Partner Violence and Children...How Should We Respond?-- Angie Boy, DrPh


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The presentation will cover the basics of partner violence, impact of violence on pregnancy/fetal development, impact on child development (birth-adolescence), resiliency in children, proper ways to respond to partner violence when children are present and resources for assistance/more information.

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  • Thank you for joining us today. We’re going to talk about partner violence during pregnancy and why it matters to organizations serving pediatric populations. We’ll address some general information about partner violence, discuss some of the health implications, how assessments can be done and finally, community resources available for victims.Note about language: For this presentation, I’m going to use she when talking about the victim and he when talking about the abuser. I recognize that men can be abuse victims as can victims in gay/lesbian relationships. However, because we are talking about violence during pregnancy, the he/she use of pronouns is appropriate.
  • The terms used to discuss partner violence will vary. Most researchers use the term intimate partner violence while advocates generally prefer the term domestic violence. Most of the terms include physical abuse, psychological or emotional abuse and sexual abuse.The prevalence rates of partner violence will vary depending on the types of abuse examined as well as whether or not the measurement included those experiencing abuse currently vs. those who have experienced abuse sometime in the last year or at some point during their lifetime.
  • This is a picture of the Power and Control Wheel. You can see physical and sexual violence around the rim of the wheel but the spokes show the variety of other tactics that abusers will use to gain power and control in the relationship. We’ll talk more in depth about these behaviors on the next slides.
  • Some of these behaviors are fairly obvious but others are more subtle. Intimidation is one that is pretty obvious. Most victims will report knowing “the look” their partners had that indicated a violent episode was about to happen. Abusers often will intimidate their victims by destroying property but it’s only property that means something to the victim.Emotional abuse is the most common type of abuse – abusers will call her names, play mind games with her and humiliate her in front of other people.Isolation is one of the more subtle forms of abuse – the abuser doesn’t automatically start forbidding outside involvement, he usually couches it in some form of jealousy (I want to spend more time with you, your family doesn’t like me, etc.) Minimizing/denying/blaming – often abusive partners will claim they didn’t hit her that hard or if she had only followed the rules, she wouldn’t have been hurt
  • Children are often used by abusers – forcing them to relay messages to their mom, using visitation swaps as an opportunity to harass the victim or abusive partners will threaten to take children away from the mom – especially a problem in immigrant communities where partner will threaten to return to country of originMany victims report their abusive partner would use money and finances as a way to control her – she would be forced to quit her job, be given an allowance or only enough money to buy groceries and will prevent her from knowing the family’s financial situationMale privilege is often used as a more subtle abusive tactic – the abuser makes all the decisions for the family, decides what the male and female roles will be and may treat her like a servantCoercion and threats are also quite common. Abusive partners may threaten to commit suicide (sign of increasing risk) or may force her into illegal behavior such as drug sales or prostitution
  • The most common question encountered when working with abuse victims is “why doesn’t she just leave?” Asking the question this way insinuates that leaving is a very easy thing to do when in reality, leaving a violent relationship is quite difficult and can often be dangerous. The better question is what barriers are preventing her from leaving?The barriers can often be quite complicated – we’ll touch on specific ones in a moment. But, the primary barriers to a victim leaving are external, not internal. They are often things she can’t control.The biggest barrier (and most dangerous) is the batterer’s control – often when a victim leaves or begins to make plans around leaving, the abuser will become more violent and controlling – he senses he is losing control and will go to great lengths to regain the control.
  • This slide shows come of the most common barriers. Fear is one of the biggest – she’s afraid of her abuser, afraid of the system, afraid of how she’ll provide, etc.Love is another big barrier. Regardless of how often or how violently she’s abused, victims report loving their abuser – they chose to remember the good times, the promises he’s made to change, etc.Self-blame is huge – victims feel like they have done something to deserve the abuse – it’s what they hear from their abuser and sometimes from other members of society. Shame also plays a strong role – many victims are ashamed to be in a violent relationship and don’t want anyone to know – this impacts help-seeking behaviorsCultural and religious beliefs about marriage and male/female roles may also create barriers to leaving.Victims often have very little money, no safe housing alternatives, difficulties with transportation, etc. and this can make leaving and starting over impossible – victims will often choose to stay with an abusive partner because they are assured of a safe place to live, food for their children, etc.Finally, victims face immense pressure to keep families intact. Pressure comes from abusive partner, family members, society, etc.You can see from this list that it isn’t as simple as just leaving – helping a victim address the barriers makes leaving possible.
  • This slide shows some of the general health impacts partner violence can have. Injuries are usually the first thing people think about. However, injuries are only a small part of the issue. Victims often have chronic pain including headaches and migraines that come from repeated injuries, blows to the head, etc. Victims also report having difficulty managing chronic conditions like asthma, diabetes or heart disease. They may have trouble getting access to medications or following doctor’s advice regarding diet/lifestyle changes.Anxiety and sleep disorders are also common among victims. Depression and potentially suicidal thoughts or actions can occur if a victim feels she can no longer cope with the abuse.
  • There are serious consequences for women in terms of their reproductive health when in violent relationships. As many as 1 in 4 women report being pressured to get pregnant or having their birth control methods sabotaged (pills thrown away, condoms destroyed, etc.). In fact, partner violence raises the risk of unintended or unplanned pregnancies two-fold. These unplanned pregnancies can lead to additional complications or health concerns for mom and baby.
  • When women experience violence in their relationship, it puts their pregnancy at risk. Women who report violence during pregnancy are less likely to receive early prenatal care (often not entering until 3rd trimester, if at all), are more likely to report negative health behaviors like smoking or alcohol use and are more likely to experience depression and attempt suicide while pregnant
  • There are potentially serious complications that can happen when violence is experienced during pregnancy. These complications can have a direct impact on the health of the mom and the health of the baby. Victims are at greater risk than non-victims for high blood pressure, vaginal bleeding, infections, severe nausea and delivering an infant requiring a NICU stay.Research has shown that victims of violence during pregnancy are almost three times more likely to be hospitalized for a non-delivery reason than non-victims.
  • Unfortunately, violence during pregnancy can lead to homicide. Homicide is the 2nd leading cause of injury-related deaths among pregnant women (MVA’s 1st). In some communities, homicide is actually the leading cause of injury-related deaths among pregnant women. These homicides are most often perpetrated by the victim’s intimate partner.
  • The violence toward the pregnant women can also have a negative impact on the infant. Studies have repeatedly shown that partner violence is associated with low gestational weight gain in moms that can lead to low birth-weight and very low birth-weight as well as pre-term delivery. These complications can lead to lifelong health and development issues.Other research has shown that moms who experience partner violence during their pregnancy have a lower maternal attachment to their infant. Researchers suspect this is because mom has to split her attention between the newborn and her abusive partner.
  • The violence against mom also puts the infant at greater risk for death in the first year of life. We also know that children whose moms are victims are less likely to have the appropriate number of well-child visits in their first year and are less likely to be fully immunized by age 2.
  • The abuse mom is experience can have an impact on how she parents. Those experiencing partner violence are more likely to exhibit signs of depression and report harsher parenting.Moms also report being afraid to discipline the children, let the kids make the rules and feeling disconnected from their child.
  • There is a documented link between partner violence and child abuse. One national survey (and many other smaller surveys) found that 50% of men who assault their wives also abuse their children.Domestic violence in the home may also lead to severe injuries and even death for the child.In talking with victims who have maltreated their child report doing so in response to threats from the abuser (using harsher discipline techniques to keep child quiet, force obedience, etc.). Generally these tactics are undertaken as a safety mechanism to prevent further violence by the abusive partner.
  • It’s important to be educated about this issue and the barriers related to leaving because research has shown that the majority of victims of partner violence who have children ARE NOT bad, ineffective parents – many are nurturing and will often over-compensate to try and mediate the impact of the abuse.Victims can’t usually leave on their own (this is doubly true when children are involved). They need help navigating the barriers to leaving the violent relationship. That’s where organizations like yours come in – you are a source of information and assistance in the community.
  • It’s not often as simple as removing the children from the home – that can often have detrimental effects on the mom and the children – the safety of mom is directly linked to the safety of the children – if you work with mom to help her get safe, the children gain a level of safety as well. There is also research to show that the resiliency of the children can be dependent on their relationship with the non-offending parent. That’s part of the reason why addressing mom’s safety is so important.Early identification of violent relationships is key and screening is part of that process.
  • Here are some sample screening questions that you may find helpful when talking to moms about healthy relationships. Notice that you aren’t asking the have you ever been hit, are you a victim of abuse type questions. You’re asking open-ended, non-judgmental questions to begin assessing the home relationship. The answers to these questions will help determine what resources might be needed.
  • These screening questions will also give you some insight into what types of resources might be needed – you want to gather as much information as you can so you can make an informed decision about resources. Your asking about the nature and extent of the violence, what risk factors are present but also what help-seeking strategies has the victim used – what needs does she perceive exist – can she get access to community resources, what help might she need, etc.
  • Here are a list of the domestic violence resources available. I’ve given you the statewide hotline number as well as the programs serving your geographic area. All counties are served by a domestic violence program (some may be covered by more than one) and all provide some level of emergency shelter as well as additional services for victims.
  • Thanks for your time – questions/concerns?If you would like more information, here is my contact info.
  • Partner Violence and Children...How Should We Respond?-- Angie Boy, DrPh

    1. 1. 2nd Annual Conference September 4, 2013
    2. 2. Partner Violence and Children: How Should We Respond? Angie Boy, DrPH Stephanie V. Blank Center for Safe and Healthy Children
    3. 3. Children’s Healthcare of Atlanta Objectives • After this session, participants will be able to: – Define partner violence and child witnessing of violence – Identify three barriers to leaving a violent relationship – List three health effects on children who witness violence – List three behavioral effects on children who witness violence – Identify two ways to screen for family violence – List two community resources available for victims of family violence 3
    4. 4. Children’s Healthcare of Atlanta Scope of the Problem • 1 in 3 women and 1 in 4 men have experienced some form of violence from their intimate partner • Partner violence impacts between 4 and 8% of pregnant women in the US each year • Estimates indicate that more than 10 million children witness partner violence each year 4
    5. 5. Children’s Healthcare of Atlanta Definition of Partner Violence • Many different definitions • Most include physical abuse, psychological/emotional abuse, and sexual abuse • Prevalence rates will vary significantly between current, recent, and lifetime abuse • Pattern of behaviors 5
    6. 6. Children’s Healthcare of Atlanta Definition of Child Witnessing • Violence that occurs when children are present: – Can be auditory, visual or inferred – Includes cases where child sees aftermath of violence (physical injuries, damage to property, etc.) • Definition may vary by state statute 6
    7. 7. Children’s Healthcare of Atlanta 7 Domestic Violence Prevention Project, Duluth, MN
    8. 8. Children’s Healthcare of Atlanta Power and Control Tactics • Intimidation – making her afraid by using looks, actions and gestures; destroying property • Emotional Abuse – calling her names, playing mind games, humiliating her • Isolation – controlling who she sees, limiting outside involvement, using jealousy to justify actions • Minimizing/denying/blaming – making light of abuse, shifting responsibility, saying abuse didn’t happen 8
    9. 9. Children’s Healthcare of Atlanta Power and Control Tactics (2) • Using children – using children to relay messages, using visitation to harass her, threatening to take children away • Economic abuse – giving her an allowance, preventing her from getting or keeping job, not letting her know about family finances • Male privilege – treating her like a servant, being the one to define men’s and women’s roles • Coercion and threats – threatening to leave or commit suicide, making her do illegal things 9
    10. 10. Children’s Healthcare of Atlanta Barriers to Leaving • “Why doesn’t she just leave?” • Primary barriers to her safety are external, not internal. • Batterer’s control is most significant obstacle to escape. 10
    11. 11. Children’s Healthcare of Atlanta What Makes Her Stay or Go Back? • Fear • Love • Promises • Self-blame, denial/minimization • Shame • Cultural/religious beliefs • Lack of money, affordable housing, transportation, places to go, job, etc. • Pressure to keep family together 11
    12. 12. Children’s Healthcare of Atlanta General Health Impacts • Injuries • Chronic pain • Headaches/migraines • Difficulty managing chronic conditions • Anxiety • Sleep disturbances • Depression • Suicidal thoughts/actions 12
    13. 13. Children’s Healthcare of Atlanta Violence Before Pregnancy • Violence in a relationship can lead to unplanned pregnancies – 1 in 4 women report their partner either pressured them to become pregnant or sabotaged their birth control so they would become pregnant • Partner violence increases the risk for unintended/unplanned pregnancies two-fold 13
    14. 14. Children’s Healthcare of Atlanta Partner Violence During Pregnancy • Women who report violence during pregnancy or in the year prior are: – Less likely to receive early prenatal care – More likely to report smoking and alcohol use during pregnancy – More likely to experience depression and attempt suicide 14
    15. 15. Children’s Healthcare of Atlanta Complications During Pregnancy • Victims are at greater risk for: – High blood pressure (preeclampsia) – Vaginal bleeding – Severe nausea, vomiting, dehydration – Urinary tract infections, kidney infections – Delivering an infant requiring intensive care unit stay • Women experiencing physical abuse during pregnancy are 2.7 times more likely to have a pregnancy-related hospitalization than non- victims 15
    16. 16. Children’s Healthcare of Atlanta 16 Homicide is the second leading cause of injury-related deaths among pregnant women. A significant proportion of all female homicide victims are killed by their intimate partners.
    17. 17. Children’s Healthcare of Atlanta Impact on Infants • Partner violence is associated with: – Lower gestational weight gain – Low birth-weight and very low birth-weight – Pre-term delivery • Mothers who experience partner violence during pregnancy have lower maternal attachment to their infant 17
    18. 18. Children’s Healthcare of Atlanta Impact on Infants (2) • Infants born to moms who are abused during pregnancy are at greater risk for death • Children of moms who disclose abuse are: – Less likely to be breastfed – Less likely to have 5 well-child visits in 1st year – Less likely to be fully immunized by age 2 18
    19. 19. Children’s Healthcare of Atlanta General Health Impact on Children • Sleep disturbances • Stomach problems • Headaches • Lack of bladder/bowel control • Depression, anxiety, somatic complaints 19
    20. 20. Children’s Healthcare of Atlanta Impacts on Younger Children (1-5) • Insecurity, anxiety, disorganized attachment behavior • Altered neurobiology of brain related to alarm response • Reduced capacity to feel emotion • Inability to relax • Reduced capacity to self-soothe • Loss of acquired language and other skills • Speech, cognitive, auditory processing delays 20
    21. 21. Children’s Healthcare of Atlanta Impacts on Older Children (6-11) • Struggle with school rules, relationships, classroom instruction • Increased absences from school • Lower IQ scores, poorer language skills, problems with attention and memory • Obvious anxiety, fearfulness and loss of self- esteem • Acting out, risk-taking behaviors • Distorted perception of self and others • Aggressive, explicit relating or engaging with other children 21
    22. 22. Children’s Healthcare of Atlanta Impacts on Adolescents • Early acquisition of caretaker role (protecting mom) • Poorly developed family skills • Increased parent-child conflicts (may result in more violence) • Susceptible to high-risk behaviors (drug use, theft, etc.) • Use of control or violence in dating relationships • Pregnancy to escape and create support system • Immature brain development • Externalizing problems (aggressive behavior) 22
    23. 23. Children’s Healthcare of Atlanta Ways Partner Violence Can Impact Parenting • Moms who experience partner violence are more likely to have maternal depressive symptoms and report harsher parenting • Mothers who report experiencing abuse report problems with parenting including: – Being afraid to discipline – Letting children make the rules – Feeling disconnected to their child 23
    24. 24. Children’s Healthcare of Atlanta Partner Violence and Child Abuse Link • A national survey found that over 50% of men who frequently assaulted their wives also abused their children • A review of child protection cases in two states found that domestic violence was present in 41- 43% of cases where severe injury or death of a child was present • Victims may be more likely to maltreat their children in response to threats of abuse by abuser 24
    25. 25. Children’s Healthcare of Atlanta Partner Violence and Child Abuse Link (2) • In one study, domestic violence preceded child abuse in 78% of cases where DV and child abuse were co-occurring • Families with DV occurring are two times as likely to have a substantiated claim of child abuse compared to families without DV 25
    26. 26. Children’s Healthcare of Atlanta Resiliency • Some mothers who face severe stress may compensate by offering increased nurturing and protection for their children • Child’s emotional recovery depends more on the quality of relationship with non-battering parent than any other single factor • Early identification/referral is key! 26
    27. 27. Children’s Healthcare of Atlanta Why it Matters to Organizations Working with Kids • Majority of victims of partner violence are not bad, ineffective, or abusive parents – many are supportive, nurturing parents who attempt to mediate the effects of abuse • Victims need access to resources to assist them in overcoming the barriers to leaving discussed earlier 27
    28. 28. Children’s Healthcare of Atlanta Why it Matters (2) • Safety of mom is linked to safety of children – addressing child abuse without addressing safety of mom won’t solve problems • Early identification is key to achieving safe outcomes for adult and child victims • Screening is a key part of early identification 28
    29. 29. Children’s Healthcare of Atlanta Recommendations • All child-serving organizations should screen/assess for the potential of family violence • Each organization should have resource list of local DV services available • As appropriate, post flyers, posters, etc. in public waiting areas • Build relationships with local organizations providing family violence services 29
    30. 30. Children’s Healthcare of Atlanta Sample Screening Questions • Could you tell me about your relationship with your partner? • All couples argue. How do you and your partner argue? • Has there been a time when you felt afraid of your partner? If so, can you tell me what happened? • Does your partner ever act jealous or possessive of you? 30
    31. 31. Children’s Healthcare of Atlanta Assessments • Assessments help determine recommendations for the family – assessments should include: – Nature and extent of partner violence – Elapsed time since exposure – Impact of violence on adults and children – Risk and protective factors of the victim and children – Help-seeking and survival strategies of the victim – Perpetrator’s level of dangerousness – Safety and service needs of the family – Availability of community resources 31
    32. 32. Children’s Healthcare of Atlanta Safety Planning • Child Safety Planning: – Violence NOT their fault – Keep yourself safe, call 911 – Talk with an adult they can trust • Adult Safety Planning: – Create list of trusted adults – Create a plan in case of emergency (where to go, who to contact, emergency money, keys, etc.) – List of family violence resources 32
    33. 33. Children’s Healthcare of Atlanta Community Domestic Violence Resources Statewide Hotline: 1-800-33-HAVEN (4-2836) To find a domestic violence organization in your area or other related resources, visit 33
    34. 34. Children’s Healthcare of Atlanta Bibliography Bair-Merritt M. Intimate Partner Violence. Pediatrics in Review. 2010; 31(4):145-150. Bauer N, Gilbert A, Carroll A, Downs S. Associations of Early Exposure to Intimate Partner Violence and Parental Depression with Subsequent Mental Health Outcomes. JAMA Pediatr. 2013; 167(4): 341-347. Borowsky I, Ireland M. Parental Screening for Intimate Partner Violence by Pediatricians and Family Physicians. Pediatrics. 2012; 110(3):509-516. Campbell K, Thomas A, Cook L, Keenan H. Resolution of Intimate Partner Violence and Child Behavior Problems After Investigation for Suspected Child Maltreatment. JAMA Pediatr. 2013; 167(3):236-242. Casanueva C, Martin S, Runyan D. Repeated Reports for Child Maltreatment Among Intimate Partner Violence Victims: Findings from the National Survey of Child and Adolescent Well-Being. Child Abuse and Neglect. 2009;33:84-93. 34
    35. 35. Children’s Healthcare of Atlanta Bibliography (2) Ellen S, Taylor D, Cruz M. Behind the Screen: Responding to Intimate Partner Violence. Pediatrics in Review. 2012;33(8): 374-375. Guedes A, Mikton C. Examining the Intersections Between Child Maltreatment and Intimate Partner Violence. Western Journal of Emergency Medicine. 2013; 14(4):377-379. Impact of Exposure to Violence on Stages of Development. Safe Start Center. North Bethesda, MD. Available at: exposure-violence-on-dev.pdf. Accessed August 14, 2013. Lamers-Winkelman F, Willemen A, Visser M. Adverse Childhood Experiences of Referred Children Exposed to Intimate Partner Violence: Consequences for their Wellbeing. Child Abuse and Neglect. 2012;36:166-179. Thackeray J, Hibbard R, Dowd D. The Committee on Child Abuse and Neglect, the Committee on Injury, Violence and Poison Prevention. Clinical Report – Intimate Partner Violence: The Role of the Pediatrician. Pediatrics. 2010;125(5):1094-1100. 35
    36. 36. Children’s Healthcare of Atlanta More Information Angie Boy, DrPH Program Manager Stephanie V. Blank Center for Safe and Healthy Children 404-785-7429 36
    37. 37. This project was supported in part by the Governor’s Office for Children and Families through the U.S. Department of Health and Human Services, Administration for Children and Families, Community Based Child Abuse Prevention and Treatment Act (CFDA 93.590). Points of view or opinions stated in this document are those of the author(s) and do not necessarily represent the official position or policies of the Governor’s Office for Children and Families or the U.S. Department of Health and Human Services, Administration for Children and Families, Community Based Child Abuse Prevention and Treatment Act (CFDA 93.590)."