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From Childhood Exposure to Domestic Violence Victimization: Female Intergenerational Transmission of Domestic Violence

Sally Black, RN, PhD, Alice Hausman, MPH, PhD, Sandra H. Dempsey, MSS, MLSP, Martha B. Davis, MSS, and Susan Robbins M.D., M.P.H.

Corresponding author:

Sally Black, RN, PhD

Health Services Department
Post Hall 114
Saint Joseph’s University
5600 City Avenue
Philadelphia, PA 19131-1395
sblack@net-thing.net

Telephone: 610-660-1530 Fax: (610) 277-3615

Alice Hausman, MPH, PhD

Department of Public Health

Temple University

Sandra H. Dempsey, MSS, MLSP
Co-Director, Institute for Safe Families

Martha B. Davis, MSS
Co-Director, Institute for Safe Families

Susan Robbins, M.D., M.P.H.
Medical Director, Pediatric and Adolescent Services
Philadelphia Department of Public Health

Childhood exposure to domestic violence (CEDV) is associated with a number of both acute and chronic illnesses. The link to illness provides opportunities for disease prevention and intervention by healthcare providers. This mixed methods study sought to document experiences, perceptions, and attitudes toward domestic violence (DV) and concerns about discussing DV with healthcare providers. Women (n=99) from four community health centers completed an anonymous survey. Fifty-one percent of women reported abuse perpetrated against their mother, 61% reported verbal abuse, physical abuse, or forced sexual contact perpetrated by an intimate partner in their own lifetime, and 55% reported that their child was exposed to violence in the home. The most common type of exposure identified was when the child heard but did not see the incident. Women with a history of personal experiences with DV victimization were more likely to report CEDV as a child than were women with no history of victimization [OR=11.56; X2 (1, n=99)=27.3, p<.001]. Results show intergenerational trends of female victimization and identify the need for a systematic approach to helping families suffering from DV.

Introduction

The persistent and pervasive presence of domestic violence (DV) can threaten a child’s safety and impair normal development (Margolin, 1998). Exposure to DV causes tension and anxiety, raising blood cortisol, adrenocortocotropic hormone, and epinephrine levels (Gunnar, 1998; Heim & Nemeroff, 2001; Schechter et al., 2004; Yehuda, Halligan, & Grossman, 2001). Under ongoing stress, nerve cells adapt to meet the need for hyper-vigilance or dissociation (Perry & Pate, 1994). These physiological changes are linked to unhealthy behaviors such as smoking, drinking, illicit drug use, high-risk sexuality, and eating disorders (Bloom, 1999; Heise & Garcia-Moreno, 2002; Plichta 2004; Roberts, Auinger, & Klein 2005; Silverman, Raj, Mucci, & Hathaway, 2001). These behaviors increase the risk of injury and chronic disease. The Adverse Childhood Experiences Study (ACES) showed a strong association between exposure to childhood stress, including DV, and early death (Felitti et al., 1998). In addition to developing stress-related problems, children exposed to DV are at greater risk of becoming the target of the physical and/or sexual abuse taking place in their homes (McCloskey, Figueredo, & Koss, 1995; Owens & Straus, 1975; Wolfe, Jaffe, Wilson, & Zak, 1985).

With an estimated 5.3 million incidents against women and 3.2 million incidents against men each year in the United States, DV is fairly prevalent (Tjaden & Thoennes, 2000). High-risk groups for DV victimization are young females of low socio-economic status, with children in the home, and with a history of substance abuse (Fantuzzo, Boruch, Beriama, Atkins, & Marcus, 1997; Wolfner & Gelles, 1993). Despite knowledge of DV prevalence, incidents of childhood exposure to domestic violence, childhood exposure to domestic violence (CEDV) is not well enumerated. CEDV is a fairly nascent field. CEDV estimates vary from 3.3 to 17.8 million children each year in the U.S. (Carlson, 1984; Spacacarelli, Sandler, & Roosa, 1994). One obstacle to investigating CEDV is the lack of a standard operational definition. The Child Witness to Violence Project describes CEDV as children “who see, hear, or live with the aftermath of DV” (Groves, 2002). ACES defines “exposure” as witnessing actions taken against the mother; she may be pushed, grabbed, slapped, have something thrown at her, get kicked, bitten, hit, threatened, or hurt with a weapon (Edwards, Holden, Felitti, & Anda, 2003). Holden (2003) uses a broader definition of “exposure”, dividing the concept into two categories: direct exposure on one hand, and exposure through consequences on the other. Direct exposure, for Holden, includes witnessing DV while in utero, seeing and/or hearing DV, participating in an incident of DV either by actively engaging or by trying to stop it, or experiencing injury as a result of a DV incident. Exposure through consequences, however, refers to a child’s exposure to the aftermath of an incident of DV. A child may see his or her mother’s injuries, experience changes in living arrangements, or learn of the violence through an outside source such as a family member. While Holden’s taxonomy offers a clear, practical definition of “exposure”, it has not been widely adopted in practice.

Screening and intervention programs are needed to help families dealing with family violence. One critical time point for screening and intervention is when a family member seeks medical care for violence-related injuries. The reality of injury can temporarily shift decision-making toward action (Prochaska & DiClemente, 1982). Healthcare agencies can provide a safe venue for disclosure and referral and are especially promising for young children who visit regularly for injuries, immunizations, or routine checkups (Onyskiw, 2002). In 1998, the American Academy of Pediatrics issued a position statement declaring that “the abuse of women is a pediatric issue”. The Family Violence Prevention Fund identified healthcare settings as an important window of opportunity for intervention efforts (Groves, Augustyn, Lee, & Sawires, 2004). Prevalence studies also support using medical offices for intervention. In an outpatient pediatric clinic, 40% of mothers had filed a restraining order against a partner (Linares et al., 1991). In one pediatric office, 2.5% of mothers reported current IPV and 14.7% reported past IPV (Parkinson, Adams, & Emerling, 2001).

This study was part of a needs assessment to estimate the prevalence of CEDV, to determine the usefulness of Holden’s taxonomy in identifying children exposed, and to identify resources requested by mothers. Three generations were studied through one survey which investigated DV victimization of the grandmother, DV victimization of the mother, and exposure of the child, all as reported by the mother. Research questions were: What are respondents’ experiences in witnessing DV against their own mother? What are respondents’ personal experiences as victims of DV? What are current levels of exposure among respondents’ children? Are mothers willing to discuss DV with health care providers? Anonymous surveys were administered to patients visiting four public health centers. The purpose of the study was to develop a coordinated system of care for families.

Methods

The survey instrument was constructed using operational definitions from several studies. Items on types of violence were adapted from ACES (Edwards et al., 2003), which was originally developed from the Conflict Tactics Scale (Straus, 1979; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Items on exposure were adapted from Holden’s taxonomy (Holden, 2003). Items were carefully worded to avoid retraumatization. Retraumatization occurs when the person seeking information increases victim stress by assigning blame to the victim, using terminology with negative connotations, or questions the victim’s decision-making (Fontes, 2004). In order to protect participants, items were worded in an unbiased and nonjudgmental manner.

Four community health centers were selected for study, based on their ability to represent diverse cultures in the service area. One center served a predominantly African American population, the second served mostly Latinos and Russians, the demographic majority frequenting the third center was mixed Asian, and the fourth served a predominantly Russian population. The surveyor spent two to three days at each center. All adult females waiting for care were asked about their willingness to participate in “a survey for moms with children under 18 years old, living with them.” Women accompanied by a partner or child over the age of two were not approached due to health department policy prohibiting DV screening in front of a third person who may be capable of disclosing the conversation to a perpetrator. Women who expressed interest were taken to a private area, where informed consent, survey, and inclusion and exclusion criteria were reviewed. The survey was administered in a private area before or after the office visit and took approximately 15-30 minutes to complete. All women who participated received a copy of the consent form, a wallet card of local IPV resources and a $10 gift certificate to a local store. Women were advised to dispose of the resource card if possession posed a danger. Several participants asked for the survey to be read aloud. For these women, each item and response was read aloud from a blank survey while the participant followed and completed on a separate survey.

Quantitative results were entered into SPSS. Data were analyzed for frequencies, odds ratios, and correlations. To calculate odds ratios and correlations, data were coded to dichotomous levels. “Never” was coded as 0. “Once or twice”, “sometimes”, “often”, and “very often” were coded as 1. Factor analyses were used to investigate Holden’s categories.

Open-ended responses were transcribed and imported into a qualitative software package. One researcher, experienced in qualitative data analysis, reviewed each quotation to determine the context. Major ideas were assigned a descriptive code. Themes were developed and reported to a committee of researchers, practitioners, and experts in DV. The committee validated themes against participant quotations.

Results

Participants

Ninety-nine women visiting four public health clinics located in a large, urban area participated in the anonymous survey. Participation rates varied by center and population. The center that served predominantly African American patients had the highest participation rate (approximately 90%). The center that served predominantly Asian patients had the lowest participation rates (approximately 60%) and most of those who participated were African American. Reasons for non-participation were not enough time, not interested, or did not feel competent in the English language. Participants were 61% African American, 11% Hispanic, 6% Asian, 6% Caucasian, with the remainder being mixed or other race. Reported ages were 18-29 years (37%), 30-45 years (43%), and over 45 years (15%). Five percent of respondents did not report age.

Respondents’ exposure as a child

Overall, 51% of women reported violence perpetrated against their own mother, the child’s grandmother. The most common types of violence respondents reported in this category included being put down with words or actions (41.6%), getting pushed, grabbed, slapped, or having something thrown at her (35.7%), and being hit repeatedly over a few minutes (20.8%) (Table 1).

Respondents’ experiences with IPV

Overall, 61% of participants reported DV victimization during their lifetime. The most common types of violence were being put down with words or actions (51.5%), getting pushed, grabbed, slapped, or being the target of a thrown object (50.0%), and being hit repeatedly (30.3%). Approximately one-quarter of women reported each of the following: being kicked, bitten, or hit (27.3%), experiencing forced sexual contact (25.3%), or being threatened with a knife or gun (23.2%).

Relationships between CEDV and DV

Women with a positive history of victimization were more likely to report CEDV in comparison to women with no victimization history [OR=11.56; 95% CI, 4.29 to 31.18; X2 (1, n=99)=27.3, p< .001]. There were significant moderate correlations between reports of the grandmother being hit repeatedly and the respondent being threatened with a weapon (r=. 474, p< .01), between the grandmother experiencing pushing, grabbing, slapping, or thrown objects and the respondent experiencing pushing, grabbing, slapping, or thrown objects (r=. 466, p< .01), and between verbal abuse directed at the grandmother and verbal abuse experienced by the participant (r=. 465, p< .01) (Table 2). These trends suggest that not only does abuse run within families, but that specific types of abuse run within families.

CEDV by respondents’ children

In response to the general question of whether their own child was exposed to DV, only 29% of participants reported CEDV. But using Holden’s taxonomy, the reported rate almost doubled to 55%. Seventy-eight percent of DV victims reported CEDV. The most common means of exposure was hearing without seeing (43.8%). This finding would be consistent with anecdotal reports of DV after children have gone to bed. Other forms were seeing the mother sad, angry, or upset after the incident (42.3%) or seeing the incident (32.6%). Factor analysis identified two principal components, which loosely match Holden’s direct and indirect categories. The direct factor included in utero exposure, intervention by the child to stop the incident, direct physical injury to the child, participation in the DV, and exposure through aftermath. The indirect factor included observing the incident, hearing but not seeing, witnessing injuries, hearing through outside conversation, and seeing the mother upset. Large loadings were seen on both the direct and indirect factors for the variable “exposure through aftermath”, suggesting that this variable may provide a combined direct and indirect effect.

Attitudes toward screening by healthcare providers

The majority of participants (62%) reported that they would feel comfortable discussing DV with their healthcare provider. Yet only one out of five participants (20%) had spoken to their provider about DV. Very few participants (12.5%) feared that their provider would notify social services if DV were disclosed. Qualitatively, women reported a wide spectrum of needs for families with DV. Major themes were the need for protection, resources, information, assurances, and behavioral management services. Some women wanted tangible resources, such as a hotline, shelter, or a protection from abuse order. Others wanted counseling with services that acknowledged the abuse. One participant wrote, “[I need] someone to assist me in getting my life back in order, teach me how to love myself and feel self worth again. Most people need help in waking up from their nightmare.” Counseling needs included help with job placement to become financially independent and mental health services for interpersonal relationship interactions.

Mothers’ perceptions of what children needed overlapped with the mothers’ own needs, reflecting the interdependence of family members. Re-occurring ideas were the need for behavioral management and counseling. One participant explained,

“My daughter has a anger problem. I sometimes wonder if it came from what she was expose to in the pass -  you child get angry and so upset that you feel she or he is uncontrollable. Maybe you guys can start a group for these parent and the children to work on such a problem.” (sic)

Mothers acknowledged that CEDV had a psychological effect on children and services were necessary for recovery. One respondent explained the need as “counseling so the cycle of abuse isn’t repeated.” Women also asked for help for partners. In the words of one respondent, “Helping my husband to have a new heart, and change of mind (becoming a new good person) will help me feel safe.”

Discussion

Two major findings of this study were the high level of intergenerational transmission of DV victimization and the ability to use Holden’s taxonomy to identify CEDV. Fifty-one percent of respondents reported DV against their mother, 61% reported personal victimization, and 55% reported that their children were exposed to DV. Other studies have identified lower rates of CEDV including 2.5% to 14.0% in ACES (Edwards et al., 2003; Felitti et al., 1998), 2.9% in the National Survey of Children’s Health (Child and Adolescent Health Measurement Initiative, 2005), 3.7% among female caregivers in a Michigan (Holtrop et al., 2004), and 20% among school-aged children (McCloskey, Figuerdo, & Koss, 1995). The prevalence of CEDV may be higher in clinical populations due to the health problems associated with CEDV.

Reported prevalence may also have been higher because clear definitions leave little room for personal interpretation. The lack of clear definitions is common across the violence and aggression fields (Gelles, 1991). Members of the general population do not always recognize subtle behaviors, such as putdowns, threats, or financial and social control as violence-related. With respect to CEDV, parents underestimate children’s exposure (Edleson, 1999; Osofsky, 1998). Some parents may simply be in denial, causing them to underestimate CEDV because they are unwilling or unable to reflect on the traumatic experiences that occur in their homes. There is a need to use consistent definitions of “childhood exposure” and “domestic violence” when attempting to communicate with the public. Because Holden’s taxonomy delineates types of exposure to violence by listing concrete examples of “direct exposure” and “exposure through consequences,” this system of describing CEDV may have been easier for the public to understand. However, it may be necessary to revise the categories based on the factor analysis where direct exposure include in utero, physical injury, joining in – either to stop or to participate in the incident, and experiencing the aftermath. Indirect exposure would include seeing the incident, experiencing subsequent emotional and physical injuries, and hearing either the incident itself or hearing about it through an outside source. Categories are important because direct exposure may cause more severe effects than indirect exposure.

In this small study sample, women who were victimized in their own relationships were eleven times more likely to report exposure as a child compared to women who were never victimized. While this odds ratio could be inflated because personal experiences with DV may trigger memories of CEDV, the high odds ratio suggests that CEDV could be a significant risk factor for female victimization. Furthermore, experiences may be carried into the next generation because 55% of DV victims reported that their own children were exposed. These patterns of familial transmission are consistent with other investigations (Ehrensaft et al. 2003; Graham-Bermann, 1998; Hotaling & Sugarman, 1986; Koenig, Ahmed, Stephenson, Jejeebhoy, & Campbell, 2006; Levondosky & Graham-Bermann, 2001).

CEDV can only be addressed by stopping the DV. Participants voiced needs for education, counseling, and resources. Healthcare providers are in a unique position to identify and intervene in family violence. Healthcare workers discuss many private issues with their patients. Most women in this study (62%) were comfortable discussing DV with a healthcare provider. Discussions can be facilitated though public service announcements in waiting areas. Ideally, discussions should start early and continue regularly. During history and physical exams, all healthcare workers should screen patients. The more patients are asked about family and community violence by different providers, the more they will come to see violence as a health issue. If a patient screens positively, healthcare workers should gather as much information as possible, assess potential for injury, assess the level of danger, assess for suicide or homicide and help the family members to form an emergency safety plan, using available resources. Interventions are dependent on age and developmental level (Joseph, Govender, & Bhagwanjee, 2006). Children need reassurance to alleviate feelings of guilt, shame or responsibility. Suggested child-focused interventions currently include art therapy, play therapy, anger management, individual or group counseling, and academic support (McKinney, Sieger, Agliata, & Renk, 2006). While the health care setting offers a promising approach to screening, it should be noted that there are limitations. In screening patients, healthcare workers need to consider the implications of screening. Mandated reporting limits confidentiality and mothers need to be aware of professional statutes. Disclosing DV in front of an older child may endanger the mother further, if the child reports the discussion back to the perpetrator. One study showed that children exposed to DV are less likely to see general practitioners and pediatricians and more likely to visit specialists, public health professionals, and social workers compared to children not exposed (Onyskiw, 2002). Therefore, training must extend beyond primary care physicians. Ultimately, interventions should also extend beyond the family unit. DV is a social issue (Levendosky & Graham-Bermann, 2001; McKinney et al., 2006). To truly address DV, society must also address the social norms that perpetuate gender stereotypes and promote violence (Peled, 1993).

Study Limitations

Limitations of this study included a small sample size, the study population, how DV was defined, and methods. This study used a purposive sampling technique. Healthcare centers were selected based on the ability to represent diverse groups of women. Patients were invited to participate based on attendance at the clinic on the day of data collection. The study sample was not representative of the larger population of female clinic patients. Therefore, results are not generalizable to the participating healthcare centers or other groups of patients. The study population was predominantly made up of racial minorities. Minority populations in America routinely face social injustices, such as racial and ethnic discrimination and poor socioeconomic conditions. Parents may teach children to respond to social injustices through aggression. If aggression spills over into interpersonal relationships, patterns of family violence could be transmitted from generation to generation, supporting the need for social interventions, rather than individual interventions. The operational definition of DV included emotional and verbal abuse, which is frequently excluded. Stalking, which is one of the more common types of DV, was excluded (Tjaden & Thoennes, 2000). Other limitations of the study were the cross-sectional, retrospective design. People who experience re-occurring trauma do not have the same opportunity to repress or forget events, as a person who does not experience trauma, suggesting self-report data by those experiencing the issue would be higher. Conversely, previous studies have found that adult reports can be fairly accurate (Dube, Williamson, Thompson, Felitti, & Anda, 2004). Self-report appeared to be consistent within the study because internal consistency reliability coefficients showed a moderately strong correlation (.88) between comparable items. A major limitation of cross-sectional studies is the inability to establish time sequence. Simply because two events were experienced by the same person does not mean that one event caused the second event. Prospective studies need to be undertaken to investigate causality and relative risk.

Conclusion

Using medical settings as an intervention point for children exposed to DV is a promising approach to addressing family violence. Many parents will obtain care for their children, even when they will not seek care for themselves. Building a healthcare system to address domestic abuse may reduce the public’s reticence to seek assistance. Supporting families suffering the physical, social and emotional effects of DV is a natural function of the healthcare system. In order to support practitioners, best practices in DV and CEDV prevention and intervention should be identified and disseminated to communities. Building a society that responds to family violence appropriately and effectively will improve the quality of life for many people.

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Table 1. Frequencies of childhood CEDV and victimization by participants

CEDV in own childhood

IPV Victimization

Put down with words or actions

41.6

51.5

Pushed, grabbed, slapped, or something thrown

35.7

50.0

Hit repeatedly

20.8

30.3

Kicked, bitten, or hit

17.9

27.3

Threatened with knife or gun

10.9

23.2

Forced sexual contact

8.0

25.3

Table 2. Correlations between CEDV as a child and victimization as an adult

Victimization in own relationship

Pushed, grabbed, slapped or something thrown

Kicked, bitten, or hit with something hard

Hit repeatedly

Threatened with knife/ gun

Forced sexual contact

Put down with words/ actions

Victimization of grand-mother

Pushed, grabbed, slapped or something thrown

.466*

.336*

.366*

.427*

.380*

.435*

Kicked, bitten, hit with something hard

.381*

.291*

.321*

.308*

.337*

.361*

Hit repeatedly

.370*

.290*

.355*

.474*

.379*

.252*

Threatened with knife/ gun

.291*

.289*

.187*

.338*

.312*

.343*

Forced sexual contact

.157

.072

.132

.115

.362*

.147

Put down with words/ actions

.454*

.392*

.368*

.399*

.395*

.465*

* Correlation is significant at the 0.01 level (one-tailed).