
im-
plemented in other child-serving systems and may offer useful
gui-
dance. For instance, in Ohio, Hamilton County’s IDENTITY
project
merges data from the County’s Child Welfare Information
System with
Cincinnati Children Hospital’s Electronic Health Record data in
order to
safely share cross-system information about children in
protective
custody (Greiner, Beal, Dexheimer, & Krummen, 2020).
4.1.3. Implementing social-emotional and relationship education
curricula
and school prevention programming
Several service providers advocated for school curricula on

healthy
relationships and social-emotional skills, suggesting that such
(2020) 105414
7
programming may prevent further violent victimization and/or
perpe-
tration in this population. This recommendation aligns with
previous
research demonstrating a linkage between DV exposure and
adolescent
dating violence (Choi & Temple, 2016; Park & Kim, 2018). As
providers
in this study suggest, it is possible that early primary prevention
pro-
gramming on relationship violence may reduce the incidence of
chil-
dren continuing the cycle of family violence through their own
in-
volvement in dating violence and adult DV. Indeed, healthy

relationship programming in schools has been linked with lower
levels
of violent victimization and perpetration in dating rel ationships
among
DV–exposed teens specifically (DePrince, Chu, Labus, Shirk, &
Potter,
2013; Wolfe et al., 2003), as well as in general adolescent
populations
(Foshee et al., 2005; Wolfe et al., 2009). Thus, primary
prevention ef-
forts in schools may offer one avenue to address the
intergenerational
cycle of family violence experienced by some children in DV
house-
holds.
4.2. Study limitations
The current study contributes valuable knowledge from service
providers themselves of how to better serve children and
families af-
fected by DV, but limitations must be noted. First, though
efforts were
made to survey a representative statewide sample of agencies
through

the Ohio Domestic Violence Network website and snowball
referrals,
approximately one quarter of contacted agencies did not
participate.
The resulting final sample may be biased in ways pertinent to
the aim of
this study; for example, agencies with less time and employee
resources
may have been less likely to respond but, for those reasons,
more likely
to identify a unique subset of needs not articulated by other
partici-
pants. The current study did not survey service recipients
themselves,
and thus the voices of those most affected by gaps in service
provision
and policy are missing. Future larger-scale studies may employ
a mixed-
methods design utilizing random sampling of both service
providers
and recipients in a broader sampling frame to generate more re-
presentative and transferable findings. Such a combined
quantitative
and qualitative approach may also elucidate how characteristics
of in-

dividual providers and agencies (e.g., role in agency,
philosophical
approaches to treatment, urban or rural location, extent of
alignment
with law enforcement, whether or not agency serves a
culturally-spe-
cific sub-population) may affect the tenor and content of their
quali-
tative responses. Finally, findings are bound by the state of
Ohio and,
due to variation in the fabric of DV–related intervention and
funding
priorities, may not translate to other states or regions in the
country.
Despite the challenges presented by this study’s regional
specificity,
there are still broad implications that can be drawn for programs
be-
yond the state of Ohio. For example, other states may consider
con-
ducting a statewide needs assessment and gap analysis–similar
to the
Ohio Linking Systems collaborative approach–as an essential
step in

developing a more robust multidisciplinary set of child-serving
systems
statewide. Furthermore, Ohio is among ten states that has
statewide
implementation of the Safe & Together Model, a collaborative
program
provided by child welfare and DV advocate teams to serve
dually-ex-
posed children and their families (Mandel, 2010; Safe &
Together
Institute, 2020). Although the benefits of the Safe & Together
Model are
considerable, our paper highlights that continued collaborative
efforts
among child-serving systems are still needed, and other states
who use
the Safe & Together model may share similar needs.
5. Conclusion
This study illuminates critical service needs of children
victimized
by domestic violence as articulated by Ohio agency providers
who work
with those children and families. Agency participants call for

more
general awareness of domestic violence and its deleterious con-
sequences for children and, relatedly, the necessity of adopting
trauma-
informed and culturally humble approaches to working with
families.
Finally, participants emphasized integrating cross-system
collabora-
tions to provide family-centered care to best treat children’s
trauma.
Although the findings of this Ohio-based study are promising,
future
research efforts are warranted. Domestic violence is a pressing
public
health problem across the United States, and additional
investigation
should identify salient gaps in service provision and research
across
other states and regions. Importantly, integrating the voices of
children
and families themselves are crucial to identifying additional
short-
comings. Together with robust data systems that monitor family
needs

and collaboratively coordinate to deliver resources, these
initiatives
may foster optimal outcomes for children who experience the
trauma of
witnessing domestic violence.
CRediT authorship contribution statement
Kristen A. Berg: Methodology, Formal analysis, Project
adminis-
tration, Writing - original draft. Anna E. Bender: Formal
analysis,
Investigation, Writing - original draft. Kylie E. Evans: Writing -
original
draft, Validation, Writing - review & editing. Megan R.
Holmes:
Conceptualization, Methodology, Investigation, Supervision,
Funding
acquisition. Alexis P. Davis: Writing - review & editing. Alyssa
L.
Scaggs: Data curation. Jennifer A. King: Writing - review &
editing,
Validation.
Appendix A. Supplementary material

Supplementary data to this article can be found online at https://
doi.org/10.1016/j.childyouth.2020.105414.
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1/h0455Service needs of children exposed to domestic viol ence:
Qualitative findings from a statewide survey of domestic
violence agencies1 Introduction1.1 Prevalence1.2 Negative
effects of childhood domestic violence exposure1.3 Co-
occurrence of child maltreatment and domestic violence1.4
Complex needs of families who experience domestic
violence1.5 Service systems that interface with families
affected by domestic violence1.5.1 Challenges faced by service
providers1.6 Current study2 Method2.1 Participants and

setting2.2 Survey items2.3 Analysis approach3 Findings3.1
Descriptives3.2 Thematic analysis findings3.2.1 Education3.2.2
Trauma-informed care3.2.3 Cultural humility3.2.4
Collaboration4 Discussion4.1 Practice and policy
implications4.1.1 Increasing education and policy around the
effects of domestic violence, ACEs, and trauma-informed
care4.1.2 Adopting paradigms of cross-system
collaboration4.1.3 Implementing social-emotional and
relationship education curricula and school prevention
programming4.2 Study limitations5 ConclusionCRediT
authorship contribution statementAppendix A Supplementary
materialReferences

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