Systems of Care Among Children Exposed to Intimate Partner

Violence (IPV)

James M. DeCarli, MPA, MPH, CHESResearch Analyst III/Behavioral Sciences

Los Angeles County, Department of Public Health, Injury & Violence Prevention Program

Part I:Background on Intimate Partner Violence (IPV)Existing Child Protective Service (CPS) SystemMental Health Impact of Children Exposed to IPVProblems IdentifiedBarriers to ChangeIdeal System

Overview

Part II:Organizational Diagnosis of CPSCurrent System Revisited-Lessons LearnedRecommendationsEvaluation Plan

Overview

Background on IPV

IPV DEFINEDIntimate Partner Violence

Domestic ViolenceFamily ViolenceRelationship Violence

No uniform definition

A physical, sexual, or psychological harm to a person by a current or former partner or spouse (MMWR, 2005)

IPV Consists of:Physical violence Sexual violence Threats of physical or sexual violence

Perpetrator & Victim

Perpetrator: More often the husband, former husband, boyfriend, or ex-boyfriend (90%)Sometimes the abuser is female (10-40%)

Victim: MotherChild

Intimate Partner Violence (IPV)

Intimate Partner Violence (IPV) is a serious, preventable public health problem affecting more than 32 million Americans (Tjaden and Thoennes 2000)

5.3 million incidents of IPV occur each year among U.S. women ages 18 and older

3.2 million occur among men ages 18 and older

Cycle of Violence

Behavioral PhasesCycle of Violence

Repeated Cycles of Violence

Repeat stress: fear anxiety, PTSD, and depression in those exposed to IPV cycles. (Margarinos, 1997).

fMRI studies have linked abuse, PTSD and neuronal loss (DeBellis et al, 2000)

Those exposed to IPV share common behavioural outcomes of those observed who have hippocampal and amygdala lesions, such as impulsive behaviours, misperceived emotions, and aggression (Margarinos, 1997).

Health Effects of IPV Victimization

Increased mortality (CDC, 2000)30-40% women killed

Increased psychological and physical effects

Psychopathology

Depressive symptoms & disordersPosttraumatic stress disorder (PTSD)Anxiety symptoms & disordersLow self-esteemSubstance abuse disordersHopelessness & helplessnessSuicidal behavior

Physical Morbidity

Physical injuriesChronic body painSleep & appetite disturbancesMiscarriage or abortionDisfigurement or disabilityRecurrent vaginal infections (i.e. STD’s)Other Complaints (Cardiac, gynecological, etc.)

Childhood Exposure to IPV

3.3 million to 10 million in U.S. per year (Fantuzzo, 1999; Carlson, 1984)

Depending on:Specific definition of witnessing violence The source of interviewThe age of child included in the survey

Occurs when children sees, is aware of, or hear physical or verbal assaults or threats between their parents/dating partners or other family members, or observe its effects

Term Used to Describe Childhood Exposure to IPV

Child abuse and maltreatmentPhysical child abuseIncest and child sexual abusePsychological maltreatment

Verbal and emotional abuseChild neglectChild exposure to violence in the home

ParentsSiblingsOther family members

(National Center for Child Abuse and Neglect)

Childhood Exposure to IPV

Children observe IPV to varying degrees:Home Environment:

May see mothers use violence in self-defense or see both parents trading self-defense See parents occasionally slap, shove, and throw thingsSome see severe violence or threats, but the victim does not leave the home where not reported to police or public agencies

(Straus & Gelles, 1990)

A child’s experience with domestic violence

(Obtained with permission, Penn State, Milton S. Hershey Medical Center, College of Medicine)

Case Review: IPV-Related FatalityMother has custody of her 6yo child (from a former relationship)

Live-in boyfriend (had no past convictions-common)Boyfriend had moved out (request of the mother) Mother experienced 1-year of stalking/threats to kill mother and child (common)

Several months prior to the fatality the boyfriend broke down the door of the mothers house, as she would not let him in

Police were called

Mother failed to report (to protect him)

Police reported case to DCFS since child was present at the time and the mother refused to press charges or allow police know of his residence

DCFS ordered the mother to file restraining order or risk child removal

Mother filled restraining order

Case ReviewBoyfriend actions:

Violated the restraining order several timesThe mother did not report the boyfriend to protect his resident status

At times would become depressedMother allow him in her home due to his sadness

Continued to stalk and harass the mother

Finally the mother stopped all contacts with the ex-boyfriend and ordered him to stop calling and seeing her

The following incident occurred 2-days later

A Child’s 911 call during a domestic dispute

(Obtained with permission, Penn State, Milton S. Hershey Medical Center, College of Medicine)

Case Review Debriefing

Symptoms of Children Exposed to IPV

29 different studies of children who witnessed IPV

BehavioralEmotionalSocialCognitivePhysical

(Kolbo, Blakely, & Engleman, 1996)

Behavioral EffectsAggressionTantrums "acting out" ImmaturityTruancy and Delinquency

(Davies, 1991; Dodge, Pettit, & Bates, 1994; Graham-Bermann, 1996c; Hershorn & Rosenbaum, 1985; Hughes & Barad, 1983; Jouriles, Murphy, & O'Leary, 1989; Sternberg, Lamb, Greenbaum, Cicchetti, Dawud, Cortes, et al., 1993)

Emotional EffectsAnxietyAngerDepressionWithdrawal Low self-esteem

(Carlson, 1990; Davis & Carlson, 1987; Graham-Bermann, 1996c; Hughes, 1988; Jaffe, Wolfe, Wilson, & Zak, 1986)

Social Effects

Poor social skillsPeer rejectionInability to empathize with others

(Graham-Bermann, 1996c; Strassberg & Dodge, 1992)

Cognitive Effects

Language lagDevelopmental delaysPoor school performance

(Kerouac, Taggart, Lescop, & Fortin, 1986; Wildin, Williamson, & Wilson, 1991).

Physical Effects

Failure to thriveProblems sleepingEating problemsRegressive behaviorsPoor motor skills, and Psychosomatic symptoms (eczema, bed wetting, etc.)

(Jaffe, et al., 1990; Layzer, Goodson, & Delange, 1986)

Specific Signs & Symptoms by Age

Toddler/Preschooler (<5)

Aware of their environmentSleeping & Eating DisordersSomatic Complaints

StomachachesHeadaches

Separation Anxiety (clinging to mother/victim)Speech, motor skill & cognitive delaysDepression & anxietyDifficulty in expressing emotions-but anger

(National Resource Center on Domestic Violence, 2002)

Specific Signs & Symptoms by AgeChildhood (5-12)

Poor in School-Exhibit few options/low successSelf esteem limitations

Frequent mood swingsErratic attendanceInability to concentrate

Poor social skillsConflicts with classmates & teachers

Excel in School-Try to overcome & suppress family dysfunctionSeek approval by doing well in structured school environment

Perfect studentMaking many friends

However:Live with unpredictable home environmentsConflict-loving/hating their parentsExperience guilt, depression, sadness, powerlessnessUnable to relax/sleepSigns of PTSD

(National Resource Center on Domestic Violence, 2002)

Specific Signs & Symptoms by Age

Adolescence (13-17)

Eating difficulties resulting in anorexia, bulimia, or obesityAcademic difficulties-leading to dropping outFeeling powerless, fear, delinquency, substance abuse, suicideIntimate partner relationships

Without proper intervention-exhibit sex roles and communication patterns learned from dysfunctional home environment-contributing to the generational cycle of violence

(National Resource Center on Domestic Violence, 2002)

Reporting LawsIPVChild Abuse

CPS Case Report Process Community Professional Roles & ResponsibilityServices for Victims of IPV

Existing System

Reporting Law-IPVCalifornia Screening Law (1995)

Health and Professionals Code ξξ1233.5, 1259.5Requires screening protocols and practices for California’s licensed clinics and hospitals]

California Penal Code, Section 11160 mandates:That a healthcare professional call the local law enforcement agency by telephone immediately or as quickly as possibleBe familiar with their specific hospital, clinic, or HMO/PPO policies and procedures regarding reporting formsReporting forms must be completed and mailed to law enforcement within 48-hours

Reporting Law-Child AbuseCal Penal Code §§, 11 164-11174.3. The California Child Abuse and Neglect Reporting Act (CANRA):

Requires mandated reporters to report known or suspected instances of child abuse or neglect to law enforcement (includes “emotional maltreatment-child exposed to IPV)

Two reports are required:Report by telephone immediately to local law enforcementFile a written report within 36 hours of receiving information regarding the incident

CPS Case Report ProcessReport

Intake

InitialAssessment

Family Assessment

Case Planning

Case Management & Treatment

Evaluation of Family Progress

Case Closure

Referral

Stage 1: ReportMandated reporter, reports incident to CPS

Stage 2: IntakeDetermine appropriateness of the reportDoes the reported case meets agency guidelines for child maltreatment?How urgent is the referral? (i.e. high –risk respond immediately or within 24-hours)

Stage 3: Initial AssessmentCPS caseworker and law enforcement determine:

Validity of the child maltreatment reportAssess risk of maltreatmentDetermine safety of the child and need for further intervention

Medical, Mental health, and other community providers also involved

CPS Case Report Process

Stage 4: Family AssessmentCPS caseworker, community treatment providers, and family reach understanding on the most critical treatment needs to be addressed

Stage 5: Case PlanningCPS caseworker and other treatment providers develop a case plan with family members

Stage 6: Case Management & TreatmentImplementation of case plan-outcomes, goals, strategies to change the conditions and behaviors that results in child abuse and neglect

CPS Case Report Process

Stage 7: Evaluation & of Family ProgressCPS caseworker & other treatment providers evaluate and measure:

Changes in the family behaviors and conditions that led to child abuse and neglectMonitor the risk elimination/reductionDetermine when services are no longer necessary

Stage 8: Case ClosureBased upon evaluation identifying risk elimination, the CPS caseworker closes the case

CPS Case Report Process

Community Professional Roles & Responsibilities

ID/Report

Intake IntakeAssess

FamilyAssess

CasePlng

CaseMgt

Treatment EvalFamily Pgm

Case Closure

CPS

Healthcare

Mental Health

Education

Legal

Law Enf.

Support Services

Lead-Initiating actionProvides advising to support lead actionProvides input under specific function

Services for Victims of IPV

Women’s SheltersCriminal Justice System

Problems Identified with SystemLimited mental health services for children

CPS does not provide adequate (U.S. Advisory Board on Child Abuse and Neglect)

ProtectionTreatmentprevention

LA area High School surveys (National Child Traumatic Stress Network, 2004)Large percentage of significant trauma history, high levels of traumatic stress symptoms and impaired functionNever received assessment or treatment

Inadequate Screening (English, Edleson & Herrick, 2005; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004)Law Enforcement

Law enforcement leaders have questioned their own responses to children who are present when police respond to adult domestic assault reports (International Association of Chiefs of Police, 1997)

Lack of Screening ToolsFamily Worries Scale Graham-Bermann (1996) Children’s Perception of Interparental Conflict Scale (Grych, Seid, & Fincham, 1992)

Problems Identified with System

Inadequate Investigation (English, Edleson & Herrick, 2005; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004)

Criminal justice systemJuvenile and family courts struggle to understand and assess the significance of child exposure when making decisions concerning custody and visitation (Jaffe, Lemon & Poisson, 2003; Kernic, Monary-Ernsdorff, Koepsell & Holt, 2005).

Barriers to Change(Provider)

Lack of education and training (Rodriguez, 1999; Sugg, 1992, 1999)

A belief that patient will be offended by screening (Sugg, 1992, 1999)

Personal discomfort from having a personal history of exposure to abuse and interpersonal violence (Sugg, 1992)

Belief and/or experience that patients will not disclose intimate partner violence (Rodriguez, 1999; Gerbert, 1999)

Lack of time to screen and respond (Rodriguez, 1999; Gerbert, 1999; Sugg 1992)

Belief of a "medical" model of care-provider does not include addressing intimate partner violence (Warshaw, 1989; Parsons, 1995; Warshaw, 1996)

Barriers to Change(Patient)

Perpetrator directly preventing access to care (McCauley, 1998)

Socioeconomic barriers to accessing care (Rodriguez 1996)

Low self-esteem and a feeling of shame (McCauley, 1998; Rodriguez 1996; Gerbert 1996)

Fear of retaliation from perpetrator (McCauley, 1998; Gerbert 1999; Gerbert, 1996)

Sense of family responsibilities and fear of loss of custody (Rodriguez 1996)

Provider appearing too busy or treating the patient negatively (Plitchta 1996; McCauley 1998; Sugg 1999, Gerbert 1996)

Fear of consequences of mandatory reporting or police involvement (Rodriguez 1996)

Barriers to Change(Institutional)

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

Ideal System

Improved mental health services for childrenDeveloped & evaluated screening tool for exposure to violenceProvider/schools/faith groups trained Community Awareness on IPV ImprovedImproved Access to Care

Part II

Organizational Diagnosis of CPS SystemCurrent System Revisited-Lessons LearnedRecommendationsEvaluation Plan

Organizational Diagnosis of CPS System

ProviderLaw EnforcementDV ShelterSchoolChild Abuse Hotline

Current System Revisited-Lessons Learned

Gaps:ProblemsBarriers to Change

Recommendations

Improved mental health services for childrenDeveloped & evaluated screening tool for exposure to violenceProvider/schools/faith groups trained Community Awareness on IPV ImprovedImproved Access to Care

Summary

Contact InformationJames M. DeCarli

jdecarli@ph.lacounty.gov

(213) 351-7846