Behaviors of children exposed to intimate partner violence before and 1 year after a treatment program for their mother

A literature review: Qualitative studies of women parenting during abuse

Many women worldwide are physically and emotionally abused, and their children are exposed to violence as well, resulting in what has become a worldwide epidemic. The Millennium Development Goals Report 2013 adopted through the United Nations' Development Program recognizes the continued need for global efforts to empower women, reduce child mortality, and improve child health. This literature review of women's experiences while parenting during abuse revealed the utilization of parenting strategies to parent their child(ren) effectively in the most difficult and traumatic of circumstances. Recommendations from all of the articles caution not to remove the child from the mother, but to give both mother and child tailored interventions and a compassionate and empathetic understanding of what these abused mothers' parenting experiences are.

IMPRoving Outcomes for children exposed to domestic ViolencE (IMPROVE): an evidence synthesis

Background

Exposure to domestic violence and abuse (DVA) during childhood and adolescence increases the risk of negative outcomes across the lifespan.

Objectives

To synthesise evidence on the clinical effectiveness, cost-effectiveness and acceptability of interventions for children exposed to DVA, with the aim of making recommendations for further research.

Design

(1) A systematic review of controlled trials of interventions; (2) a systematic review of qualitative studies of participant and professional experience of interventions; (3) a network meta-analysis (NMA) of controlled trials and cost-effectiveness analysis; (4) an overview of current UK provision of interventions; and (5) consultations with young people, parents, service providers and commissioners.

Settings

North America (11), the Netherlands (1) and Israel (1) for the systematic review of controlled trials of interventions; the USA (4) and the UK (1) for the systematic review of qualitative studies of participant and professional experience of interventions; and the UK for the overview of current UK provision of interventions and consultations with young people, parents, service providers and commissioners.

Participants

A total of 1345 children for the systematic review of controlled trials of interventions; 100 children, 202 parents and 39 professionals for the systematic review of qualitative studies of participant and professional experience of interventions; and 16 young people, six parents and 20 service providers and commissioners for the consultation with young people, parents, service providers and commissioners.

Interventions

Psychotherapeutic, advocacy, parenting skills and advocacy, psychoeducation, psychoeducation and advocacy, guided self-help.

Main outcome measures

Internalising symptoms and externalising behaviour, mood, depression symptoms and diagnosis, post-traumatic stress disorder symptoms and self-esteem for the systematic review of controlled trials of interventions and NMA; views about and experience of interventions for the systematic review of qualitative studies of participant and professional experience of interventions and consultations.

Data sources

MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, Applied Social Sciences Index and Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, Social Care Online, Sociological Abstracts, Social Science Citation Index, World Health Organization trials portal and clinicaltrials.gov.

Review methods

A narrative review; a NMA and incremental cost-effectiveness analysis; and a qualitative synthesis.

Results

The evidence base on targeted interventions was small, with limited settings and types of interventions; children were mostly < 14 years of age, and there was an absence of comparative studies. The interventions evaluated in trials were mostly psychotherapeutic and psychoeducational interventions delivered to the non-abusive parent and child, usually based on the child’s exposure to DVA (not specific clinical or broader social needs). Qualitative studies largely focused on psychoeducational interventions, some of which included the abusive parent. The evidence for clinical effectiveness was as follows: 11 trials reported improvements in behavioural or mental health outcomes, with modest effect sizes but significant heterogeneity and high or unclear risk of bias. Psychoeducational group-based interventions delivered to the child were found to be more effective for improving mental health outcomes than other types of intervention. Interventions delivered to (non-abusive) parents and to children were most likely to be effective for improving behavioural outcomes. However, there is a large degree of uncertainty around comparisons, particularly with regard to mental health outcomes. In terms of evidence of cost-effectiveness, there were no economic studies of interventions. Cost-effectiveness was modelled on the basis of the NMA, estimating differences between types of interventions. The outcomes measured in trials were largely confined to children’s mental health and behavioural symptoms and disorders, although stakeholders’ concepts of success were broader, suggesting that a broader range of outcomes should be measured in trials. Group-based psychoeducational interventions delivered to children and non-abusive parents in parallel were largely acceptable to all stakeholders. There is limited evidence for the acceptability of other types of intervention. In terms of the UK evidence base and service delivery landscape, there were no UK-based trials, few qualitative studies and little widespread service evaluation. Most programmes are group-based psychoeducational interventions. However, the funding crisis in the DVA sector is significantly undermining programme delivery.

Conclusions

The evidence base regarding the acceptability, clinical effectiveness and cost-effectiveness of interventions to improve outcomes for children exposed to DVA is underdeveloped. There is an urgent need for more high-quality studies, particularly trials, that are designed to produce actionable, generalisable findings that can be implemented in real-world settings and that can inform decisions about which interventions to commission and scale. We suggest that there is a need to pause the development of new interventions and to focus on the systematic evaluation of existing programmes. With regard to the UK, we have identified three types of programme that could be justifiably prioritised for further study: psycho-education delivered to mothers and children, or children alone; parent skills training in combination with advocacy: and interventions involving the abusive parent/caregiver. We also suggest that there is need for key stakeholders to come together to explicitly identify and address the structural, practical and cultural barriers that may have hampered the development of the UK evidence base to date.

Future work recommendations

There is a need for well-designed, well-conducted and well-reported UK-based randomised controlled trials with cost-effectiveness analyses and nested qualitative studies. Development of consensus in the field about core outcome data sets is required. There is a need for further exploration of the acceptability and effectiveness of interventions for specific groups of children and young people (i.e. based on ethnicity, age, trauma exposure and clinical profile). There is also a need for an investigation of the context in which interventions are delivered, including organisational setting and the broader community context, and the evaluation of qualities, qualifications and disciplines of personnel delivering interventions. We recommend prioritisation of psychoeducational interventions and parent skills training delivered in combination with advocacy in the next phase of trials, and exploratory trials of interventions that engage both the abusive and the non-abusive parent.

Study registration

This study is registered as PROSPERO CRD42013004348 and PROSPERO CRD420130043489.

Funding

The National Institute for Health Research Public Health Research programme.

Effectiveness of home visiting in reducing partner violence for families experiencing abuse: a systematic review

BACKGROUND

Intimate partner violence (IPV) against women is a major, global societal problem with enormous health consequences both for mother and child. Home visiting interventions in families at risk of abuse seem promising in decreasing IPV. In this systematic review, we aim to assess the effectiveness of home visiting in reducing IPV experienced by mothers.

METHODS

We conducted a systematic review using the Pubmed, PsychINFO and Embase databases from inception until March 2014, with a specific search strategy for each database.

RESULTS

Of the 1258 articles identified, 19 (six different home visiting studies) met our inclusion criteria and were examined in detail. Three different types of studies were identified: the primary focus of one study was on the abused mother and the secondary focus on the children (Australia); two studies (Hawaii, The Netherlands) with a primarily focus on reduction of child abuse and a secondary focus on IPV and finally three studies from the USA, which only aimed at reducing child abuse by providing support to the mother. The Australian study reported a significant lowering of the IPV score at 1-year follow-up (15.9 versus 21.8, adjusted difference -8.67, 95% confidence interval [CI]: -16.2 to -1.15). The Hawaii-study showed significantly lower rates of physical assault after 3 years follow-up (incidence rate ratio [IRR] 0.85; 95% CI: 0.71-1.00) and the Dutch study showed a significant decrease of mothers' physical assaults 2 years after birth (odds ratio 0.46; 95% CI 0.24-0.89). The other three studies showed no significant reduction of IPV.

CONCLUSIONS

Home visiting interventions that support abused women explicit to stop IPV seem to be effective in reducing IPV. However, it is not known whether these results are effective in the long term.

Support by trained mentor mothers for abused women: a promising intervention in primary care

BACKGROUND

Intimate partner violence (IPV) against women is a major health problem and negatively affects the victim's mental and physical health. Evidence-based interventions in family practice are scarce.

OBJECTIVE

We aimed to evaluate a low threshold home-visiting intervention for abused women provided by trained mentor mothers in family practice. The aim was to reduce exposure to IPV, symptoms of depression as well as to improve social support, participation in society and acceptance of mental health care.

METHODS

A pre-post study of a 16-week mentoring intervention with identified abused women with children was conducted. After referral by a family doctor, a mentor mother visited the abused woman weekly. Primary outcomes are IPV assessed with the Composite Abuse Scale (CAS), depressive symptoms using the Symptom Checklist (SCL 90) and social support by the Utrecht Coping List. Secondary outcomes are analysed qualitatively: participation in society defined as employment and education and the acceptance of mental health care.

RESULTS

At baseline, 63 out of 66 abused women were referred to mentor support. Forty-three participants completed the intervention programme. IPV decreased from CASt otal 46.7 (SD 24.7) to 9.0 (SD 9.1) (P ≤ 0.001) after the mentor mother support programme. Symptoms of depression decreased from 53.3 (SD 13.7) to 34.8 (SD 11.5) (P ≤ 0.001) and social support increased from 13.2 (SD 4.0) to 15.2 (SD 3.5) (P ≤ 0.001). Participation in society and the acceptance of mental health for mother and child improved.

CONCLUSIONS

Sixteen weekly visits by trained mentor mothers are a promising intervention to decrease exposure to IPV and symptoms of depression, as well as to improve social support, participation in society and the acceptance of professional help for abused women and their children.

"Meet me at the hill where we used to park": interpersonal processes associated with victim recantation

Our study used live telephone conversations between domestic violence perpetrators and victims to answer novel questions about how and why victims arrive at their decision to recant and/or refuse prosecution efforts. From October 2008 to June 2011, we conducted a qualitative study involving 25 heterosexual couples, where the male perpetrator was being held in a Detention Facility (in the U.S.) for felony-level domestic violence and made telephone calls to his female victim during the pre-prosecution period. We used 30-192 min of conversational data for each couple to examine: 1) interpersonal processes associated with the victim's intention to recant; and 2) the couple's construction of the recantation plan once the victim intended to recant. We used constructivist grounded theory to guide data analysis, which allowed for the construction of a novel recantation framework, while acknowledging the underlying coercive interpersonal dynamic. Our results showed that consistently across couples, a victim's recantation intention was foremost influenced by the perpetrator's appeals to the victim's sympathy through descriptions of his suffering from mental and physical problems, intolerable jail conditions, and life without her. The intention was solidified by the perpetrator's minimization of the abuse, and the couple invoking images of life without each other. Once the victim arrived at her decision to recant, the couple constructed the recantation plan by redefining the abuse event to protect the perpetrator, blaming the State for the couple's separation, and exchanging specific instructions on what should be said or done. Our findings advance scientific knowledge through identifying, in the context of ongoing interactions, strategies perpetrators used--sympathy appeals and minimization--to successfully persuade their victim and strategies the couple used to preserve their relationship.Practitioners must double their efforts to hold perpetrators accountable for their actions, and efforts made to link victims to trusted advocates who can help them defend against perpetrators' sophisticated techniques.

Supporting mothering: service providers' perspectives of mothers and young children affected by intimate partner violence

Although negative outcomes from intimate partner violence (IPV) are not inevitable, IPV is recognized to have profound negative effects on child development. We conducted a qualitative descriptive study of service providers' understandings of the impact of IPV on mothers, young children (birth to 36 months), and mother-infant/child relationships, and of the support needs of these mothers and young children. Service providers suggested that IPV negatively influenced caregiving and identified a pressing need for information and strategies to help mothers promote and protect their young children's development. Although service providers struggled to articulate ideal forms of assistance to promote maternal-infant/child relationships, they agreed that mothers and young children experiencing IPV required more support than is currently available.

Applying community-based participatory research methods to improve maternal and child health in Karachi, Pakistan

To achieve health for all, the development of partnerships between community residents and researchers is essential. Community-based participatory research (CBPR) engages community members, uses local knowledge in the understanding of health problems and the design of interventions, and invests community members in the processes and products of research. CBPR pivots on an iterative process of open communication, mutual respect, and power sharing to build community capacity to sustain effective health interventions. This article describes how the tenets of CBPR were applied by a multidisciplinary, international research team of maternal-child health specialists toward better health for women and children in multilingual, multiethnic, low socioeconomic communities in Karachi, Pakistan.

Partner abuse or violence, parenting and neighborhood influences on children's behavioral problems

We examined the relationship between neighborhood characteristics, parenting behaviors, experiences of intimate partner abuse or violence (IPV) and children's behavioral problems in a socioeconomically diverse sample of 383 families residing in an urban environment. Data were collected in the Fall/Winter of 2002. The census block group of residence was used as our measure of neighborhood. Census block groups typically contain 1500 residents on average. IPV was measured using a modified version of the HITS (physically Hurt, Insult, Threaten, and Screamed at) scale, a short four item tool assessing emotional and physical violence to which we added an item capturing domination or emotional control. IPV in the last year was reported by 50% of the sample with rates varying by socioeconomic position; families with the lowest and highest income reported the most IPV. Patterns of association between parenting, neighborhood and the children's behavioral problems differed for families who reported IPV in the last year compared to families who reported no IPV. While positive neighborhood characteristics such as high levels of Community Involvement with Children - based upon four scales capturing neighborhood levels of social interaction and collective socialization of children - were protective for high levels of behavioral problems among families not reporting IPV, this protective effect was not seen among families who did report IPV. Hypothesized interactions between negative neighborhood characteristics and IPV-namely that behavioral problems would be worse among families experiencing IPV in highly economically deprived or areas with negative social climates-were not supported by our data. These interactions between neighborhood factors and IPV were not explained by parental factors.

Behaviors of Children Following a Randomized Controlled Treatment Program for Their Abused Mothers

OBJECTIVE

To determine if a treatment program offered to abused mothers positively affects the behaviors of their children.

METHODS

A randomized, two-arm, clinical trial was used to measure child behavior at 6, 12, 18, and 24 months following the application of two levels of abuse treatment services to abused mothers: (1) abuse assessment and receipt of a wallet-size referral card, or (2) abuse assessment, receipt of a wallet-size referral card, and nurse case management sessions. The setting was public primary care clinics. The participants were 233 women who reported physical or sexual abuse within the preceding 12 months, and who had at least one child, ages 18 months to 18 years, living with them. Outcome measures were scores on the Child Behavior Checklist (CBCL) at baseline, 6, 12, 18, and 24 months. CBCL scores for a clinically-referred sample of children served as a comparison group.

RESULTS

All children improved significantly (p < .001) on CBCL scores from intake to 24 months, regardless of which treatment protocol their mother received. By 24 months, the majority of children and adolescents had scores significantly less than the referred norms. Children ages 18 months to 5 years showed the most improvement and teenagers showed the least improvement.

CONCLUSIONS

Disclosure of abuse, such as that which happens during abuse assessment, was associated with the same improvement in child behavior scores as a nurse case management intervention. Routine abuse assessment and referral have the potential to positively improve the behavioral functioning of children exposed to domestic violence.

Violent lives of women: critical points for intervention/life charting

Each year, 5.3 million women are abused and several thousand die at the hands of intimate partners. If family violence were better understood, it could be predicted, described by patterns and prevented. Life charting (LC) is a method developed to explicate complex phenomena, such as bipolar disorder. This study tested the feasibility and usefulness of LC in deriving data about critical points in life when interventions could reduce or prevent family violence. Two research questions guided the study: (1) Does LC yield valid, reliable data when used as a review with women exposed to violence? (2) Is LC feasible for use in research?