The document discusses systems of care for children exposed to intimate partner violence. It covers: 1) Background on intimate partner violence and its impact on children's mental health and development. Existing child protection systems are described as having limited mental health services and inadequate screening/investigation. 2) Barriers to improving care including a lack of provider training, patient barriers to disclosure, and insufficient institutional support/resources. 3) The ideal system would provide improved mental health services for children, develop screening tools, train providers/communities, and improve access to care. Further organizational assessment of relevant agencies and an evaluation plan are proposed.

1. Systems of Care Among Children
Exposed to Intimate Partner
Violence (IPV)
James M. DeCarli, MPA, MPH, CHES
Research Analyst III/Behavioral Sciences
Los Angeles County, Department of Public Health,
Injury & Violence Prevention Program

2. Overview
Part I:
Background on Intimate Partner Violence (IPV)
Existing Child Protective Service (CPS) System
Mental Health Impact of Children Exposed to IPV
Problems Identified
Barriers to Change
Ideal System

3. Overview
Part II:
Organizational Diagnosis of CPS
Current System Revisited-Lessons Learned
Recommendations
Evaluation Plan

4. Background on IPV

5. IPV DEFINED
Intimate Partner Violence
Domestic Violence
Family Violence
Relationship Violence
No uniform definition
A physical, sexual, or psychological harm to a person by
a current or former partner or spouse (MMWR, 2005)
IPV Consists of:
Physical violence
Sexual violence
Threats of physical or sexual violence

6. Perpetrator & Victim
Perpetrator:
More often the husband, former husband,
boyfriend, or ex-boyfriend (90%)
Sometimes the abuser is female (10-40%)
Victim:
Mother
Child

7. Intimate Partner Violence (IPV)
Intimate Partner Violence (IPV) is a
serious, preventable public health problem
affecting more than 32 million Americans
(Tjaden and Thoennes 2000)
5.3 million incidents of IPV occur each year
among U.S. women ages 18 and older
3.2 million occur among men ages 18 and
older

8. Cycle of Violence

9. Behavioral Phases
Cycle of Violence

10. Repeated Cycles of Violence
Repeat stress: fear anxiety, PTSD, and depression in those exposed
to IPV cycles. (Margarinos, 1997).
fMRI studies have linked abuse, PTSD and neuronal loss (DeBellis
et al, 2000)
Those exposed to IPV share common behavioural outcomes of
those observed who have hippocampal and amygdala lesions, such
as impulsive behaviours, misperceived emotions, and aggression
(Margarinos, 1997).

11. Health Effects of IPV Victimization
Increased mortality (CDC, 2000)
30-40% women killed
Increased psychological and physical
effects

12. Psychopathology
Depressive symptoms & disorders
Posttraumatic stress disorder (PTSD)
Anxiety symptoms & disorders
Low self-esteem
Substance abuse disorders
Hopelessness & helplessness
Suicidal behavior

13. Physical Morbidity
Physical injuries
Chronic body pain
Sleep & appetite disturbances
Miscarriage or abortion
Disfigurement or disability
Recurrent vaginal infections (i.e. STD’s)
Other Complaints (Cardiac, gynecological,
etc.)

14. Childhood Exposure to IPV
3.3 million to 10 million in U.S. per year (Fantuzzo, 1999;
Carlson, 1984)
Depending on:
Specific definition of witnessing violence
The source of interview
The age of child included in the survey
Occurs when children sees, is aware of, or hear
physical or verbal assaults or threats between
their parents/dating partners or other family
members, or observe its effects

15. Term Used to Describe
Childhood Exposure to IPV
Child abuse and maltreatment
Physical child abuse
Incest and child sexual abuse
Psychological maltreatment
Verbal and emotional abuse
Child neglect
Child exposure to violence in the home
Parents
Siblings
Other family members
(National Center for Child Abuse and Neglect)

16. Childhood Exposure to IPV
Children observe IPV to varying degrees:
Home Environment:
May see mothers use violence in self-defense or
see both parents trading self-defense
See parents occasionally slap, shove, and throw
things
Some see severe violence or threats, but the
victim does not leave the home where not reported
to police or public agencies
(Straus & Gelles, 1990)

17. A child’s experience
with domestic violence
(Obtained with permission, Penn State, Milton S. Hershey Medical Center, College of Medicine)

18. Case Review: IPV-Related Fatality
Mother has custody of her 6yo child (from a former relationship)
Live-in boyfriend (had no past convictions-common)
Boyfriend had moved out (request of the mother)
Mother experienced 1-year of stalking/threats to kill mother and
child (common)
Several months prior to the fatality the boyfriend broke down the door
of the mothers house, as she would not let him in
Police were called
Mother failed to report (to protect him)
Police reported case to DCFS since child was present at the time and
the mother refused to press charges or allow police know of his
residence
DCFS ordered the mother to file restraining order or risk child removal
Mother filled restraining order

19. Case Review
Boyfriend actions:
Violated the restraining order several times
The mother did not report the boyfriend to protect his resident status
At times would become depressed
Mother allow him in her home due to his sadness
Continued to stalk and harass the mother
Finally the mother stopped all contacts with the ex-boyfriend and
ordered him to stop calling and seeing her
The following incident occurred 2-days later

20. A Child’s 911 call
during a domestic dispute
(Obtained with permission, Penn State, Milton S. Hershey Medical Center, College of Medicine)

21. Case Review Debriefing

22. Symptoms of Children Exposed
to IPV
29 different studies of children who
witnessed IPV
Behavioral
Emotional
Social
Cognitive
Physical
(Kolbo, Blakely, & Engleman, 1996)

23. Behavioral Effects
Aggression
Tantrums
"acting out"
Immaturity
Truancy and
Delinquency
(Davies, 1991; Dodge, Pettit, & Bates, 1994; Graham-Bermann, 1996c;
Hershorn & Rosenbaum, 1985; Hughes & Barad, 1983; Jouriles, Murphy, &
O'Leary, 1989; Sternberg, Lamb, Greenbaum, Cicchetti, Dawud, Cortes, et
al., 1993)

24. Emotional Effects
Anxiety
Anger
Depression
Withdrawal
Low self-esteem
(Carlson, 1990; Davis & Carlson, 1987; Graham-Bermann, 1996c; Hughes,
1988; Jaffe, Wolfe, Wilson, & Zak, 1986)

25. Social Effects
Poor social skills
Peer rejection
Inability to empathize with others
(Graham-Bermann, 1996c; Strassberg & Dodge, 1992)

26. Cognitive Effects
Language lag
Developmental delays
Poor school performance
(Kerouac, Taggart, Lescop, & Fortin, 1986; Wildin, Williamson, & Wilson, 1991).

27. Physical Effects
Failure to thrive
Problems sleeping
Eating problems
Regressive behaviors
Poor motor skills, and
Psychosomatic symptoms (eczema, bed
wetting, etc.)
(Jaffe, et al., 1990; Layzer, Goodson, & Delange, 1986)

28. Specific Signs & Symptoms by Age
Toddler/Preschooler (<5)
Aware of their environment
Sleeping & Eating Disorders
Somatic Complaints
Stomachaches
Headaches
Separation Anxiety (clinging to mother/victim)
Speech, motor skill & cognitive delays
Depression & anxiety
Difficulty in expressing emotions-but anger
(National Resource Center on Domestic Violence, 2002)

29. Specific Signs & Symptoms by Age
Childhood (5-12)
Poor in School-Exhibit few options/low success
Self esteem limitations
Frequent mood swings
Erratic attendance
Inability to concentrate
Poor social skills
Conflicts with classmates & teachers
Excel in School-Try to overcome & suppress family dysfunction
Seek approval by doing well in structured school environment
Perfect student
Making many friends
However:
Live with unpredictable home environments
Conflict-loving/hating their parents
Experience guilt, depression, sadness, powerlessness
Unable to relax/sleep
Signs of PTSD
(National Resource Center on Domestic Violence, 2002)

30. Specific Signs & Symptoms by Age
Adolescence (13-17)
Eating difficulties resulting in anorexia, bulimia, or
obesity
Academic difficulties-leading to dropping out
Feeling powerless, fear, delinquency, substance
abuse, suicide
Intimate partner relationships
Without proper intervention-exhibit sex roles and
communication patterns learned from dysfunctional home
environment-contributing to the generational cycle of violence
(National Resource Center on Domestic Violence, 2002)

31. Existing System
Reporting Laws
IPV
Child Abuse
CPS Case Report Process
Community Professional Roles &
Responsibility
Services for Victims of IPV

32. Reporting Law-IPV
California Screening Law (1995)
Health and Professionals Code ξξ1233.5, 1259.5
Requires screening protocols and practices for California’s licensed
clinics and hospitals]
California Penal Code, Section 11160 mandates:
That a healthcare professional call the local law enforcement
agency by telephone immediately or as quickly as possible
Be familiar with their specific hospital, clinic, or HMO/PPO policies
and procedures regarding reporting forms
Reporting forms must be completed and mailed to law enforcement
within 48-hours

33. Reporting Law-Child Abuse
Cal Penal Code §§, 11 164-11174.3. The
California Child Abuse and Neglect Reporting
Act (CANRA):
Requires mandated reporters to report known or
suspected instances of child abuse or neglect to law
enforcement (includes “emotional maltreatment-child
exposed to IPV)
Two reports are required:
Report by telephone immediately to local law enforcement
File a written report within 36 hours of receiving information
regarding the incident

34. CPS Case Report Process
Report
Intake
Referral
Initial
Assessment
Family
Assessment
Case Planning
Case Management
& Treatment
Evaluation of
Family Progress
Case Closure

35. CPS Case Report Process
Stage 1: Report
Mandated reporter, reports incident to CPS
Stage 2: Intake
Determine appropriateness of the report
Does the reported case meets agency guidelines for child
maltreatment?
How urgent is the referral? (i.e. high –risk respond immediately
or within 24-hours)
Stage 3: Initial Assessment
CPS caseworker and law enforcement determine:
Validity of the child maltreatment report
Assess risk of maltreatment
Determine safety of the child and need for further intervention
Medical, Mental health, and other community providers also
involved

36. CPS Case Report Process
Stage 4: Family Assessment
CPS caseworker, community treatment providers,
and family reach understanding on the most critical
treatment needs to be addressed
Stage 5: Case Planning
CPS caseworker and other treatment providers
develop a case plan with family members
Stage 6: Case Management & Treatment
Implementation of case plan-outcomes, goals,
strategies to change the conditions and behaviors
that results in child abuse and neglect

37. CPS Case Report Process
Stage 7: Evaluation & of Family Progress
CPS caseworker & other treatment providers evaluate
and measure:
Changes in the family behaviors and conditions that led to
child abuse and neglect
Monitor the risk elimination/reduction
Determine when services are no longer necessary
Stage 8: Case Closure
Based upon evaluation identifying risk
elimination, the CPS caseworker closes the case

38. Community Professional Roles & Responsibilities
ID/ Intake Intake Family Case Case Treatment Eval Case
Report Assess Assess Plng Mgt Family Pgm Closure
CPS
Healthcare
Mental
Health
Education
Legal
Law Enf.
Support
Services
Lead-Initiating action
Provides advising to support lead action
Provides input under specific function

39. Services for Victims of IPV
Women’s Shelters
Criminal Justice System

40. Problems Identified with System
Limited mental health services for children
CPS does not provide adequate (U.S. Advisory Board on Child Abuse and
Neglect)
Protection
Treatment
prevention
LA area High School surveys (National Child Traumatic Stress Network, 2004)
Large percentage of significant trauma history, high levels of traumatic stress symptoms
and impaired function
Never received assessment or treatment
Inadequate Screening (English, Edleson & Herrick, 2005; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004)
Law Enforcement
Law enforcement leaders have questioned their own responses to children who are
present when police respond to adult domestic assault reports (International Association
of Chiefs of Police, 1997)
Lack of Screening Tools
Family Worries Scale Graham-Bermann (1996)
Children’s Perception of Interparental Conflict Scale (Grych, Seid, & Fincham,
1992)

41. Problems Identified with System
Inadequate Investigation (English, Edleson & Herrick,
2005; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004)
Criminal justice system
Juvenile and family courts struggle to understand
and assess the significance of child exposure when
making decisions concerning custody and visitation
(Jaffe, Lemon & Poisson, 2003; Kernic, Monary-
Ernsdorff, Koepsell & Holt, 2005).

42. Barriers to Change
(Provider)
Lack of education and training (Rodriguez, 1999; Sugg, 1992, 1999)
A belief that patient will be offended by screening (Sugg, 1992,
1999)
Personal discomfort from having a personal history of
exposure to abuse and interpersonal violence (Sugg, 1992)
Belief and/or experience that patients will not disclose
intimate partner violence (Rodriguez, 1999; Gerbert, 1999)
Lack of time to screen and respond (Rodriguez, 1999; Gerbert, 1999; Sugg
1992)
Belief of a "medical" model of care-provider does not
include addressing intimate partner violence (Warshaw, 1989;
Parsons, 1995; Warshaw, 1996)

43. Barriers to Change
(Patient)
Perpetrator directly preventing access to care (McCauley, 1998)
Socioeconomic barriers to accessing care (Rodriguez 1996)
Low self-esteem and a feeling of shame (McCauley, 1998;
Rodriguez 1996; Gerbert 1996)
Fear of retaliation from perpetrator (McCauley, 1998; Gerbert 1999;
Gerbert, 1996)
Sense of family responsibilities and fear of loss of custody
(Rodriguez 1996)
Provider appearing too busy or treating the patient
negatively (Plitchta 1996; McCauley 1998; Sugg 1999, Gerbert 1996)
Fear of consequences of mandatory reporting or police
involvement (Rodriguez 1996)

44. Barriers to Change
(Institutional)
Lack of training of healthcare personnel
multiple research issues, including a remarkably large number of crucial
unanswered questions;
lack of uniform or standard definitions used in the field of intimate partner violence
research;
lack of funding for research on violence, especially violence against women;
lack of societal resources for treatment and prevention of intimate partner violence
for both victims and perpetrators;
numerous legal issues, including mandatory healthcare reporting laws that do not
require patient consent, insurance discrimination against victims and survivors of
intimate partner violence, lack of privacy protections of the medical records of
victims/survivors of intimate partner violence, lack of legal requirements for
education about violence for licensure of medical personnel, and lack of legal
incentives for development of healthcare-based programs;
lack of sufficient diagnostic and procedural codes for violence;
lack of reimbursement for intimate partner violence-related services;
lack of financial and other support for development of violence screening and
treatment programs. Enhancement of screening and treatment by providers and
healthcare systems may require a number of different, concurrent approaches that
directly address provider, patient, and institutional barriers.

45. Ideal System
Improved mental health services for
children
Developed & evaluated screening tool for
exposure to violence
Provider/schools/faith groups trained
Community Awareness on IPV Improved
Improved Access to Care

46. Part II
Organizational Diagnosis of CPS System
Current System Revisited-Lessons
Learned
Recommendations
Evaluation Plan

47. Organizational Diagnosis of CPS
System
Provider
Law Enforcement
DV Shelter
School
Child Abuse Hotline

48. Current System Revisited-Lessons
Learned
Gaps:
Problems
Barriers to Change

49. Recommendations
Improved mental health services for
children
Developed & evaluated screening tool for
exposure to violence
Provider/schools/faith groups trained
Community Awareness on IPV Improved
Improved Access to Care

50. Summary

51. Contact Information
James M. DeCarli
jdecarli@ph.lacounty.gov
(213) 351-7846