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Futures Without Violence eJournal
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Connecting the Dots: Children’s Exposure to Violence and Home Visiting Programs

by Elena Cohen and Isa M. Woldeguiorguis

Elena Cohen

Safe Start Center
5515 Security Lane, Suite 800
North Bethesda, MD 20852
Email: ecohen@jbsinternational.com

Isa M. Woldeguiorguis

Safe Start Center
@ JBS International
5515 Security Lane, Suite 800
North Bethesda, MD 20852

Points of view and opinions in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice.

In the past two decades, we have gained an increased understanding of the scope and consequences of children’s exposure to domestic violence. Focus has shifted from thinking that children are tangential and disconnected from the violence and trauma of their parents to learn that children’s responses and recovery from exposure to violence are particularly dependent on the context of the experience—especially their relationship with their families.

Exposure to violence and other forms of traumatic stress frequently co-occur with child abuse, neglect, and substance abuse forming a complex web of issues that pose significant challenges for programs and service systems. Many of the services designed to prevent or address these problems are “siloed” and often inadequate in their capacity to address family issues comprehensively. In addition, poverty and institutional racism limit families’ and service providers’ options and can undermine possible solutions resulting in disparities in health and well-being outcomes for children and families. The same is true for home visiting programs.

The purpose of this article is to raise awareness and provide practical suggestions for home visiting programs with regards to working with families affected by domestic violence. This article will focus on addressing the safety and developmental needs of children exposed to violence by ensuring safety and expanding parenting capacity of non-abusive caregivers while rebuilding broken family relationships.

Home Visiting Programs

Home visiting has been used as an early intervention and prevention strategy that pairs families—particularly those that are distressed—with trained staff (professional or paraprofessional) to provide parenting information, resources, and support throughout the child’s first few years. Using strengths-based approaches, home visitors create a trusting relationship and deliver services such as specialized curricula, therapeutic interventions, and parenting education to parents and children in the family’s home. In addition, home visiting programs operate as a link between families and other community services—not just through referrals but by helping parents understand the value of the services and how to access them.

President Obama’s federal budget request for FY 2010 called on Congress to fund a major new home visiting initiative—$8.6 billion over the next 10 years—to provide states with funding primarily to support home visiting models that have proven, through rigorous evaluation, to have positive effects on critical outcomes for children and their families (Boonstra, 2009).

Some of the most rigorously evaluated home visiting programs include Healthy Families, Healthy Start, Nurse-Family Partnership, Parents as Teachers, and Safe Care. Program evaluations show a range of positive results for home visiting programs. For example, an examination of 60 home visiting programs found small but statistically significant effects on parents’ behaviors, attitudes and educational attainment, and documented a significant reduction in potential child abuse and neglect (Daro, 2007). Nevertheless, several other studies have indicated that home visiting programs are not universally successful. For example, a randomized controlled trial of the Nurse Family Partnership in Elmira, NY revealed that the program did not significantly reduce the reported incidents of child abuse and neglect in families experiencing domestic violence. However, in families where domestic violence was not a confounding factor, the program was effective at reducing child maltreatment (Eckenrode, Ganzel, Henderson, Smith, Olds, Powers, Cole, Kitzman, & Sidora, 2000).

Families in Home Visiting Programs

Promoting the different outcomes of home visiting programs is tied directly to ensuring that families are safe and that their parenting is not compromised. In all the home visiting approaches, the home visitor serves as a bridge across philosophies, policies and procedures, families and agencies, and community concerns. Families that are targeted by home visiting programs, however, often experience a range of problems such as maternal depression, substance abuse, and/or domestic violence. These issues often occur along with poverty, compounding the challenge of delivering effective home visiting services.

Children’s Exposure to Violence

As evidenced in the findings of the National Survey of Children’s Exposure to Violence (NatSCEV), children’s exposure to violence, crime, and abuse are pervasive in the United States (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2010). More than 60% of the children surveyed were exposed to crime, abuse, and violence within the past year, either directly or indirectly. Furthermore, nearly half of the children had experienced at least two different types of victimization and 8% experienced seven or more kinds of victimizations.

The negative impacts of exposure to violence, especially when compounded by instability and uncertainty in the absence of a strong attachment to a caregiver, begin to multiply and can affect every area of a child’s functioning. Cognitive, attention, and emotional resources that are normally devoted to the developmental process are applied instead to coping and survival strategies (Dutra, Bureau, Holmes, Lyubchik, & Lyons-Ruth, 2009).

Not all exposure to violence has a long-term impact on children. Certain factors can provide a powerful buffer from the intense stress and anxiety that may occur when they are exposed to violence. These factors include the presence of a stable loving adult, positive relationships among family members, communication and good problem-solving capacity between parents, the stability and responsiveness of systems and staff that interact with the child and access to social supports and interventions for parents and other caregivers (Cohen, Kracke, &McAlister Groves, 2009).

This new understanding of the vulnerability of children exposed to violence creates a renewed sense of urgency about intervening early in their lives. Literature reviews and program practice demonstrate that parents who have been exposed to violence themselves and those currently living with domestic violence, may have difficulties performing their parenting tasks and meet their children’s developmental needs (Levendosky & Graham-Bermann, 2001). However, this does not automatically indicate that home visitors can assume that parents living with violence and other traumatic stressors show greater deficiencies in parenting than their non-abused counterparts. Many parents living with violence and other traumatic stressors, including domestic violence, tend to parent adequately and sometimes even compensate through increased nurturing and protection of their children (Lieberman &Van Horn, 2008). Research also underscores that the risk of child maltreatment is reduced once the adult victim achieves safety and that adult victims, despite ongoing abuse, can be effective parents and mediate the impact of their children’s exposure to domestic violence (Holt, Buckley & Whelan, 2008).

Women indicate that offending parents often interfere with their parenting, and that they often make decisions to stay with or leave the perpetrator based on their sense of the best interests of the child (Ritchie & Holden, 1998). As a result of living in constant fear, households with domestic violence may fail to provide opportunities to develop a basic sense of trust and security that is the foundation of healthy emotional development. One-third of abused women experience post-traumatic stress disorder, low self-esteem, depression, and anxiety (Genelle, Sawyer Davis, Hansen, & DiLillo,2004).

In the case of the father or father figures, Guile (2004) found little information about fathers and parenting capacity in households with domestic violence. When compared to their nonviolent counterparts, these fathers are less likely to have been involved with their children, more likely to have used negative child-rearing practices such as slapping, and are more authoritarian and controlling, and less consistent (Bancroft & Silverman, 2002).

Should Exposure to Violence be Reported to Child Welfare?

The question of whether exposure to violence should trig­ger the need for a report to child protective services is one of the most difficult issues for many service providers including home visitors. Home visitors, as others, have an institu­tional and legal mandate to keep children safe. Everyone agrees that there are some situations in which exposure to violence justifies a report to child protection agency. In practice, however, those judgments are much harder to make. A critical question is whether situations of children’s exposure to violence belong in the child welfare system at all or are better handled by voluntary service systems. This is demonstrated in situations when experts arrive at far different con­clusions, using the same hypothetical situations, about when the intervention of the child welfare system is appropriate.

Involvement with the child welfare system should be a last resort for any family. Friends and neighbors, clergy, health professionals, community organizations, and many others should be available as a first line of support and help. Specialists with responsibilities for educating families and community-based organizations, including domestic violence advocates, can assist them in providing better information to the women they serve. Through this educational process, community groups can help clarify the expectations, legal procedures, potential support, and consequences of engagement with the child welfare system.

Suggestions for Home Visiting Programs

The following are a set of recommendations to improve program infrastructure and service delivery that will help home visitation programs to meet their primary goals of ensuring safety of the child and non-abusing parent, improving parenting knowledge, beliefs, expectations, skills and behavior, facilitating the child’s healing and resumption of developmental process, and repairing/rebuilding relationships within the family.

1. Identify children who have been exposed to violence

The most important first step is to identify, as early as possible, children who are exposed to violence. Given what is known about the prevalence of co-occurring domestic violence and child abuse/neglect, programs should have universal screening policies in place and all home visitors should be trained to ask relevant questions and make observations about the possibility of domestic violence.

Home visitors are in a unique position to watch for physical signs (bruises, unexplained changes in behavior, emotional signs such as depression or anxious behavior). Systematically identifying and referring children exposed to violence requires the development and implementation of policies, procedures, and practices that include documenting the presence of children during episodes of violence that result in agency interactions with caregivers in known settings (e.g., at a crime scene, in a domestic violence shelter, in dependency court) and incorporating screening questions into existing intake protocols.

2. Integrate strategies to address exposure to violence and domestic violence into home visiting protocols

Planning for services in families with domestic violence must always take into consideration the child’s experience of violence and its effects as well as the potential danger to the child’s safety. It is critical to develop a safety plan for the adult victim and the child. In domestic violence situations, child safety usually depends upon the safety and protection of the adult victim. The ultimate goal is to end violence against both the children and the abused partner. The child’s need for attachment, safety, and security—which may change over time—should be the constant frame of reference during service planning.

3. Link families with community-based services

Home visitors can provide a variety of opportunities for families with young children exposed to violence or at high risk of exposure to access needed services (for example, health care, early childhood, child protective services and domestic violence professionals) and engage parents/caregivers into needed services for their children and themselves. To be able to do this work, programs must support and foster collaborative partnerships and cross-agency training with child welfare and domestic violence agencies and other providers that serve the families.

4. Include evidence-based strategies in the parenting education activities

Parenting education is provided by most home visiting programs. Key issues related to parenting education include determining the parents’ capacity to protect their children, helping parents understand how their own exposure to violence influences their parenting, and introducing practices that improve the non-offending parent-child bond which is often strained or fractured by the violence.

Parenting classes often have different approaches and philosophies, target audiences, and goals. Effective parent training interventions include Parenting Wisely, Nurturing Parent, STEP, and Project 12-Ways. Most of these programs are not provided in the home or specifically target children’s exposure to violence. An additional consideration is that while these programs have demonstrated a number of positive outcomes, their success in building trauma-related parenting capacity has not been assessed.

Programs designed to provide parenting skills without violence for men who batter have emerged in the last decade. These parenting programs are usually supplementary sessions within existing offending-parent intervention programs or a separate curriculum. The EVOLVE program, for example, integrates six lessons on fatherhood into a larger curriculum for perpetrators (Donnelly, Mederos, Nyquist, Williams, & Wilson, 2000). The Family Violence Prevention Fund developed the Fathering After Violence Project which includes exercises that can be integrated into batterer intervention programs and into curricula for fatherhood programs in other systems (Arean & Davis, 2007).

5. Refer children to specialized services

The kinds of exposure to violence that children, youth, and families in home visiting programs experience are typically not associated with a single event such as an accident or a school shooting. Rather, they are usually interpersonal in nature, intentional, prolonged and repeated, occur in childhood and adolescence, and may extend over years of a person’s life. If untreated, the impact of the exposure can interfere with children’s healthy development and lead to long-term difficulties with school, relationships, jobs, and the ability to participate fully in a healthy life.

Diverse mental health interventions have been developed to increase protective factors and decrease behavioral and emotional symptoms that result from exposure to violence. Child Parent Psychotherapy for Family Violence (CPP-FV), an evidence-based intervention for infants and toddlers, uses a parent-child dyadic model (Lieberman, Ghosh Ippen, and Van Horn, 2006). For school-age children, treatment programs such as Kids Club and Mom’s Empowerment include a child intervention while the non-offending parent simultaneously attends separate sessions to learn how to help their children cope (Graham-Berman, Banyard, Lynch, & DeVoe, 2007). Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) is provided in schools to groups of children to help them develop skills, regulate emotions, and build resiliency (Stein, Jaycox and Karaoka, 2003). Other evidence-based interventions for children for who have been exposed to toxic stress include: Trauma-Focused Cognitive Behavior Therapy (TF-CBT), Abuse-Focused Cognitive Behavior Therapy (AF-CBT); Parent Child Interaction Therapy (PCIT); and Project 12-Ways/Self-Care for Child Neglect (http://www.nctsn.org).

6. Support the mental wellness of home visitors

Adults who work with children exposed to violence may experience significant emotional impact. They are exposed to intense stressors that can have a negative effect on their physical and emotional well-being. Feelings of stress, exhaustion, and sadness are common. Physical symptoms may include headaches, stomach upset, and muscle aches and pains. Exposure to the tragic stories of children can trigger the same feelings of fear and anxiety in the professional that the child is feeling. To prevent burnout and assure quality, adults who work with these children need specific support and supervisory services. Stress management, peer support, and high-quality on-the-job supervision are critical (Rice & Groves, 2005).

Conclusion

Home visitors have an extraordinary opportunity to respond to the needs of children exposed to violence and their families. To support home visitors, the programs must invest in infrastructure building through policy development and training. Whatever the model of home visitation, program impact is dependent upon the skills and sensitivity of the home visitor and providing the home visitor with a framework that provides training, skill development, protocols and support to address domestic violence with the families they serve.

References

Arean, J. D. & Davis, L. (2007). Working with fathers in batterer intervention programs: Lessons from the Fathering After Violence Initiative. In J. L. Edleson & O. J. Williams (Eds.), Parenting by men who batter (pp. 118–130). New York: Oxford University Press.

Bancroft, L. & Silverman, J. (2002). The batterer as parent: Addressing the impact of domestic violence on family dynamics. Thousand Oaks, CA: Sage.

Boonstra, H (2009, Summer). Home visiting for at-risk families: A primer on a major Obama Administration initiative. Policy Review. 12, 3, 11-15.

Cohen, E. , Kracke, K., McAlister Groves, K. (2009). Understanding Children’s Exposure to Violence. Moving from Evidence to Action: The Safe Start Series on Children Exposed to Violence. Issue Brief #1, North Bethesda, MD: Safe Start Center.

Daro D. (2007). Home Visitation: Assessing Progress, Managing Expectations. Chicago, Ill: Chapin Hall Center for Children. Retrieved on February 10, 2011 from http://www.chapinhall.org.

Dore, M. M., & Lee, J. M. (1999). The role of parent training with abusive and neglectful parents. Family Relations, 48, 313–325.

Donnelly, D., Mederos, F., Nyquist, D., Williams, O. J., and Wilson, S. G. (2000). Connecticut’s EVOLVE Program: A 26 & 52 week culturally competent, broad-based, skill-building, psycho-educational curriculum for male domestic violence offenders with female victims. State of Connecticut Judicial Branch: Rocky Hill, Connecticut

Dutra, L., Bureau, J. F., Holmes, B., Lyubchik, A., & Lyons-Ruth, K. (2009). Quality of early care and childhood trauma: A prospective study of developmental pathways to dissociation. Journal of Nervous Mental Disorders, 197(6), 383-90.

Eckenrode, J., Ganzel, B., Henderson, C., Smith, E., Olds, D., Powers, J., Cole, R., Kitzman, J., and Sidora, K. (2000) Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. Journal of the American Medical Association 284, 11, 1385-1391.

Finkelhor, D, Turner, H., Ormrod, R., Hamby, S., & Kracke, K. (2009, October). Children’s exposure to violence” A comprehensive national survey. Juvenile Justice Bulletin. www.ncjrs.gov/pdffiles1/ojjdp/227744.pdf.

Genelle K. Sawyer, C.A. Davis, D.J. Hansen, M.F, & DiLillo, D. (2004, November). Examining the Context of Domestic Violence: Relationship of Current and Past Partner Psychological Aggression and Physical Assault to Parenting. Poster Presented at the 38th Annual Convention of the Association for the Advancement of Behavioral Therapy, New Orleans, LA. Retrieved on February 10, 2011 from http://www.unl.edu/psypage/maltreatment/documents/AABT2004_DomesticViolenceandParentingHandout.pdf

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Guille, L. (2004) Men who batter and their children: An integrated review. Aggression and Violent Behaviour, 9, 129-163.

Holt, S., Buckley, H.., Whelan, S. (2008). The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse and Neglect 32 797-810.

Levendosky, A., Graham-Bermann, S.A (2001). Parenting in battered women: The effects of domestic violence on women and their children. Journal of Family Violence, 16, 2, 171-192.

Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford Press.

Lieberman A.F., Ghosh Ippen C., Van Horn, P.J. (2006). Child-Parent Psychotherapy: Six month follow-up of a randomized control trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45(8), 913-918.Rice, K. and Groves, B. (2005), Hope and Healing: A Caregivers Guide to Helping Young Children Exposed to Violence. Washington, DC: Zero to Three.

Ritchie, K. L and Holden, G. W. (1998). Parenting stress in low income battered and community women: Effects on parenting behavior. Early Education and Development, 9, 97–112.

Stein B.D., Jaycox, L.H., Kataoka S.H. (2003). A mental health intervention for school children exposed to violence. Journal of the American Medical Association, 290, 5, 603-611.