Author’s Affiliations:

¹ Research Coordinator, 800 Rose Street, MN 673, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, Lisandra.garcia@uky.edu: Corresponding author

² Verizon Wireless Endowed Chair, Center for Research on Violence Against Women Professor of Epidemiology, Department of Obstetrics and Gynecology, College of Medicine, Department of Epidemiology, College of Public Health, Associate Dean for Research, College of Public Health, University of Kentucky, KY

³ Assistant Professor, 800 Rose Street, C357. Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY

⁴ Head Nurse, Department of Maternal Care Services, University of Kentucky, Lexington, KY

⁵ Chair and Associate Professor, the Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY

⁶ Parry Chair and Professor in Health Promotion & Disease Prevention, College of Nursing, Texas Woman’s University, Houston, TX

⁷ John M Nokes Professor and Chair of the Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, VA

Acknowledgements:  Authors wish to recognize the financial support for this project by the Department of Obstetrics and Gynecology and the University of Kentucky School Of Medicine.

Introduction

Self-reported stress and symptoms of depression or anxiety are associated with pre-term delivery and small for gestational age infants. These pregnancy outcomes are risk factors for impaired cognitive and developmental outcomes for infants  (Van de Weijer-Bergsma, Wijnroks, & Jongmans, 2008).  Higher stress and lower economic resources may have a synergistically negative effect on pregnancy outcomes (Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999).  Highly stressful life events reported during pregnancy are associated with shorter mean gestational age and an increased risk of preterm delivery (Murphy, Schei, Myhr, & Du Mont, 2001; Yost, Bloom, McIntire, & Leveno, 2005).  Abuse during pregnancy, a significant stress-inducing event, is associated with low birth weight, preterm delivery, fetal loss and maternal homicide by a partner (Campbell et al., 1999; Coker, Sanderson, & Dong, 2004; Janssen et al., 2003; Murphy et al., 2001; Silverman, Decker, Reed, & Raj, 2006; Yost et al., 2005).

There is no clear evidence that screening for psychosocial risk factors improve health outcomes for women.  The United States Preventive Health Task Force classified screening as an “I” indicating insufficient evidence to support universal screening for family violence (Nelson, Nygren, McInerney, & Klein, 2004).  However, in a recent prospective, randomized trial, women who received screening and a standardized intervention were noted to have fewer recurrences of violence, a reduced likelihood of a very preterm infant, and an increased mean gestational age (Kiely, El-Mohandes, El-Khorazaty, & Gantz, 2010).  In 2006, the American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women recommended “screening for psychosocial risk factors at least once each trimester regardless of social status, educational level, or race and ethnicity” (ACOG Committee Opinion No. 343: Psychosocial Risk Factors: Perinatal Screening and Intervention, 2006).  The recent Institute of Medicine report recommended that women’s preventive services include “screening and counseling for all women and adolescent girls for interpersonal and domestic violence in a culturally sensitive and supportive manner” (Clinical Preventive Services for Women: Closing the Gaps, 2011, p. 123).

We present our experience in the implementation of psychosocial screening of pregnant women at their first prenatal care visit at the University of Kentucky Department of Obstetrics and Gynecology.  Special focus is given to the attitudes of health care providers on screening.

Methods

Psychosocial screening of all new obstetric (OB) patients was instituted by nursing staff in spring, 2008.  Two groups of patients received prenatal care through the Department of Obstetrics at the University of Kentucky.  One group included high risk patients (defined by a range of health conditions that may negatively influence pregnancy outcomes and referred from providers in central and eastern Kentucky).  The second group was an international population of low risk women, primarily Spanish speaking.

Psychosocial screening included questions about current and lifetime physical, sexual, or psychological abuse, perceived stress, housing instability, unplanned pregnancy, substance use, and depressive symptoms.  Questions were adapted from the ACOG screening guidelines (“ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention,” 2006) along with the Edinburgh Postnatal Depression Scale (Bennett, Einarson, Taddio, Koren, & Einarson, 2004).  Questions were available in both English and Spanish (see Appendix A).  Since none of the nurses were bilingual, three certified Spanish speaking interpreters assisted with screening Spanish speaking patients.  Our nurse manager worked with a hospital information technology team to include the psychosocial screening questions in a newly created electronic medical record.  The chronology of implementation of universal psychosocial screening in our clinic is provided in Table 1.  This project was approved by the University of Kentucky Institutional Review Board. Because psychosocial screening was implemented universally for all new patients, individual consent was not required.  As described in Appendix A, nurses read a statement informing patients of our clinic’s screening policy and to let them know that if child or spouse abuse was disclosed, nurses were required to report these events.

To ensure that nurses were comfortable with asking women about psychosocial risk factors and knew where to refer women who screened positive to specific psychosocial factors, an expert in both psychosocial screening and the health effects of physical and sexual violence on pregnancy outcomes provided an entire day of training using the Abuse During Pregnancy:  Protocol for Prevention & Intervention as an instructional manual (McFarlane, Parker, & Morgan, 2007).  Nursing staff requested further training and expressed the need for addition skills in addressing depression and partner violence with patients.  To address these needs, we organized a year-long seminar series with community-based service providers.  The seminars, which were 45 minutes in length, were offered every other month.  The meetings happened before the normal work shift started; all staff working with obstetric patients were invited (N=8).  Overall, we had 60% attendance for the seminars.   A Universal Screening and Resource Book (see Appendix A) was developed with comprehensive information concerning community resources along with protocols for a positive screen.

A primary objective of this study was to determine the time required from initiation of electronic medical record psychosocial screening until comprehensive screening was achieved (defined as at least 90% of patients screened).  To evaluate the implementation of the psychosocial screening, we performed a retrospective review of all new pregnant women receiving care in the OB clinic with electronic medical records beginning in March 2008 through February 2009.  The clinic administration provided a list of all 534 new patients seen in the clinic between March 2008 and February 2009 to the researchers. One trained graduate research assistant electronically reviewed all 534 medical records.  The review consisted of basic demographic information on the patient (age, race, health insurance status and education level, smoking status in the past 3 months, alcohol consumption and drug use during pregnancy) as well as the patient’s response to each of the psychosocial screening items (see Table 2).  These data were directly entered into an Access database from the electronic medical record. We abstracted medical records at two, six, and 12 months after implementation of the electronic medical record. Additional objectives included assessing the prevalence of positive screens for psychosocial screening.

In an attempt to understand how our health care providers responded to the psychosocial screening, we asked all health care providers with a role in screening  (e.g. registered nurses, resident and attending physicians) to complete an on-line survey using Survey Monkey software.  All health care providers in the Department of Obstetrics and Gynecology who had direct responsibilities for prenatal care and screening were invited to participate in the electronic survey (n=54).  Providers were sent an email invitation with a link to the Survey Monkey web-site.

Results

Sample Demographics

Seventy percent of our population (n=534) was exclusively Spanish speaking.  Twelve percent of screened women were between the ages of 16 and 19 years, 28% were 20 to 24 years old, 47% were between 25 and 34 years of age and 13% were age 35 or older.  Eighty four percent (n=439) had health care covered through Medicaid and data were missing for 12 women for this variable.

Time to Comprehensive Psychosocial Screening

Progress toward comprehensive psychosocial screening was summarized in Figure 1.  Within two months from initiating comprehensive screening, 75% of all new patients were consistently being screened for housing security, personal safety, and abuse. Screening for depression was not comprehensive until six months; this delay was in part a function of the software programming. Screening for substance abuse was harder to implement because our clinic uses urine screens and these results were already available in the electronic medical record.  Most nurses opted not to additionally query patients about substance use given biologic testing.

Figure 1. Timeline to Implement Psychosocial Screening (N=534)

Frequency of Psychosocial Risk Factors among Screened Prenatal Care Patients

Data regarding the proportion of patients who screened positive for psychosocial risk factors are presented in Table 2.  Among the 534 new patients seen in OB clinics between March 2008 and February 2009, 10.7% disclosed lifetime physical or sexual violence, and 6% disclosed current physical, sexual or psychological abuse (being threatened, stalked, controlled, or “in any other way made you feel unsafe”).  There was no documentation of screening for psychosocial items for 24 women; screening may have occurred but no indication of the patient being screened was noted in the medical record.  Additionally, 3.4% of women felt unsafe in their home, 9.8% of women reported being current smokers, 14.5% reported living with someone who smoked cigarettes, 4.4% reported alcohol use during pregnancy, and 2.1% disclosed illicit drug abuse including use of prescription drugs for recreational purposes.  Having difficulty keeping prenatal care appointments was expressed by 9.5% of screened women.  When asked about the timing of the current pregnancy, 8.5% disclosed that they did not want the pregnancy (not presented in table 2).  Very high current stress levels (5 of 5-point scale) was reported by 7.5% of women screened and 12% had depressive symptom scores of greater than 20 indicating depression on the Edinburgh Depression Scale.  Finally, one or more psychosocial risk factors were reported by 40% of those screened and 7.9% disclosed more than two psychosocial risk factors.

Qualitative Measures of the Impact of Screening on Patients

Case reports can shed some light on the actual experience of a patient who screened positive for psychosocial factors.  Three brief reports which provide some evidence of the value of screening for individual women are shown in the sidebars.

Health Care Providers’ Perspective on Psychosocial Screening

We invited all 57 nurses, attending physicians, fellows and residents to participate on an online survey via Survey Monkey.  The response rate was 40%.  Of the 23 responding health care providers, 6 were physicians, 6 were nurses, 1 was a fellow, and 10 were residents. Health care providers were asked, “In your opinion, what is the difficulty of screening women for abuse and depression?”  Responses included:  “finding time in busy clinic to screen patients and address positive screenings for depression and abuse,” “asking the right questions to get them to disclose any issues they may be having, and establish a rapport,” “bringing up the issue, especially in the setting of having other persons in the room,” “arranging follow-up with a social worker”, and “language barriers.”

Health care providers were also asked, “What resources would you need to screen your patients for psychosocial risk factors?” Most providers thought that having a social worker in the clinic would reduce the time burden on nurses to provide needed referrals for patients who screened positive for a psychosocial risk factor.  One provider noted, “A social worker or even an on-site counselor to provide immediate help or provide patients with a safety plan.”  Others recognized the additional time associated with conducting psychosocial screening.  Responses included, “It would be most helpful to feel like you did not have to rush because you have so many patients to be responsible for screening in a morning.”

Finally, we asked health care providers whether their patients had disclosed any health benefits of psychosocial screening in terms of health benefits of being screened for abuse or depression.  Fifty percent of nurses and 20% of attending physicians, residents, and fellow residents responded that they thought that their patients benefited from screening.  Health care providers were also asked   whether screening made things worse for their patients.  The majority of both physicians and nurses did not think screening made their patients’ situation worse.

Discussion

Monitoring the implementation of psychosocial screening using the electronic medical record (EMR) was essential to determining that the screening was universally provided to all new patients.  The EMR was useful as an assessment tool because it made monitoring easier and the EMR was designed so that   answers to the psychosocial screening items had to be provided for the nurse to move to the remainder of the items in the health care visit. This does not mean that the nurses necessarily asked the items requiring answers in the EMR, however this design feature increased the likelihood that the items may be addressed in some way.  Frequent communication with the nursing staff as well as attending physicians to ensure screening was functioning smoothly was very important. Although physicians were supportive of screening, we regularly needed to provide autonomy to the nurses in these screening efforts given the strong external pressure for high patient volume and clinic efficacy.  Physician leadership and support for universal screening was essential for screening rates to remain high.

Some of our findings were similar when compared to data from a national sample but there were also distinct differences.  In our population, 3.9% of women screened disclosed current physical or sexual violence (while not reported in Table 2, all women disclosing sexual violence also disclosed physical violence).  This rate was similar to the 1.8%-6.0% range of physical violence in the prior 12 months reported from 29 states in the Pregnancy Risk Assessment and Monitoring System (“Pregnancy Risk Assessment Monitoring System (PRAMS), Physical  Abuse “, 2008).  The frequency of smoking during pregnancy was in the range of the national PRAMS data (5.1% to 28.7%) (“Pregnancy Risk Assessment Monitoring System (PRAMS), Tobacco Use,” 2008), yet much lower than the 37% that was reported by PRAMS specifically for women in Kentucky (Anderson et al., 2008).  A similar pattern was observed for passive smoke exposure.  This observation may be explained by a lower smoking rate in Spanish speaking women who comprised almost 70% of our clinic population.  Our self-reported rate of alcohol consumption (4.4%) was comparable to the range reported in the national PRAMS of 3.0%-12.1% (“Pregnancy Risk Assessment Monitoring System (PRAMS),Alcohol use,” 2008) and the rate of 5% from Kentucky PRAMS (Anderson et al., 2008). Because universal implementation of screening for depressive symptoms was not in place until August 2008, we restricted analysis to women screened between August 2008 and February 2009 (n=290).  The estimate of depressive symptoms during pregnancy in our clinic was 12.0% which is comparable to those reported in other clinical populations ranging from 7.4%- 12.8% (Bennett et al., 2004). The prevalence of psychosocial risk factors in our population suggests that nurses conducting the screening were asking the questions in a way that pregnant women can and did disclose psychosocial risk factors.

There were many stories of how screening changed our practice, and how psychosocial screening improved women’s lives as described in the three case reports.  Although screening alone may not change the well-being of patients, it does allow disclosure and provides an opportunity for patients to access clinic or community interventions.  Building rapport, providing compassionate responses to disclosure, and making appropriate referrals were crucial to helping women make their best decisions to increase their safety and well-being.

Half of the nurses surveyed indicated that psychosocial screening, particularly abuse screening, was beneficial for OB patients while only 20% of physicians concurred that psychosocial screening was beneficial.  Observing the benefits of screening may be a function of when the questions were asked and who asked the questions.  In our screening protocol, nurses were instructed to conduct all screening in a private setting.  Patient responses were entered into the electronic medical record which physicians all had access to but may or may not have reviewed and thus may not have known the screening results and/or discussed issues of patient safety and well-being.  It is most likely that physicians were aware of screening if the abuse was current and nurses called this disclosure to the physician’s attention.  It is also likely that physicians were aware of the potential problem situations resulting from screening given the additional time needed for the nurse and other staff to counsel the patient and provide referrals before the physician visit could occur.  Physicians were less likely to see the possible benefits of screening that some patients may experience when nurses ask about their safety, well-being and prior abuse experienced.  Asking about violence validates this experience for some women.  Further, asking about violence even among those who have never experienced violence demonstrates knowledge of the frequency and health threat violence does have for many patients.  Through our experience with implementing psychosocial screening in a busy prenatal care setting, we have noted at least four challenges which may be helpful for others implementing psychosocial screening.  The first challenge is unique to states with required reporting laws.  The remaining three challenges are common to the overwhelming majority of prenatal care clinics.

Challenge 1: Mandatory reporting

According to the KRS 209.030, 620.030, the Commonwealth of Kentucky mandates reporting of spousal abuse to the Kentucky Department of Community Based Services (DCBS).  Reports must be made by “Any person, including physicians and nurses, who have reasonable cause to suspect that a child or adult has suffered abuse, neglect, or exploitation.”  Mandatory reporting laws in the state of Kentucky cover any crime committed against a person under 18, all cases of domestic violence, and cases of abuse and neglect of persons over the age of 18 who are “physically or mentally challenged” (“KY Acts ch. 157,” 1976; “KY Acts ch. 423,” 1986).  The primary challenge of this law for psychosocial screening was the additional time required to inform the patient of the law and complying with mandatory reporting requirements for abuse.  The law may have negatively affected patients’ willingness to disclose abuse due to fear of the partner or fear of deportation, given our unique population. To guide health care providers in the reporting process, we created a protocol for health care workers to use in reporting current spousal abuse (physical or sexual). This protocol included a script with the information needed to properly report the abuse by telephone. The following is an example of such a script: “This is Jane Doe, a RN at the XX clinic.  In interviewing Mrs. X, she indicated that in the past 12 months her husband pushed, shoved, slapped, hit, kicked or otherwise physically hurt her.  Her phone number is 222-222-2222.  We are treating her for unrelated conditions.” Our protocol stipulated that the patient be present for this call because women need to be in control of decisions and communications that directly impact their well-being.  While reporting to DCBS is mandatory in Kentucky, a patient can refuse services.  Typically the DCBS sends a letter to an address provided by the health care provider or makes telephone calls to offer referral services.  Women can provide an alternate address to which this letter can be mailed.  Per our screening protocol, we required that all women who screened positive for either physical or sexual abuse be provided with the hotline numbers and web sites for the Kentucky Association of Sexual Assault Program and/or the Kentucky Domestic Violence Programs.  Thus all patients with these needs received this information during the screening.

Challenge 2: Finding a private time/space to safely screen

As is true for many busy obstetrics clinics, family members frequently accompany patients during their health care visits. Because patient safety was of paramount importance, we established a “solo” visit policy. While family members could come to the prenatal care visit, they were not invited into the examination room with the health care provider. On solo visits, nurses asked psychosocial screening questions and provided referrals as needed. This screening was conducted in a private room with only the nurse and patient present. This practice protected the patient as well as the health care provider. It is possible that some partners may become suspicious of the health care providers and/or patients and attempt to locate the patient within the facility. If nurses or other staff perceived any immediate danger, they were instructed to call the security department and a guard would come to the clinic to assist.  During in-service meetings (described in detail below), we worked with local police to obtain the contact information for police detectives who handle domestic violence or sexual assault cases as well as contact information for police domestic violence advocates. Additionally, we worked with hospital security to inform them that we were initiating screening and that it was possible that their assistance might be required. In the year of implementation, we did not need any hospital security or local police support to assist our nursing or physician staff in addressing a hostile partner.

Challenge 3: Finding the time needed to screen and refer patients

We observed that having physician support at the highest level was essential for the continued success and maintenance of psychosocial screening.  Our findings indicate that the issue was not the time to screen the majority of patients (usually less than 2 minutes), but rather the time needed to provide referrals services and conduct mandatory reporting for women who reported current spousal abuse.  Typically, patients who disclosed abuse had more than one other psychosocial stressor thus requiring multiple referrals. Contacting agencies to find services for patients who were depressed and/or abusing drugs was challenging due to the limited number of mental health services for pregnant women.  We also recognized that providing brochures to patients was not the safest or the most effective way to offer referrals.  Therefore, we developed a resource guide to include hotline and web page resources for women experiencing the range of psychosocial risk factors (e.g. violence, stress, substance abuse, depression).  According to our protocol, the patient was given resource phone numbers for domestic and sexual abuse services with no other identifiers that were written on the back of the clinic business card to maintain her safety.  Patients were asked to take the card only if it was safe to so and health care providers reinforced the need for safety planning.

Challenge 4: Building Comfort and Confidence in Nurses Ability to Screen and Refer

Nurses were primarily responsible for conducting the psychosocial screening.  During the training provided on how to screen for domestic and sexual abuse in a health care setting, we received feedback that nurses needed a connection with the service providers to which they would be referring women.  Nurses needed to feel comfortable and confident in referring patients for services.  In response, we provided a staff “in-service” to bring representatives from other community-based referrals to our clinic to meet the staff, present their services, and allow time for clinic staff to ask questions and build rapport.  The first in-service featured the Executive Director of the local domestic violence shelter.  Examples of other in-services included representatives of the local Rape Crisis Center, police, social workers, and in-patient substance abuse treatment facilities.  Our implementation team arranged and attended these meetings. This level of direct communication between the health care team screening patients and the referral agencies was essential in increasing nurses’ comfort and confidence in both conducting the screening and making referrals.  These meetings were also an excellent opportunity to talk with nurses about what was and was not working relative to our goal to implement comprehensive psychosocial screening.  Nurses’ feedback was useful in continued negotiation with administrators regarding time for nurses to screen and provide referrals for women in need of such services.  While the majority of physicians supported efforts to screen and provide resources for patients, the time required for some patients (and some nurses) was problematic.  Continuing efforts to negotiate both additional time and to enhance skills to more effectively screen and effectively refer patients to the range of services were important for both patients and health care providers.

In conclusion, our experience in implementing screening for psychosocial risk factors indicated that screening was feasible and that we were able to establish comprehensive screening in a relatively short time frame.  The majority of both patients and health care providers indicated that screening did not negatively affect patient care and well being.

Table 2. Proportion of 534 Prenatal Care Patients Screened Positive for Psychosocial Risk Factors

* Because universal implementation of screening for depressive symptoms was not in place until August 2008, we have restricted this analysis to women screened in August and beyond (n=290 screened).

† Lifetime violence includes current as well as past violence

References:

ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention. (2006). Obstet Gynecol, 108(2), 469-477. doi: 108/2/469 [pii]

Anderson, A. R., Jewell, T., Jones, K., Robl, J., Kanotra, S., & Shepherd, R. (2008). Kentucky PRAMS Pregnancy Risk Assessment Monitoring Systems 2008 Data Report Kentucky Cabinet for Health and Family Services (pp. 1-83). Frankfort: Kentucky Cabinet for Health and Family Services.

Bennett, H. A., Einarson, A., Taddio, A., Koren, G., & Einarson, T. R. (2004). Prevalence of depression during pregnancy: systematic review. Obstetrics and  Gynecology, 103(4), 698-709.

Campbell, J., Torres, S., Ryan, J., King, C., Campbell, D. W., Stallings, R. Y., & al., e. (1999). Physical and nonphysical partner abuse and other risk factors for low birth weight among full term and preterm babies: a multiethnic case- control study.  American Journal of Epidemiology, 150, 714-726.

Clinical Preventive Services for Women: Closing the Gaps. (2011) The National Academy Press (pp. 117-123). Washington, DC: Institute of Medicine (IOM).

Coker, A. L., Sanderson, M., & Dong, B. (2004). Partner violence during pregnancy and risk of adverse pregnancy outcomes.  Paediatric and Perinatal Epidemiology, 18(4), 260-269.

Janssen, P. A., Holt, V. L., Sugg, N. K., Emanuel, I., Critchlow, C. M., & Henderson, A. D. (2003). Intimate partner violence and adverse pregnancy outcomes: a population-based study.  American Journal of Obstetrics & Gynecology., 188(5), 1341-1347.

Kiely, M., El-Mohandes, A. A. E., El-Khorazaty, M. N., & Gantz, M. G. (2010). An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial. Obstetrics and Gynecology, 115(2), 273-283.

KY Acts ch. 157, KRS 209.030 C.F.R. § 4 (1976).

KY Acts ch. 423, KRS 620.030 C.F.R. § 64 (1986).

McFarlane, J., Parker, B., & Morgan, B. (2007). Abuse during Pregnancy: A Protocol for Prevention & Intervention. March of Dimes Nursing Monograph.

Murphy, C. C., Schei, B., Myhr, T. L., & Du Mont, J. (2001). Abuse: a risk factor for low birth weight? A systematic review and meta-analysis. CMAJ, 164(11), 1567-1572.

Nelson, H. D., Nygren, P., McInerney, Y., & Klein, J. (2004). Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the US preventive services task force. Annals of Internal Medicine, 140(5), 387-396.

Plichta, S. B., Duncan, M. M., & Plichta, L. (1996). Spouse abuse, patient-physician communication, and patient satisfaction. American Journal of Preventive Medicine, 12(5), 297-303.

Pregnancy Risk Assessment Monitoring System (PRAMS) – Alcohol use. (2008, 11/18/2010). Data for all states for – 2008 – Indicator of whether mother reported having any alcoholic drinks during the last 3 months of pregnancy Retrieved 1/3/2012, 2012, from http://apps.nccd.cdc.gov/cPONDER/default.aspx?page=DisplayAllStates&state=0&year=9&category=2&variable=9

Pregnancy Risk Assessment Monitoring System (PRAMS) – Physical  Abuse (2008, 11/18/2010). Data for all states for – 2008 Retrieved 3/1/2012, 2012, from http://apps.nccd.cdc.gov/cPONDER/default.aspx?page=DisplayAllStates&state=0&year=9&category=1&variable=20

Pregnancy Risk Assessment Monitoring System (PRAMS)  – Tobacco Use. (2008, 11/18/2010). Data for all states for – 2008 Indicator for whether mother smoked during the last three months of pregnancy  Retrieved 1/3/2012, 2012, from http://apps.nccd.cdc.gov/cPONDER/default.aspx?page=DisplayAllStates&state=0&year=9&category=27&variable=31

Rini, C. K., Dunkel-Schetter, C., Wadhwa, P. D., & Sandman, C. A. (1999). Psychological Adaptation and Birth Outcomes: The Role of Personal Resources, Stress, and Sociocultural Context in Pregnancy. [doi:]. Health Psychology, 18(4), 333-345.

Silverman, J. G., Decker, M., R,, Reed, E., & Raj, A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195, 140-148.

Van de Weijer-Bergsma, E., Wijnroks, L., & Jongmans, M. J. (2008). Attention development in infants and preschool children born preterm: A review. [doi: DOI: 10.1016/j.infbeh.2007.12.003]. Infant Behavior and Development, 31(3), 333-351.

Yost, N. P., Bloom, S. L., McIntire, D. D., & Leveno, K. J. (2005). A prospective observational study of domestic violence during pregnancy. Obstetrics and Gynecology , 106, 61-65.

Appendix A

University of Kentucky

Psychosocial Screening Tool And Community Resource

Contents

Section 1  Introduction

Section 2  Prenatal Screening Tool

Section 3  Community Referrals

Section 4  Safety Planning

Section 5  Victim Services

Section 6  Additional Agencies

Introduction

Protocol for OB Routine Psychosocial Screening

Staff to conduct:  Nursing staff

When to conduct?

• At the screening prenatal care visit
• At each trimester of pregnancy
• At the postpartum visit

What is included?

• Introduction
• Psychosocial screener in Spanish and English
• Resources for making referrals (e.g. rape crisis, drug use, smoking cessation, suicide ideation or depression)
• Instructions for required reporting spousal abuse

SCREENING DOCUMENT IS ALSO AVAILABLE IN SPANISH UPON REQUEST.

NOTE TO NURSE INTERVIEWER: WOMEN SHOULD BE INTERVIEWED ALONE.

Read the following text to women who have never completed the psychosocial screener

• Because we care about your safety and health we are introducing a new set of questions to help us provide the best care we can and to help meet the needs for your own life situation.
• These may be new questions that have not been asked by other nurses or doctors, but they are an important part of your prenatal care.
• A few of the questions we will ask will involve the topic of abuse.
• If during our assessment you tell me that a child in your home is being abused or you tell me that your husband is physically or sexually abusing you, this worries me.  Please know that I am required by Kentucky State Law to report this abuse to the Kentucky Cabinet for Health and Family Services.
• The purpose of this report is to help you find out about services available in the community.
• I will make this call with you in the room so that you can talk with them about the services you may want or need.
• You may refuse services.
• I can also tell you about these services and help you contact these agencies when you are ready.
• For your safety your husband will not be informed that this report has been made.

OB Staff

Prenatal Care Screening Tool

1. Do you have any problems (job, transportation, childcare, or others issues) that prevent you from keeping your health care appointments?

• Yes
• No

2. Do you feel safe where you live?

• Yes
• No

3. In the past 2 months, have you used any form of tobacco?

• Yes [refer to tobacco-quit line] (Plichta, Duncan, & Plichta, 1996)
• No

4. Do you live with someone who smokes cigarettes?

• Yes[consider mention of tobacco quit line]
• No

5. In the past 3 months, have you used alcohol (including beer, wine, or mixed drinks)?

• Yes [consider alcohol and substance abuse referrals]
• No

6. In the past 3 months, have you used drugs that were not prescribed for you to get high or feel good?

• Yes [consider alcohol and substance abuse referrals]
• No

7. In the past 12 months, how many times have you moved (change where you live)?

_____ ____ TIMES

8. On a scale of 1 to 5, how would you rate your current stress level?

Low_________________High

1         2         3        4        5

9. If you could change the timing of this pregnancy, would you want it?

• earlier
• later
• not at all
• no change

As you are pregnant or have recently had a baby, we would like to know how you are feeling.  Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

10. I have been able to laugh and see the funny side of things

• As much as I always could
• Not quite so much now
• Definitely not so much now
• Not at all

11. I have looked forward with enjoyment to things

• As much as I ever did
• Rather less than I used to
• Definitely less than I used to
• Hardly at all

12. I have blamed myself unnecessarily when things do not go well

• Yes, most of the time
• Yes, some of the time
• Not very often
• No, never

13. I have been anxious or worried for no good reason

• No, not at all
• Hardly ever
• Yes, sometimes
• Yes, very often

14. I have felt scared or panicky for no very good reason

• Yes, quite a lot
• Yes, sometimes
• No, not much
• No, not at all

15. Things have been getting on top of me

• Yes, most of the time I haven’t been able
• Yes, sometimes I haven’t been coping as well
• No, most of the time I have coped quite well
• No, I have been coping as well as ever

16. I have been so unhappy that I have had difficulty sleeping

• Yes, most of the time
• Yes, sometimes
• Not very often
• No, not at all

17. I have felt sad or miserable

• Yes, most of the time
• Yes, quite often
• Not very often
• No,  not at all

18. I have been so unhappy that I have been crying

• Yes, most of the time
• Yes, quite often
• Only occasionally
• No, never

19. The thought of harming myself has occurred to me

• Yes, quite often (affirmative answers need notation and MD notification)
• Sometimes
• Hardly ever
• Never

(Current Psychological Abuse)

20. During the last 12 months, has ANYONE threatened you, followed you, stalked, controlled your activities or in any other way made you feel unsafe?

• No
• Sometimes
• Yes [for affirmative answers- yes and sometimes, consider referrals for partner violence]

If Yes or sometimes, WHO________________________________________

(Current physical abuse)

21. During the last 12 months, has ANYONE pushed, shoved, slapped, hit, kicked or otherwise physically hurt you?

• No
• Sometimes
• Yes(for affirmative answers- yes and sometimes, consider referrals of partner violence]

If Yes or sometimes, WHO __________________________________________

 (Current Sexual Abuse)

22. During the last 12 months, has ANYONE forced or coerced you into sexual activities?

• No
• Sometimes
• Yes [for affirmative answers- yes and sometimes, consider referrals for victims of partner violence]

If  Yes or sometimes, WHO__________________________________

In answering the next two items, please think your experiences in your lifetime.

23. Has ANYONE pushed, shoved, slapped, hit, kicked or otherwise physically hurt your?

• No
• Sometimes
• Yes [for affirmative answers- yes and sometimes, consider referrals for partner violence]

If  Yes or sometimes, (Just to make sure, you are not including something that happened in the last 12 months)

WHO__________________________________________

Did this happen when you were a child (<18 years old)

• Yes  Child Abuse
• No    Adult Abuse

24. Has ANYONE forced or coerced you into unwanted sexual activities?

• No
• Sometimes
• Yes [for affirmative answers- yes and sometimes, consider referrals for victims of partner violence]

If  Yes or sometimes, (Just to make sure, you are not including something that happened in the last 12 months)

24.a. WHO__________________________________________

If yes 24.b.  Did this happen when you were a child (<18 years old)

• Yes            Child Abuse
• No             Adult Abuse

Community Referrals

*Call Hospital/Clinic Security only if patient or staff is in immediate danger.

*Call local police only if patient wants to report abuse.

*When giving brochures, ascertain that possession will not jeopardize client safety. 

Safety Planning

During an explosive incident:

*If an argument seems unavoidable, try to be in a room with access to an exit.  Try to stay away from the bathroom, kitchen, bedroom, or anywhere weapons are readily available.

*Practice how to get out of your home safely.  Identify which routes would be best.

*Have a bag packed and ready.  Keep it at a relative or friend’s house in order to leave quickly.

* Identify one or more neighbors you can tell about the violence and ask that they call the police if they hear a disturbance coming from your house.

* Devise a codeword to use with your children, family and friends when you need to call the police.

* Decide and plan for where you will go if you have to leave home (even if you think you won’t have to).

* Use your instincts and judgment.  If the situation is very dangerous, consider giving the person you fear what they want to calm them down.  You have the right to protect yourself until you are out of danger.

*Remember, You don’t deserve to be hit or threatened!

If you have a Protective Order

*Keep the protective order on your person at all times.  Give a copy to a trusted friend, neighbor, or family member.  Be sure to give a copy to your children’s school if necessary.

* Cal the police if the person you filed the order against breaks the protective order.

* Inform employers, family, friends, neighbors, and your family physician that you have a protective order in effect.

Preparing to Leave

*Open a savings account and/or credit card in your own name to establish your own independence.  Remember to change passwords and restrict access.

* Get your own post office box.  You can then privately receive checks and letters to become more independent.

* Leave money, and extra set of keys, copies of important documents, extra medicines, and clothes with someone you trust or in a safe place so you can leave quickly.

* Determine who would be able to let you stay with them or lend you some money.

* Keep the shelter hotline phone number close at hand for emergencies, or better yet, memorize the number.

* Consider alternate plans for pet care

* Review your safety plan as often as possible in order to plan the safest way to leave.

Remember: Often victims of Domestic Violence are in the most danger when they leave an abusive situation

Safety and Electronic Devices

Electronic devices including computers, cell phones, land phones, etc. can be used to monitor your behavior and even stalk your whereabouts.  Be aware of the information that can be retrieved using caller ID, redial, phone and computer histories.

Cars and cell phones often have GPS (Global Positioning Systems) that can be used to track your current location and where you have been.

Public domain computers at the library or coffee houses are good alternatives when trying to avoid having communication traced.

Safety at Home and Work

*Change locks on doors as soon as possible.  Be sure to secure windows.

*Schedule an appointment with a safety planner from the Sheriff’s Department to come to your home.

*Discuss a safety plan with your children so they know how to access help when needed.

*Inform your children’s daycare, school, bus driver, etc. about who has permission to pick up your children.

*Inform neighbors and landlords that they should call the police if they see your abuser around your home.

*Inform appropriate resources at work such as office or building security of the situation.  Provide them with a picture if possible.

*Screen calls whenever possible.

*Have a safety plan when you leave work.  Have security escort you to your car and wait until you are safely on your way.  Use a variety of routes to avoid predictability.

Checklist

What to take when you leave:

Identification

• Driver’s license
• Children’s birth certificates
• Your birth certificate
• Social Security cards
• Welfare Identification

Financial

• Money and/or credit cards
• Bankbooks
• Checkbooks

Legal Papers

• PROTECTIVE ORDER – keep it with you at all times
• Lease, rental agreement, house deed
• Car title, registration and insurance papers
• Health and life insurance papers
• Medical records for you and children
• School records
• Work permits/Green cards/VISA
• Passport
• Divorce and Custody papers, marriage license
• Pre-trial bond release papers

Other

• House and car keys
• Medications
• Jewelry
• Address Book
• Pictures of you, children, and the abuser
• Children’s small toys
• Toiletries/Diapers
• Change of clothes for you and the kids
• Social security numbers for all family members

Kofi Annan, 7^th Secretary-General of the United Nations

Martha Davis, MSS and Sandy Dempsey, MSS, MLSP

Co-Directors, Institute for Safe Families

www.instituteforsafefamilies.org

The Institute for Safe Families (ISF) is a Philadelphia-based, non-profit organization whose mission is to strengthen families by creating healthy, nurturing environments that promote the positive development of children and prevent family violence.  In the last five years, ISF has been working steadily to develop programs and materials that identify how early trauma affects the full development of children.  Resources developed by ISF have been disseminated worldwide and incorporated into nationally distributed curricula.

ISF developed trainings and curricula for early care and education providers (CHANCE), child welfare providers (Parenting After Violence), and health care providers (RADAR).  What underlies these efforts and unifies our approach among all of our programs is that childhood stressors—family violence, abuse and neglect, substance abuse, etc.—are interrelated and often occur within the same families.  As research has shown, a critical factor that makes stressful events tolerable as opposed to toxic, is the presence of supportive adults who create safe environments, while helping children learn to cope and recover from violence and adversity.  The focus then becomes finding practical ways in multiple settings and systems that assess, intervene, and prevent frequent stressors encountered by children.

The ISF Process 

For each program initiative, ISF partners with organizations such as the Philadelphia Department of Public Health (PDPH), local children’s hospitals, universities, domestic violence and child trauma service providers, the Pennsylvania Chapter of Prevent Child Abuse, the Pennsylvania Chapter of the American Academy of Pediatrics and the Center for Non Violence and Social Justice at Drexel University.

For over two decades, ISF has used a four-step process to address systemic change.  This process has been essential in getting the systems involved to focus on family violence and adverse childhood experiences.  These may not be the primary issues for the system, but likely are significant secondary issues affecting their practice.

1. Experts in the field and key stakeholders within relevant systems are brought together to form a Think Tank or Network, facilitated by ISF staff.  These teams of clinicians, advocates, and service providers explore issues regarding family safety and the positive development of children that are relevant to that system, looking for innovative interventions for complex problems.
2. Current research is collected and evaluated, and innovative ideas are explored.  Services are devised and with ISF leadership, training curricula is often developed by these groups.  Collaborating organizations implement the direct services provided.  Through its Think Tanks and Networks, ISF most often assists in the development of policies and procedures, while delivering training and education to staff that are responsible for service delivery.
3. As part of service implementation, ISF facilitates forums that bring together multi-disciplinary providers in order to further examine the problem area.  These groups discuss specific cases, while planning and reviewing integrated services. These forums offer service providers opportunities for peer support, skill enhancement, and discussion of policy implications for the systems serving the population.
4. ISF conducts or facilitates evaluations of the effectiveness of the training, intervention, and service delivery.  Participating organizations act upon information from the evaluation and the information is disseminated as widely as possible to promote replication and inform future directions in programming and policy development.

Six ISF programs that focus on children exposed to violence are described below.  Each of these programs has been developed using this four-step process.

CAMP (Children and Mom’s Project/Pediatric Champions)

CAMP is a citywide collaboration led by ISF.  CAMP was piloted at St. Christopher’s Hospital for Children and the Children’s Hospital of Philadelphia primary care clinics, and is now being expanded throughout Philadelphia.  Lutheran Settlement House’s Bi-lingual Domestic Violence Program provided additional leadership in developing this work.  Through CAMP, families are screened for domestic violence using our Pediatric RADAR tool; services are provided to prevent further violence; and professionals help mothers and children recover and heal.  Since 2005, the St. Christopher’s Hospital for Children’s on-site domestic violence counselor has seen over 650 survivors of domestic violence and their families; the need continues to grow.  As of October, 2010, the counselor has received 230 referrals for services.  Upon referral from the hospital staff, the onsite domestic violence counselors are able to respond immediately in person.  The services most often provided to domestic violence victims are supportive counseling, housing support, safety planning, and legal advice.  The program started in the St. Chris Ambulatory clinics and now referrals come from all over the hospital.

When CAMP began, medical residents were surveyed regarding their knowledge and attitudes toward the screening for domestic violence. Following that survey and prior to training, a chart audit determined how many families were already being screened for domestic violence. Less than 1% of charts had any documentation of screening.  After just three months of intervention and training, screening rates in the Ambulatory Clinic rose to 36% and has been sustained since. Due to the success of increased screening rates and referrals, CAMP—which began in the outpatient ambulatory clinics—is now a fully funded and institutionally valued hospital-wide effort.  There is a hospital policy on domestic violence for patients and staff. New staff is trained in the policy and protocol of CAMP.

CAMP demonstrates that the “Pediatric Champions” model is key to instituting sustainable change, due to the emphasis on leadership and teamwork.  In a recently published study on what sets hospitals apart in terms of low acute myocardial infarction mortality, researchers looked at what distinguished top-performing and low-preforming hospitals (Curry, et.al. 2011).  They found no specific process or protocol helped the top hospitals; the success translated into teamwork and collaboration.  The most successful hospitals had a positive culture.  This culture is characterized by shared organizational values and goals, consistent involvement of senior management, broad staff presence and expertise, effective communication and coordination among interdependent groups, and an approach to problem solving that involves collective learning and growth.  These hospitals had an approach similar to the models used by ISF.  This includes CAMP, which employs a multidisciplinary team and intervention with a shared vision, values and goals, buy-in from senior administration, clear communication, and coordinated effort.

CAMP is now set up in two phases.  Phase One consists of ISF identifying, training, and mentoring “Pediatric Champions” within new pediatric health care settings.  These “Champions” facilitate Phase Two: actual establishment of CAMP services.  ISF currently supports six pediatric settings with the CAMP/Pediatric Champions model.  These sites evaluate our work to ensure goal completion.

Partnering with Parents  

This past year, ISF worked in partnership with national experts to develop an innovative and multi-purpose toolkit—Partnering with Parents (PwP).  PwP promotes healthy brain development through family violence assessment and teaching positive parenting strategies.  The PwP Toolkit helps pediatricians and other child-serving providers address these issues by bridging the gap between highly correlated risk factors and pathways for more streamlined assessment, intervention, and prevention.  The toolkit helps providers facilitate counseling for parents, while also providing additional resources for parents.  These resources are important steps in PwP that are aimed to increase positive parenting, while mitigating the effects of childhood exposure to violence and adversity.

Family Safe Zone

In 2012, ISF will develop and pilot The Family Safe Zone, a comprehensive educational and intervention program.  The goals are to assess for, intervene in and prevent child abuse, while focusing on preventing exposure to violence and adversity.  Our vision is that the Family Safe Zone pilot project will operationalize the information within the PwP Toolkit.  The program will be piloted and evaluated at St. Christopher’s Hospital for Children (SCHC) and its ambulatory pediatric clinics.  Components of the program include:

• Engaging the pediatric health care community at SCHC in child abuse prevention by raising awareness about child abuse and encouraging active roles in preventing it

• Educating professionals, hospital staff, and community members on methods to positively intervene in situations that may become unhealthy for children

• Encouraging positive parenting practices by having a PwP Counselor work with parents to improve their knowledge about the negative effects of corporal punishment, family violence, and the effects of trauma on early brain development

• Evaluating the utility and effectiveness of this project

Spare the Rod

Spare the Rod is an ISF initiative used to replace physical punishment with other more effective discipline measures.  The goal is to promote Philadelphia as a “no-hitting, no-spanking” city, while helping parents employ positive alternatives to physical discipline.  The association between physical punishment and increased aggression over time is irrefutable (Grogan-Kaylor, 2005).  This includes an elevated risk of future violence toward family members and intimate partners (Cast et.al. 2006; Douglas, 2006; Straus, et.al., 1997).  Evidence indicates that frequent and harsh physical punishment—characterized as discipline rather than child maltreatment—can also alter the structure and function of a child’s brain and the internal balance of stress hormones (Bugental et.al. 2003; Watts-English et.al. 2006).

The Philadelphia Adverse Childhood Experiences (ACE) Study Task Force

In 2012, ISF will convene and facilitate the Philadelphia ACE Study Task Force.  The goal is to examine ways to operationalize the ACE Study information in child-serving organizations, such as pediatrics, child welfare, and early care and education.  The ACE Study began in 1995 and is ongoing.  The study examined childhood origins of many of our Nation’s leading health and social problems.  Findings from the ACE Study indicate that childhood adverse experiences increase the risk for the ten most common causes of adult death in the United States.  This study underscores the relationship of childhood abuse, neglect, domestic violence, and other related experiences on health throughout the lifespan.  The findings are consistent with recent discoveries about the neurobiology of stress and the effect of stress on the developing central nervous system.

ISF will conduct a national survey to assess “who, what, where, when and how” the ACE Study information is being used.  Our goal is to translate the science and findings of the ACE Study into regional pediatric practice.  ISF, in collaboration with Prevent Child Abuse PA, the PA Chapter of the American Academy of Pediatrics, and the Philadelphia Public Health Department, will hold a major conference for state and regional pediatric clinicians on “How to Use the ACE Study in a Pediatric Setting.”

ISF is motivated by the new and emerging science on toxic stress, trauma, and early child development.  Part of the challenge in the coming decade, will be to find practical ways to translate this science into meaningful action among providers and communities, while improving the safety and health of all families and children.  For more information about ISF and resources, go to www.instituteforsafefamilies.org.

References

Anda, RF, Felitti, VJ, & Bremner, JD. (2006). The Enduring Effects of Abuse and Related Adverse Experiences in Childhood:  A convergence of evidence from neurobiology and epidemiology, Eur Arch Psychiatry Clin Neuroscience, 256, 174-186.

Anda, RF. (2005). The Health and Social Impact of Growing Up With Adverse Childhood Experiences:  The Human and Economic Costs of the Status Quo.  Paper downloaded from ACEstudy.org

Anda, RF.  Adverse Childhood Experiences and Population Health in Washington:  The Face of a Chronic Public Health Disaster.  Results from the 2009 Behavioral Risk Factor Surveillance System, July, 2, 2010.

Bugental DB, Martorel GA, Barraza V. (2003). The hormonal costs of subtle forms of infant maltreatment. Hormones and Behavior,43,237-244.

Cast, A. D., Schweingruber, D., & Berns, N. (2006). Childhood Physical Punishment and Problem Solving in Marriage. Journal of Interpersonal Violence, 21(2), 244-261.

Congressional Briefing. Anda, RF and Felittii, VJ. Adverse Childhood Experiences as a National Public Health Problem. Sponsored by the American Academy of Pediatrics and The Family Violence Prevention Fund. Capitol Hill, Washington, DC. April 18, 2006.

Curry, LA; Spatz, E; Cherlin, E; Thompson, JW; Berq, D;Ting, HH; Decker, C; Krumholz, HM; & Bradley, EH. (2011). What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study.  Annals of Internal Medicine, 154,384-390.

Douglas, E. (2006). Familial violence socialization in childhood and later life approval of corporal punishment: a cross-cultural perspective. The American Journal of Orthopsychiatry, 76(1), 23-30.

Grogan-Kaylor A. Corporal punishment and the growth trajectory of children’s antisocial behavior. (2005). Child Maltreatment,10,283-292.

McColgan, M.D., Cruz, M; McKee, J; Dempsey, S; Davis, M; Barry, P; Yoder, A.L.; Giardino, A. Results of a multifaceted Intimate Partner Violence training program for pediatric residents. Child Abuse & Neglect (2010), doi:10.1016/j.chiabu.2009.07.008

Straus MA, Sugarman DB, Giles-Sims J. (1997). Spanking by parents and subsequent antisocial behavior of children. Archives of Pediatric Medicine, 151(8),761-767.

Straus MA. (1996). Spanking and the making of a violent society. Pediatrics,98(24),837-842.

Watts-English, T, Forston, B, Gibler, N, Hooper, S, & De Bellis, M. (2006). The Psychobiology of Maltreatment in Childhood. Journal of Social Issues, 62(4), 717-736.

A pilot study by Haymore and colleagues describes how an innovative intervention can be adapted to offer survivors of family violence the opportunity to express and process their feelings through photography.  As always, hearing survivors’ perspectives helps to keep us grounded in our work.  This issue concludes with notes from the field from an organization, the Institute for Safe Families (ISF).  An innovator in the field of family violence, ISF describes several programs addressing children’s exposure to violence including initiatives to address physical punishment.  ISF is currently launching a Task Force to examine how the science on adverse childhood experiences can be integrated into pediatric practices.

Linda Chamberlain, Editor

As part of a special Office on Women’s Health funded initiative on maternal child health and violence called Project Connect: A Coordinated Public Health Initiative to Respond to Domestic and Sexual Violence (see more about Project Connect in this issue), Futures Without Violence is releasing a curriculum on domestic violence for home visitors. The curriculum is one of several resources that have been created through Project Connect, a special initiative on maternal and child health and violence (see more about Project Connect in this issue). Informed by several years of working with home visitation programs, authors Linda Chamberlain and Rebecca Levenson have developed and piloted a curriculum that includes PowerPoint presentations with speaker’s notes and a supporting bibliography of relevant research. This training resource is designed to be interactive and also includes discussion questions, exercises, role plays as well as accompanying training DVDs. The following topics are covered in the curriculum:

• Overview of Federal Benchmarks for Addressing Domestic Violence in Home Visitation Programs
• How Domestic Violence Affects Home Visitation Goals and Staffing
• Brief Overview of Domestic Violence: Definitions and Dynamics
• Screening and Safety Planning for Domestic Violence in Home Visitation
• Impact of Domestic Violence on Perinatal Health Outcomes
• Making the Connection: Domestic and Sexual Violence and Reproductive Coercion
• The Effects of Domestic Violence on Children
• Impact of Violence on Mothering and Promoting Resiliency for Children
• Childhood Exposure to Violence and Its Impact on Parenting
• Preparing Your Program And Supporting Staff Exposed to Violence and Trauma
• Fathering After Violence
• Mandated Reporting for Child Abuse: Challenges and Considerations

The curriculum includes safety cards for clients and a video demonstrating how a home visitor can use the Healthy Moms, Happy Babies safety card (see more information below) to talk with clients about domestic violence and safety planning. It also includes another safety card, Loving Parents, Loving Kids and an accompanying video to support home visitors educating parents about how childhood exposure to violence can affect parenting and steps to take that make a difference as a child abuse prevention strategy. Also included are the First Impressions DVD, a resource designed to educate parents about how exposure to domestic violence can impact brain development, and the DVD, Something My Father Would Do, which features men who describe their experiences of growing up in violent households and how it influenced their lives, relationships, and parenting skills. Pre-training and post-training surveys are also provided. The curriculum and training resources will become available shortly on a combination DVD/CD that can be requested at www.futureswithoutviolence.org/health.

2) Home Visitation Safety Card: Healthy Moms, Happy Babies

Healthy Moms, Happy Babies: Creating Futures without Violence is a folding card that asks questions in a self-quiz format to help mothers to assess if they are in a healthy relationship or a relationship that may be unsafe or dangerous. The safety card also asks about coping strategies and includes information about safety planning and how to get help (national hotlines). This tool folds up to the size of a business card (3.5″ x 2″) and is available in English and Spanish. Safety cards can be requested at www.futureswithoutviolence.org/health.

3) Home Visitation Safety Card: Loving Parents, Loving Kids

Loving Parents, Loving Kids: Creating Futures without Violence is a safety card for women that perinatal health care providers can distribute to patients. In addition to providing safety resources for women, this tool also functions as a prompt for perinatal health care providers by providing quick phrases to improve discussions with women about the impact of domestic violence on their parenting and children. This safety card outlines questions women may ask themselves about their relationships, birth control use and parenting, while offering supportive messages and referrals to national support services for help. This tool folds up to the size of a business card (3.5″ x 2″) and is available in English and Spanish. Safety cards can be requested at www.futureswithoutviolence.org/health.

4) Quality Improvement/Quality Assessment Tool

Futures Without Violence has developed a quality improvement/quality assessment tool to help home visitation programs to measure how their programs are addressing domestic violence. The tool includes sections on:

• Assessment methods including screening for lifetime exposure to violence and integrated assessment for violence, depression, and substance abuse
• Intervention strategies for clients who disclose victimization
• Networking and training
• Self-care and support for staff
• Data and evaluation
• Client education and prevention
• Resources and policies

This comprehensive assessment tool, which outlines optimal responses for each of the sections, can be used to track progress as home visitation programs implement new violence policies, and is also useful resource for program evaluation. The tool can be downloaded at www.futureswithoutviolence.org/health.

5) Guide for Policy Makers

Futures Without Violence recently released a guide for policy makers on home visitation and domestic violence. The publication, Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment, highlights the importance of addressing domestic violence within the context of home visits, makes the connection between domestic violence and home visitation program goals, and describes the overlap between domestic violence and child maltreatment. An overview of national home visitation models includes innovative home visitation programs that are designed to address domestic violence. Practice recommendations for integrating domestic violence into home visiting are outlined for policy makers. The guide can be downloaded atwww.futureswithoutviolence.org/health.

6) Home Visitation and Intimate Partner Violence: Recommendations for Policy and Program Development

The purpose of this document is to build on the strategies described in the Guide for Policy Makers (see item 5 above) by outlining ten core recommendations that funders, policymakers, and program managers should incorporate into home visiting programs. These recommendations, shown below, can be downloaded at www.futureswithoutviolence.org/health.

10 Core Recommendations:

1. Establish goals and objectives for home visiting programs to address the complexities and continuum of intimate partner violence (IPV) and its relationship to maternal and child health, safety, and wellbeing.
2. Collect data on IPV and incorporate IPV into all program evaluations.
3. Incorporate routine questions on IPV, reproductive coercion, and children’s exposure to violence into intake and other program forms and add content on IPV in resources and educational materials for families.
4. Train staff on IPV and children’s exposure to violence.
5. Make appropriate service referrals for IPV, sexual assault, reproductive coercion, and for children exposed to violence.
6. Collaborate and develop partnerships with domestic violence and sexual assault advocacy programs/shelters and child welfare agencies to coordinate policies and develop best practices.
7. Build capacity to address IPV by providing culturally appropriate services and hiring staff that reflect the diversity of the community being served
8. Implement standard practices and safety protocols related to IPV.
9. Support and supervise staff toaddress vicarious trauma and support those who have their own experiences of violence and abuse.
10. Engage and work with fathers and father-figures.

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

Graham-Bermann S.A., Banyard V., Lynch S., DeVoe E.R. Community-based intervention for children exposed to intimate partner violence: An efficacy trial. Journal of Consulting and Clinical Psychology, 75, 2, 199-209.

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.

]]> http://www.futureswithoutviolence.org/health/ejournal/2011/04/connecting-the-dots-childrens-exposure-to-violence-and-home-visiting-programs/feed/ 0 http://www.futureswithoutviolence.org/health/ejournal/2011/04/domestic-violence-within-the-context-of-home-visitingeight-lessons-from-the-dove-intervention/ http://www.futureswithoutviolence.org/health/ejournal/2011/04/domestic-violence-within-the-context-of-home-visitingeight-lessons-from-the-dove-intervention/#comments Thu, 07 Apr 2011 17:28:32 +0000 vedalyn http://endabuse.org/health/ejournal/?p=466 by Linda Bullock, PhD, RN, FAAN; Phyllis Sharps, PhD, RN, FAAN and the DOVE Research Teams

Linda F.C. Bullock, PhD, RN, FAAN
University of Virginia
School of Nursing
Claude Moore Educational Bldg
P.O. Box800826
Charlottesville, VA 22908-0826
Phone:  (434) 982-1966
Email: lcb2u@virginia.edu

Phyllis W. Sharps, PhD, RN, CNE, FAAN
Dept. of Community Public Health Nursing
Johns Hopkins University
School of Nursing
525 North Wolfe Street – Room 432
Baltimore, MD 21205
Phone: (410) 614-5312
Email: psharps@son.jhmi.edu

Dr. Bair-Merritt’s article in this e-journal issue, Home Visiting Programs’ Response to Intimate Partner Violence: What We Know and Why It Matters for the Health of Our Children,” makes it clear that children exposed to intimate partner violence (IPV) in the home are impacted negatively by the violence. She points out that the impact of this exposure may be minimized if there is a relationship between a supportive caregiver and the child. Historically, one of the main outcomes of home visitation programs has been to strengthen a caregiver’s supportive parenting role through education and role modeling. Addressing issues of partner violence in the home, however, has not traditionally been a part of home visiting services. In a recent NIH/NINR-funded study, Domestic Violence Enhanced Visitation Intervention (DOVE) [R01 NR009093; Dr. Phyllis Sharps, Principal Investigator, Johns Hopkins University, School of Nursing], an empowerment intervention (DOVE) that home visitors can use to reduce the impact of IPV is being tested in rural Missouri and urban Baltimore. The lessons learned from this study provide rich data for other home visiting programs.

My research team (Bullock, Co-Principal Investigator) has been working with home visitors in several different home visitation programs throughout a large area of Missouri. The home visiting programs that are field testing the DOVE intervention include two Missouri Department of Health and Senior Services prenatal home visiting programs: the Nurse Family Partnership® program (Building Blocks) and the Missouri Community-Based Home Visiting program (MOCBHV). The Lutheran Family and Children Services home visiting program also participated in the field testing. Nearly a hundred home visitors of varying backgrounds and licensures have worked with the research team in implementing and testing the DOVE intervention in 24 of the 115 counties in Missouri.

Over the course of the first eighteen months of the grant, many formal and informal training sessions for the home visitors were conducted by the researchers. Even with repeated trainings, we were faced with a huge recruitment problem for the study. Eighteen months into the study, there were few referrals because the home visitors claimed they were not finding any women in their caseloads that were positive for current abuse or abuse in the past year. It appeared as if IPV had disappeared in Missouri. The research team and the State Health Department decided to hold another required intensive training in the state’s capitol city for all home visitors, but this time we would also address the barriers to assessing for IPV that could be occurring. This training used different strategies from those in previous training sessions. First, a male expert in the area of IPV was brought in as a key speaker to address the issue of problems with the male partner being in the home at the time of the visit thus preventing the home visitors from screening. Second, role playing was employed so that every home visitor had an opportunity to assess or be assessed while role playing as a woman who was experiencing abuse. Each home visitor also had the opportunity to observe an assessment and make comments to the assessor and the person being assessed about how they viewed the role play as an outsider looking in on an interview.

As a final step, participants were divided into focus groups of six to eight home visitors to determine what they thought were barriers and facilitators for implementing IPV assessments and interventions within their case loads (Eddy et al, 2008). We learned that one of the main barriers to addressing IPV in the home was a lack of knowledge on how to address IPV in this situation. This fueled stress and fear in the home visitors. The stress came from a feeling of inadequacy and fear of making a fool of themselves when they talked to the women about the violence. Home visitors also discussed feeling stressed in trying to control their own personal feelings when addressing the issue. There were also fears regarding safety; not only for the women but also for themselves. The most important facilitator identified by home visitors was a feeling of having a good rapport with the woman and knowing that the woman trusted her. Being able to talk about these barriers and facilitators seemed to make a difference because after this training, referrals to the DOVE study increased in Missouri.

Through five years of experience in Missouri, many lessons have been learned about how to effectively implement assessments and interventions for IPV during home visits. The home visitors have learned from our expertise in the area, but we have also learned from them. We believe that sharing these lessons can be valuable to others. Critical factors to be considered when implementing protocols within home visiting programs are listed below with excerpts from the focus groups conducted with home visitors.

Lessons Learned and Quotations from the Home Visitor Focus Groups

1. Training is best done in conjunction with local resources such as local women’s shelters, law enforcement agencies, and legal services. The home visitors we have worked with expressed the need to understand the laws in their area and what services are available. As one home visitor said:

So that would have been a good educational piece to know what happens when mom and baby go into shelter what will happen next? Am I going to lose my food stamps, am I still going to get “ will I lose everything because I go to shelter and then I won’t have anything? I am just stuck there and I don’t have any answers for those questions.”

Having representatives from the shelter and law enforcement agencies present at IPV trainings can help answer questions like the one above. Along with wanting to know what happens when a woman decides to seek refuge, other questions the home visitors had included laws for mandated reporting of IPV, child abuse laws, and legal resources that were available and how to refer to those services. It has been our experience that the home visitors not only appreciate being able to ask their questions and receive answers from the experts, but they find it valuable to be introduced to local contacts that they can call on in the future as other questions arise.

2. Role playing in training sessions helps to increase the comfort level and the likelihood of home visitors asking the questions and intervening.

The other thing was practicing the questions and hearing how other people are saying their questions and stuff, because I know personally I am like I am getting all into someone’s business and are they going to tell me the truth or not? Even if I ask these questions or did I just put up another wall or am I still going to have the same ¦ there are certain things you can ask as a home visitor that you wonder if you are putting up a wall and then the next time you come there is that little stand back like what is she going to ask me or do I want to continue to have that strong relationship with a strong foundation. So that scares me, but listening to how others are saying it and constantly saying it and then at the end the one woman was saying if I offended you in any way, I am really sorry. Tell me how it felt when I asked you those questions so you can become a better communicator with the subject.

Another home visitor echoed a similar feeling:

I have never had any training on DV so I had never learned about screening. I had never learned about any of that. Even just doing the role playing scenario upstairs really helped me because I had never been forced to ask those questions before and use that. And it was good to try it out on someone that was not going through it instead of having been placed in it and having to do it.

Although usually met with resistance from training participants, it is well worth pushing the issue of role playing during the training and having facilitators present that can help guide this exercise. It has been our experience that for many home visitors, this is the first time they have ever asked the questions out loud. Practicing in a training session not only improves their skills in assessing and intervening, it provides an opportunity to go beyond the first time to ask step.

3. Before the information being presented can be fully utilized by home visitors, the training needs to address their attitudes and beliefs about violence and their own personal experiences with violence.

I think that concept of stirring the pot and that you are going to make it worse just reminded me that I need to look at the whole box or picture and that the outcome is that they learn and they are safe. If it means that he is mad at me and won’t let me come back but she has the numbers that she needs then I need to get over it cause it is not about me, it’s about her and her baby.

Another home visitor clearly struggled with addressing the issue of violence. When confronted, she found her own experiences with the issue were getting in the way of helping other women:

My stress comes into the point of being able to control my feelings. I worked for a family for 1 ½ to 2 years and didn’t even know that he was abusive and out of the blue one evening she shared her abusive experiences and because of the bond that I shared with her and my sister’s abusive relationship, I wept and I felt bad about that because we are trained not to cry with the family because the concern is that you are going to make her sad. Which in one sense it did make her feel bad but I guess in a good sense it shows her that I am very sympathetic and that I feel her pain in some sense. I am also concerned that as I continue to work with mom if I will be able to handle the emotional part of it.

Other home visitors were more positive in how they were able to handle the issue:

I want to address the idea of frustration and I think that anyone that is going to do this job at some point you have to draw that line of what you can accomplish and then leave it up to them to some point whether it is smoking, abuse or sleeping with their baby or all of those things. You can only give them so much information and then it is up to them. This is the same type of situation. You can’t make them get out of that relationship, but you can give them support and be there for them and that when they are ready you are there for them and will help them.

We all bring our own personal history to any task, but a valuable first step is to acknowledge that history and move beyond that point. Without this crucial step, it is difficult to effectively deal with others experiencing similar problems.

4. The training needs to specifically address communication styles when talking to women about violence.

Over many years of working with vulnerable women, we have come to appreciate their acute abilities to pick up on what we call the phony factor. As one home visitor put it, Making it real, and being real with them, this is what I have heard and this is what I have seen. Home visitors need to understand that they must be totally non-judgmental when talking to women about violence “particularly when addressing the reproductive coercion that may accompany physical and emotional violence. Some home visitors in our training understood their role is to provide information and resources and the woman’s role is to decide what is best for her family. As expressed by this home visitor:

Being careful not to put your personal judgments out there “ making sure you are not prejudging them. What if she does say yes “ what are you going to say? How am I going to make it look like it’s okay, it’s alright and I am glad that you are sharing this with me instead of ‘Girl, how could you’

5. The training should also address concerns the home visitors may have such as whether a requirement to report to authorities such as child protection services will ruin the trust they are trying to build.

We have to consider, do we hotline the situation if we see abuse? It is a little more intrusive with hotline calls and mandating reporting. I think that we think on that end “safety. The duty to warn and safety and I think that is always a concern for us. So, now we have built this relationship with her and if she discloses to us and we hotline her, will that tear down that relationship with her and if she discloses to me that the children in the home might be at risk, that if they pick up the kids, they would have to be in foster care. That is just some of the things that might be going through our heads.

This home visitor clearly struggles with her responsibilities of being a mandated reporter and her role as a helping person for this family. Training should demonstrate how working in partnership with the woman, letting her know that you will not report her without her full knowledge, not only empowers her but also builds trust and confidence so that she can confide her inner thoughts and feelings. This extends to the woman also knowing that what she shares will be confidential, and is of particular importance in rural areas such as Missouri.

6. A huge barrier for home visitors in addressing violence is the presence of the male abuser in the home.

This was a common concern among all the home visitors we have worked with in Missouri, and one that became less of a problem after we brought in a male expert in the area of IPV. Based on his advice and our experiences, we train home visitors to take the woman’s lead on how to deal with her partner. We also recommend the home visitor have brochures in her/his bag that address fathering and/or child development. If the client’s partner appears during the visit, the home visitor can engage him in his role in helping to ensure the child has the best chance of developing to his/her full potential. It seemed that this may not be something home visitors consider, as seen in the following quote,Maybe that is a good idea to bring in some information pamphlets with me in case I have to shift ¦ and he walks into the room one day unexpectedly. During the training, we also suggested that if the home visitor feels uncomfortable discussing IPV in the home for fear of the male partner, then she could meet the woman at another location for one of the scheduled visits. In response, a home visitor stated, I had never thought about meeting her at the WIC clinic or her primary care “you know that is something we can do because they are in the house and I think that is going to have a big impact on our program.

7. Working with families where abuse is occurring is not a happy experience for anyone, particularly when there is a lack of resources in the community for referral. This is reflected in the following statement by a home visitor:

“so it’s like now what do I do because I can’t leave phone numbers to call. I have no way to get you transportation which happens in —which is the site that I am from. I have girls that don’t have a phone and don’t have transportation. I can’t leave phone numbers. I can’t say here is this transportation. So, what do I do? There is my question, because I am stuck.”

Over the five years of working with the DOVE study, we have come to appreciate that, perhaps, the most important thing for any woman is to have the opportunity to discuss her situation with someone, like a home visitor, who will not judge her and who will let her have control of what she needs to do to keep herself and her children safe. In circumstances like these, we have trained home visitors to offer the use of their own cell phone to work out a safety plan with an advocate at either a local shelter or the National Domestic Violence Hotline (1-800-799-SAFE).

When I first started I had that inner sense of ˜Oh my gosh, I have to do something inside me “ you stay calm on the outside and you do the nursing thing “but on the inside I was going crazy. Then I realized that like anything else it has a cycle and that people are not always ready at the same time and in my situation like other programs, I am in their lives for a long period of time. So, I am noticing with these ladies that the more I see these ladies the more they see you, the more they see you caring by connecting them with something. It helps them open up and empowers them “so I just take it just a little bit at a time.

8. Because work in this area is difficult, we recommend frequent team meetings or regularly scheduled meetings with a supervisor for debriefing.

We have found this important in our own work with women experiencing abuse. One of the home visitors expressed the same sentiment:

I think that my struggle is feeling a little inadequate and not knowing what to say. I can encourage them and tell them that what is happening is not okay. I haven’t had a lot of experience with physical abuse but right now I am dealing with verbal and emotional abuse with two of my clients and just thinking that I don’t know the perfect thing to say, and others said taking it home and being so upset and thinking I don’t know how long you can do this type of work since it affects me so much so a variety of emotions.

With Sec 2951 of the 2010 Healthcare Reform Bill, Maternal, Infant, and Early Childhood Home Visiting Programs, calling for home visitation programs to be strengthened by providing comprehensive services to improve outcomes in at risk families, the lessons from DOVE are invaluable. States will be required to measure improvement in rates of IPV, particularly among those women receiving home visitation services. Although IPV is not something that home visitors have ignored when working with families, it is not a health issue that is routinely assessed or addressed in a standardized procedure during most home visits. Not addressing IPV could be one reason that the outcomes home visitors hope to achieve have not been realized.

In summary, it is vital to assess each woman for current IPV so that resources can be offered to improve the health and safety of clients and their children. For assessments to be accurate and for an intervention to be effective, however, very specific training and support must be available for those providing the services. More than how to assess and intervene; the training must include role playing, specific strategies to address barriers that could prevent talking about the issue in the home environment, and last, but not least, the provider’s personal feelings or experiences that may intrude. The DOVE model provides home visiting programs a ready means of implementing this training and intervention. Failure to deal with the elephant in the room will ultimately cause more harm than good.

References

Eddy, T., Kilburn, E., Chang, C., Bullock, L., Sharps, P., and the DOVE Research Team. (2008). Facilitators and barriers for implementing home visit interventions to address intimate partner violence: Town and gown partnerships. Nursing Clinics of North America, 43, 419-435.

Megan H. Bair-Merritt, MD, MSCE

200 North Wolfe Street, Office 2021
Baltimore, MD 21287
Phone: (443) 287-8954
Email: mbairme1@jhmi.edu

Home visiting programs across the United States vary with regard to specific elements of model implementation such as frequency, duration and timing of visits, and educational background of the home visitors. Despite differences in design, however, most home visiting programs target families deemed to be at-risk for adverse outcomes; depending upon the study, ~15-45% of families enrolled in home visiting programs report intimate partner violence (IPV) (Chamberlain, 2007). Additionally, all home visiting programs are united in their goal to optimize maternal and child health. In order to most successfully achieve this overarching goal, home visiting programs should include standardized protocols to assess for IPV and to provide assistance both to women experiencing abuse and to the children exposed to this violence.

The following article describes why inclusion of IPV-specific content is an important component of ensuring excellent child health, what is known in the scientific literature about the impact of home visiting programs on IPV, and what interventions are currently being studied as options for adding IPV- specific content to home visiting models. Finally, recommendations are made for translating research to practice. Complementary information can be found in the Davis, James, & Stewarts’ (2010) guide for policy makers on IPV and home visiting.

Why is the inclusion of IPV screening and response important in ensuring excellent child health?

Childhood exposure to IPV independently predicts poor child health and development. Thus to maximize children’s well-being, IPV must be recognized and addressed, and mothers’ health, safety and positive parenting skills must be supported.

The National Scientific Council on the Developing Child (2005) defines a toxic stressor as “stressful events that are chronic, uncontrollable, and/or experienced without the child having access to support from caring adults” (p. 1); such stressors activate children’s stress response system, with chronic activation of this system potentially leading to permanent physiological changes which have been associated with adverse health outcomes (National Scientific Council on the Developing Child, 2005). Childhood IPV exposure is a particularly potent “toxic stress” for children because it is often chronic and uncontrollable, and it may impact caregivers’ ability to engage in positive parenting practices (Levendosky, Leahy, Bogat, Davidson, & von Eye, 2006).

Childhood IPV exposure has been associated with poor social-emotional child health outcomes from infancy through adolescence (Kitzmann, Gaylord, Holt, & Kenny, 2003; Holt, Buckley & Whelan, 2008). Infants exposed to IPV may exhibit signs of traumatic stress such as frequent crying and inability to comfort, particularly when their mothers have experienced severe abuse and have resultant symptoms of post-traumatic stress disorder (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006). Toddlers display excessive separation anxiety, increased aggression with peers and lower social competence (Howell, Graham-Bermann, Czyz, & Lilly, 2010). School age children frequently blame themselves for the IPV, and are at increased risk for both internalizing (e.g. anxiety, depression) and externalizing (e.g. aggression) disorders (McFarlane, Groff, O’Brien, & Watson, 2003; Hazen, Connelly, Kelleher, Barth, & Landsverk, 2006). Finally, adolescents exposed to IPV are more likely than their peers to engage in risk-taking behaviors such as substance use and abuse, and risky sexual behavior (Holt, et al., 2008). Teenagers exposed to IPV are also more likely to enter into relationships characterized by dating violence (Holt, et al., 2008).

Emerging evidence also supports that children exposed to IPV are at increased risk of a host of physical health problems (Bair-Merritt, Blackstone, & Feudtner, 2006). Boynton-Jarrett, Fargnoli, Suglia, Zuckerman, & Wright (2010) reported that children exposed to “chronic” IPV had an 80% increase in odds of obesity at 5 years of age. Suglia, Enlow, Kullowatz, & Wright (2009) found that IPV-exposed children develop asthma at twice the rate of children not exposed. Interestingly, however, Suglia et al. (2009) found that IPV-exposed children were protected from this increase in asthma incidence if there were high levels of positive maternal-child interaction. This latter finding suggests that interventions that strengthen the relationship between a supportive caregiver and a child, such as home visiting, may help to buffer the adverse impact of IPV on child health.

Finally, children exposed to IPV have altered, and sub-optimal, health care use patterns. These children are less likely to attend regular well-child care with a primary provider, and are more likely than non-exposed peers to be under-immunized (Bair-Merritt, Crowne, Burrell, Caldera, Cheng, & Duggan, 2008). When severe IPV is occurring, they may be more likely to visit the emergency department (Bair-Merritt, Feudtner, Localio, Feinsten, Rubin, & Holmes, 2008). In general, children exposed to IPV incur ~20% higher health care costs than children who are not exposed (Rivara, et al., 2007).

The presence of IPV may limit home visiting programs’ ability to prevent child maltreatment.

The American Academy of Pediatrics states that “identifying IPV may be one of the most effective means to prevent child abuse…” (Thackeray, et al., 2010; p. 1094). This statement is based in part on the common co-occurrence of child maltreatment and IPV. Review studies have estimated that the median overlap in at-risk samples is between 30 and 60% (Appel & Holden, 1998; Edleson, 1999).

Some home visiting programs have had documented success in reducing child maltreatment (Bilukha, et al., 2005). However, an analysis of data from Nurse-Family Partnership in Elmira, New York found that while, in general the home visiting program reduced child maltreatment, rates did not decrease significantly when frequent IPV was present (Eckenrode, et al., 2000). Thus, IPV is the proverbial “elephant in the room.” Without properly addressing violence within the caregivers’ relationship, efforts to prevent child maltreatment may fall short.

What is known in the scientific literature about the impact of home visiting programs on IPV?

The evidence is limited, and existing study findings need to be replicated in other home visiting programs.

A review conducted by Bilukha et al. (2005) examined the relationship between home visiting and the prevention of myriad types of family violence. This review concluded that there was insufficient evidence to determine if home visitation was associated with reduced rates of IPV and called for further research in this area. Several studies, however, have examined the impact of home visiting on IPV. For example, reports from the Nurse-Family Partnership in Denver, Colorado found lower rates of IPV for nurse-visited women when children were four years of age (Olds, et al., 2004), but no program effects on IPV for women in Memphis at 6 or 12 year follow-ups (Olds, et. al., 2004; Olds, et al., 2010).

Bair-Merritt, et al. (2010) recently published a study using data from the Hawaii Healthy Start Program (HSP) to determine whether home visiting was associated with reduced rates of both maternal IPV victimization and perpetration. Results indicated that in the home visiting group, as compared to the control group, rates of IPV victimization decreased and rates of IPV perpetration decreased significantly during the three years of program implementation when children were aged 1 to 3 years. At long-term follow-up when children were 7 to 9 years of age, rates of IPV victimization and perpetration decreased for both intervention and control mothers but there were no longer statistically significant differences between the two groups (Bair-Merritt, et al., 2010).

The recent Hawaii HSP study raises two important issues that warrant further comment. First, measurement and definitions are important if IPV is a primary outcome of interest. It is preferable that IPV not be viewed as “present” or “absent,” but that researchers and program evaluators consider program impact on frequency or rates of IPV; while the ultimate goal is cessation of IPV, reduction in frequency also may be beneficial to maternal and child health. Also, when considering child impact, IPV victimization and perpetration should both be considered.

Second, an association existed between home visiting and reduced IPV even though Hawaii HSP home visitors reported discomfort with their knowledge about IPV, and did not consistently link women experiencing abuse with resources (Duggan, et al., 2004). This reticence to ask women about IPV has been documented in other home visiting studies as well (Tandon, Parillo, Mercer, Keefer, & Duggan, 2008). Reductions in IPV instead may have been related to the home visitors’ encouragement of maternal self-efficacy and to the longitudinal relationship of the mother and home visitor.

Finally, recent evidence suggests that the ability of home visitors to form trusting relationships with mothers, and to potentially reduce IPV, may relate to the mother’s attachment status and depression. Using data from Healthy Families Alaska, Duggan, Berlin, Cassidy, Burrell & Tandon (2009) found that the program had a differential impact on IPV based upon the mother’s baseline depression and attachment status. Specifically, the program attenuated IPV, but only with depressed mothers who scored low to moderate on baseline measures of discomfort with trust/dependence (Duggan, et al., 2009).

What IPV interventions are currently being studied as enhancements to home visiting models?

Recognizing IPV identification and response as a critical part of home visiting, sites across the country are testing the effectiveness of IPV-specific content delivered during home visiting. Two of these projects are detailed here with additional promising programs detailed in the Davis, James, & Stewarts’ Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment. A Guide for Policy Makers” (2010).

With funding from Centers for Disease Control and Prevention through the West Virginia University Injury Control Research Center, investigators from several academic centers are conducting a study to develop and evaluate a model of an in-home IPV intervention for mothers enrolled in the Nurse Family Partnership program (NFP).  For phase 1 of the study– development of the IPV intervention– qualitative case study methods have been used.  The intervention is currently being pilot tested for feasibility and acceptability.  The second phase of the study will involve a cluster randomized controlled trial (RCT) to test the effectiveness of the NFP plus IPV intervention compared with the existing NFP model in improving the client’s quality of life and reducing the recurrence of IPV.  NFP sites are currently being recruited for the RCT; enrollment of participants is planned to start in the fall of 2010.

The DOmestic Violence Enhanced Home Visitation (DOVE) Project is a National Institutes of Health (NIH/NINR) funded research project conducted over 5 years as a collaborative effort between Johns Hopkins University, the Baltimore City Health Department, the University of Missouri, and Missouri Department of Health and Senior Services. The DOVE intervention is a highly-structured public health nurse-administered IPV home visitation program, designed to educate new mothers who screened positive for IPV and reduce their overall risk of continued IPV. To date 257 women have been recruited. Initial results show that, compared to control mothers who did not receive the intervention, women in the DOVE group reported significantly lower physical and sexual IPV scores at delivery (p<.05). At 18 months post- delivery, DOVE participants reported lower overall total IPV scores and lower scores on negotiation and psychological IPV (p<.05) as measured by the Conflict Tactics Scale. These reductions are a promising trend and provide evidence that integrating IPV-specific content into existing home visiting programs may reduce IPV against pregnant and parenting women.

How can research best translate to policy and practice?

To most effectively promote children’s healthy growth and development, home visiting programs should include IPV-specific content.

Although writing such a recommendation is easy, translating research to practice is challenging, and must be done with significant forethought and care. Some flexibility in IPV-specific program content is important to meet the individual needs of the communities that each program serves. However, several general recommendations can be made:

1. Home visitation programs should include explicit, evidence-based content designed to screen for and address IPV. Emerging results from trials such as the NFP study and DOVE should help to inform the use of evidence-based practices. Until results of these trials are disseminated, existing literature about efficacious IPV interventions tested in non-home visiting settings may be a useful guide. For example, Kiely, et al. (2010) reported results from a randomized controlled trial of a tailored IPV counseling intervention that was delivered to women in prenatal clinics. The authors found that women who received the intervention group experienced lower odds of recurrent IPV (Kiely, et al., 2010).

2. Once the IPV-specific content is integrated into home visiting models, an implementation system must be put into place to ensure that home visitors acquire, maintain and apply the skills necessary to enact this content. For example, the ability to successfully implement IPV-specific content may differ based on qualities of the home visitor or the family, and the implementation system needs to specifically address these issues. This likely will take an investment in time and money to train, supervise and coach home visitors, and must include an honest assessment of barriers to screening and management.

3. Programs should routinely assess fidelity. As discussed in #2, a well-conceived implementation plan with quality improvement initiatives may foster model fidelity (Rubin, 2010).

4. If IPV-specific content is delivered with fidelity, programs should consider if this content is effective; however, program evaluators must decide a priori how they will define and measure effectiveness. This likely should include outcomes related to the home visitor (such as knowledge of IPV and its impact on children and awareness of community-based IPV resources) and the caregiver (such as rates of IPV, steps taken toward safety planning, connection with community-based IPV resources). To assess whether IPV is ongoing, one option is administering a validated IPV measure at regular intervals. Repeated screening may be necessary because it is common for caregivers to transition into and out of violent relationships (Bair-Merritt, Ghazarian, Burrell, & Duggan, submitted). Caregiver reporting of frequency, severity and directionality of IPV also may be helpful in evaluating program effectiveness in reducing IPV.

5. A related consideration is whether there are circumstances in which the content is more or less effective, and how the content should be modified to best meet the needs of families for whom it is less effective.

The focus of this issue of the e-journal on the intersection of home visiting and IPV is timely given the recent federal funding of home visitation programs as part of health reform. Moving ahead, close collaboration between researchers, practitioners, advocates and policy makers is needed to optimize the delivery of IPV-specific content as part of the home visitation model.

References

Appel, A., & Holden, G. (1998). The co-occurrence of spouse and physical child abuse: A review and appraisal. J Family Psych, 12, 578-599.

Bair-Merritt, M.H., Blackstone, M., & Feudtner, C. (2006). Physical health outcomes of childhood exposure to intimate partner violence: a systematic review. Pediatrics, 117(2), e278-290.

Bair-Merritt, M.H., Crowne, S., Burrell, L., Caldera, D., Cheng T., & Duggan, A. (2008) Impact of intimate partner violence on children’s well-child care and medical home. Pediatrics, 121(3), e473-480.

Bair-Merritt, M.H., Feudtner, C., Localio, A.R., Feinsten, J.A., Rubin, D., Holmes, W.C. (2008). Health care use of children whose female caregivers have intimate partner violence histories. Arch Pediatr Adolesc Med, 162, 134-139.

Bair-Merritt, M.H., Ghazarian, S., Burrell, L., & Duggan, A.K. (submitted). Intimate partner violence in mothers at-risk for child maltreatment: classes of violence and movement between classes over time. Public Health Reports.

Bair-Merritt, M.H., Jennings, J.M., Chen, R., Burrell, L., McFarlane, E., Fuddy, L., Dugan, A.K. (2010). Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start home visitation program. Arch Pediatr Adolesc Med, 164, 16-23.

Bilukha, O., Hahn, R., Crosby, A., Fullilove, M.T., Liberman, A., Moscicki, E., Snyder, S….Briss, P.A. (2005) The effectiveness of early childhood home visitation in preventing violence: a systematic review. Am J Prev Med, 28, 11-39.

Bogat, G.A., DeJonghe, E., Levendosky, A.A., Davidson, W.S., von Eye, A. (2006) Trauma symptoms among infants exposed to intimate partner violence. Child Abuse Negl, 30, 109-125.

Boynton-Jarrett, R., Fargnoli, J., Suglia, S.F., Zuckerman B., & Wright, R.J. (2010). Association between maternal intimate partner violence and incident obesity in preschool-aged children. Arch Ped Adol Med, 164, 540-546.

Center on the Developing Child at Harvard University (2010). The Foundations of LifelongHealth Are Built in Early Childhood. http://www.developingchild.harvard.edu

Chamberlain, L (2007). Published studies on home visitation with findings relevant to domestic violence. Family Violence Prevention & Health Practice. 6,  http://www.endabuse.org/health/ejournal/archive/1-6/

Davis, L., James, L., & Stewart, K. (2010) Realizing the Promise of Home Visitation: Addressing Domestic Violence and Child Maltreatment. A Guide for Policy Makers http://www.endabuse.org/userfiles/file/Children_and_Families/Realizing%20the%20Promise%20of%20Home%20Visitation%202-10.pdf

Duggan, A.K., Berlin, L.J., Cassidy, J., Burrell, L., & Tandon, S.D. (2009). Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants. J Consult Clin Psychol, 77, 788-799.

Duggan, A., Fuddy, L., Burrell, L., Higman, S.M., McFarlane, E., Windham, A., & Sia, C. (2004).

Randomized trial of a statewide home visiting program to prevent child abuse: impact in reducing parental risk factors. Child Abuse Negl. 2004;28(6):623-643.

Eckenrode, J., Ganzel, B., Henderson C., et al. (2000). Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. JAMA, 284(11),1385-1391.

Edleson, J. (1999) The overlap between child maltreatment and woman battering. Violence Against Women, 5,134-54.

Hazen, A.L., Connelly, C.D., Kelleher, K.J, Barth, R.P., & Landsverk, J.A. (2006). Female caregivers’ experiences with intimate partner violence and behavior problems in children investigated as victims of maltreatment. Pediatrics, 117: 99-109.

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 Negl, 32, 797-810.

Howell, K.H., Graham-Bermann, S.A., Czyz, E., Lilly, M. (2010). Assessing resilience in preschool children exposed to intimate partner violence. Violence Vict, 25: 150-164.

Kitzmann, K.M., Gaylord, N.K., Holt, A.R., Kenny, E.D. (2003) Child witnesses to domestic violence: a meta-analytic review. J Consult Clin Psych, 71(2), 339-352.

Levendosky, A.A., Leahy, K.L, Bogat, G.A, Davidson, W.S., von Eye, A. (2006) Domestic violence, maternal parenting, maternal mental health, and infant externalizing behavior. J Fam Psychol, 20, 544-552.

McFarlane, J.M., Groff, J.Y., O’ Brien, J.A. & Watson, K. (2003). Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white, and Hispanic children. Pediatrics, 112, e202-e207.

National Scientific Council on the Developing Child (2005). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. http://www.developingchild.net

Olds, D., Kitzman, H., Cole, R., et al. Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550-1559.

Olds, D., Kitzman, H.L., Cole, R.E., Hanks, C.A., Arcoleo, K.J., Anson, E.¦.Stevenson, A.J. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending. Arch Pediatr Adolesc Med, 164, 419-424.

Olds, D., Robinson, J., Pettit, L., et al. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560-1568.

Rivara, F., Anderson, M., Fishman, P., Bonomi, A.E., Reid, R.J., Carrell, D., Thompson, R.S. (2007) Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics, 120(6), 1270-1277.

Rubin, D. (2010). Video on http://www.pewtrusts.org/our_work_detail.aspx?id=922

Suglia, S.F., Enlow, M.B., Kullowatz, A., & Wright, R.J. (2009). Maternal intimate partner violence and increased asthma incidence in children: buffering effects of supportive caregiving. Arch Pediatr Adolesc Med, 163, 244-250.

Tandon, S.D., Parillo, K., Mercer, C., Keefer, M., & Duggan, A.K. (2008). Engagement in paraprofessional home visitation: families

reasons for enrollment and program response to identified reasons. Women’s Health Issues, 18, 118-129.

Thakeray, J.D., Hibbard, R., Dowd, M., and The Committee on Child Abuse and Neglect, and the Committee on Injury, Violence, and Poison Prevention (2010). Intimate partner violence: the role of the pediatrician. Pediatrics, 125, 1094-1100.

Home visitation holds great promise as an intervention and prevention strategy for domestic violence (DV). Years ago, I did not make that connection. At the time, I was working for a visionary public health leader who, in the face of consideration resistance, was supportive of me starting a domestic violence training initiative in a maternal and child health program. At the same time, she was considering the potential of home visitation to prevent child maltreatment and asked me to be involved during the initial stages of gathering information and program development. During the implementation phase of the paraprofessional home visitation model that was selected, I urged the program managers to consider expanding their training and protocol to include assessment and intervention for DV but the program followed a specific protocol and the program developers were not supportive of adaptations or changes. I was quickly consumed with our domestic violence initiative and paid little attention to what was happening with this home visitation program as it expanded to several sites.

Less than a decade later, I would be extensively involved with in the intersection between delivering home visitation services and addressing DV both on the national level and in my home state of Alaska. A randomized controlled trial of the Alaska-based home visitation program produced disappointing results and the failure to systemically address domestic violence was identified as one of the key factors limiting program effectiveness. We responded with an intensive plan to provide training and technical assistance. Program management and staff were very receptive but the highly publicized evaluation results and missed opportunities to address prevalent risk factors such as domestic violence put a quick end to funding before changes could be implemented and evaluated. Subsequent analyses of the evaluation data examined how maternal levels of depression, attachment anxiety, and discomfort with trust/dependence moderated program impacts. Interestingly, findings indicated that program impacts were moderated by both maternal depression and attachment insecurity for several outcomes including DV (Duggan et al, 2009).

My next experience of working with programs offering home visitation services truly shaped the work and resource development that I have been doing since on this issue. I joined Rebecca Levenson of the Family Violence Prevention Fund on a nationwide trek to provide training and technical assistance to Healthy Start sites— this federally funded program utilizes a variety of home visitation/case management models to promote their goals and these range from the Nurse Family Partnership and Healthy Families America to Parents As Teachers and other community worker models of care. From Hawaii to Oregon to Pennsylvania to Alabama, we witnessed firsthand the unique window of opportunity that home visitation programs have to promote healthy relationships and the ongoing challenges that home visitors faced working with families experiencing domestic violence. We quickly realized that what worked in clinical settings was not necessarily a good fit for home visits and that training and assessment for domestic violence had to be tailored to the ‘relationship’ based framework of home visitation which looks very different that a clinical checklist during a brief visit. It became clear that all sites needed core competencies to respond to domestic violence benchmarks to measure their progress and to create a universal standard of care in the field.

In this issue of Family Violence Prevention and Health Practice, we hear from leading experts in the field who are evaluating the impact of existing home visitation programs on DV and designing innovative home visitation initiatives to address DV. The challenges of responding to children’s exposure to violence in home visitation programs are examined. This issue also provides the opportunity to highlight new resources that the Family Violence Prevention Fund has developed for home visitation programs. With increased attention and funding to implement home visitation services across the United States, we have an extraordinary opportunity to advocate for integration of screening and intervention for DV into all home visitation services and support both proven and innovative practices that address DV within the context of home visits.

References

Duggan AK, Berlin LJ, Cassidy J, Burrell L, Darius Tandon S. Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants. J Consult Clin Pyschol. 2009; 77(4):788-799.

Vicki Breitbart, EdD, LCSW
Vice President of Planning, Research, and Evaluation

Lisa Colarossi, PhD, LCSW
Director of Research and Evaluation

Planned Parenthood of New York City

Correspondence to:  Dr. Lisa Colarossi, Director of Research and Evaluation, Planned Parenthood of New York City, 26 Bleecker Street, New York, NY 10012. lisa.colarossi@ppnyc.org

Acknowledgements
The authors would like to thank the many people who have contributed over time to the work described in this paper, including Drs. Leslie Davidson and Vaughan Rickert at Columbia University, and Anne Robinson, Leslie Rottenberg, and Jini Tanenhaus from Planned Parenthood of New York City. The opinions expressed in this article do not necessarily reflect those of Planned Parenthood Federation of America, Inc. Research discussed in this paper were funded by the Centers for Disease Control (U49 CE000731) and the Robert Wood Johnson Foundation.

Implementing Intimate Partner Violence Screening in an Urban Family Planning Center

At Planned Parenthood of New York City (PPNYC), which serves a large number of clients annually from diverse racial, ethnic, and age groups, staff from our three health care centers perceive intimate partner violence (IPV) as a pressing and critical issue.  In 1998 when revisions were being made to medical history forms, PPNYC recognized the importance of incorporating brief standard screening questions to identify clients who had experienced sexual and physical assaults.  The screening questions were chosen from the available research literature about health care and IPV screening.  With this change came a new policy and procedure for screening and referral processes, which included training of health care staff and required universal screening and referral.  All health care clients are screened for IPV, regardless of gender or type of relationship, including marital, dating, and same-sex partnerships.  Since PPNYC’s clients are primarily women (98%), this paper focuses on female clients.

Research to Develop a New Screening Tool

In 2003, researchers from PPNYC and Columbia University began a collaborative investigation into the prevalence and nature of intimate partner violence in young women ages 15 to 24 years.  The focus of this project was to develop an IPV screening approach to identification, management, and referral within health care settings that would be acceptable to younger women, who had not been the focus in previous publications about screening.  It included the development and testing of a comprehensive IPV screening tool and a provider training component focused on working with young women.  Before the project began, PPNYC conducted a brief survey to assess provider attitudes and practices regarding screening for IPV (N = 15).  Eighty-seven percent of providers were overwhelmingly supportive of the need for screening but more than half (60%) were generally concerned about how to incorporate the screening into an already busy schedule.  It was, therefore, critical for the project to develop a new screening tool that would enhance clinical practice and not deter from other tasks and activities of the health care setting. The definition of IPV we used to guide this project was as follows: a pattern of assaultive and coercive behaviors that may include physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats.  We looked at these behaviors as perpetrated by someone involved in an intimate relationship where the actions were aimed at establishing control by one partner over another. The initial research project had two phases.

In Phase I of the project (see Zeitler et al., 2006), we conducted an anonymous survey to investigate the attitudes and expectations of young women concerning physical, verbal, and sexual intimate partner violence as well as their attitudes toward screening by health care providers.  Women completed an audio-assisted computer survey that employed the validated Conflict in Adolescent Dating Relationship Inventory (Wolffe, Reitzel-Jaffe, Wekerle, Rasley, & Straatman, 2001). This tool measured self-reported experiences with an intimate partner’s violent behavior and included several open-ended questions.  Of the 645 ethnically diverse women aged 15 to 24 who were family planning patients, 45% (290) reported having EVER been abused by a partner (physical, sexual, or emotional). Of those who had been abused, 55% (159) reported that they had been asked by a provider, but only 20% (58) had disclosed the information when asked.  Ninety percent (580) of women responded positively to being screened, saying that they would not mind answering screening questions in the health care setting. Among the choices for whom they would want to talk to about IPV more women reported that they wanted to speak with a health care provider (95%) compared to their mother (90%) or a counselor (89%).

The survey results were augmented by women’s qualitative comments on the necessity of talking about one’s problems in order to solve them. Women said that screening could serve an educational purpose to help young women recognize different forms of control.  In addition, we found that the language used to ask the questions was of paramount importance.  For example, women reported discomfort with the word “abuse” and said that they preferred responding to descriptions of behaviors rather than labels. Based on the results of Phase I, we developed training for providers and provisional screening tools that were piloted in the same health center six months later.

In Phase II (see Rickert et al., 2009), we piloted three sets of screening questions that were added to the standard medical history form completed by all health center clients as follows: a version that asked about IPV victimization only, a version that asked about a broader range of relationship issues, and one that asked about the woman’s use of violence in addition to her victimization. Young women, 15 to 24 years of age, were randomly assigned to complete one of the three tools for violence screening (N = 799). No significant differences emerged between  the three screening tools for reports of physical and/or sexual abuse ever  or within the last year. We also assessed provider feasibility and acceptability across the three screening approaches and found no significant differences. Providers, on the average, were comfortable talking about IPV with any of the approaches. Overall, the findings from Phase II of the study suggested that brief screening for IPV could easily be incorporated into health care services without interrupting the patient flow.

Policy and Practice Changes Resulting from the Initial Phases of Research

The researchers brought these findings to PPNYC health care providers and administrators for a discussion about how the study could impact their practice.  Additionally, other new studies provided evidence that the use of standardized screening questions increased the frequency of provider discussions with patients about IPV and of higher identification rates among OB/GYN clinics that implemented screening protocols versus those that did not (e.g., Trabold, 2007). This may be due to the “normalizing” of IPV screening questions for both patients and providers by including the questions within the routine context of collecting medical history information (Owen-Smith et al., 2008).  This also signals to patients that abuse is viewed as an important health care issue.

There was overwhelming support for revising the policy for identifying IPV with a new set of questions that would contain language focused more on specific behaviors rather than on abstract labels of “abuse.” Providers also wanted to ensure that the new screening questions would help situate any questions about IPV into the context of the woman’s relationship. Due to the growing body of evidence on the impact of both past and current abuse, providers wanted to screen for both. With this in mind, a committee of health care professionals collaborated with the researchers to develop the new policy and screening tool.  The revised screening tools included the new questions shown in table 1. The revised policy included universal screening of all patients as part of their medical history.  A written and verbal screen is conducted, and patients are referred to an on-site social worker for further assessment and planning and additional referrals to local IPV organizations and hotline numbers. Not only did this research impact the policy and practices of PPNYC, but the umbrella organization for this agency center, Planned Parenthood Federation of America, also developed a policy that encourages IPV screening by all of its affiliates.

Table 1. Screening questions

Evaluation of the New Screening Tool
After the new screening tool and policy were in place for one year, a comparative study was conducted to compare IPV disclosure rates of women who had completed the original older screening tool in 2006 (n=420) and those who completed the new screening questions in 2007 (n=385) (see table 1; Colarossi, Breitbart, & Betancourt, 2009a). Data were collected from chart reviews of randomly selected patients across the three PPNYC health centers. Twenty-two percent (85) of women completing the newer form disclosed current and/or past IPV, compared to 9% (38) of women who answered the older questions. No reporting differences were found by race/ethnicity, health center location, marital status, primary language, payment, or service type. Further logistic regression analyses revealed that after controlling for age, women completing the new screening form were more than 2.5 times more likely to report past and current violence (mutually exclusive) and over 4 times more likely to report experiencing both past and current violence compared to women who reported the original screening form.

We believe that asking only a few more screening questions, which used language about specific behaviors and allowed for more response options (a scale rather than yes/no for most questions), and specifying the time frame provided options for women to report IPV that were not as constraining or stigmatizing as using language such as “abuse” and definitive yes/no responses without a context that were used on the older form.

To further evaluate our updated screening policy for provider barriers to screening, we conducted five focus groups with seventy-five PPNYC health care providers, of whom 65 (87%) also completed written surveys about barriers to screening in family planning clinics (see table 2 for sample questions from the survey).  Providers included certified nurse-midwives, nurse practitioners, physician assistants, social workers, and health care associates. Barriers included lack of time, training, and referral resources. Attitudes toward screening were positive overall, but a number of providers expressed frustration with clients’ lack of follow-up to recommended referrals, were concerned about taking too much time away from other health care matters, and believed that certain job roles were more appropriate for conducting screening than others. Providers also expressed a desire for more training about the connection between IPV and reproductive health as well as for responding to disclosures of violence (Colarossi, Breitbart, & Betancourt, 2009b). As a result, a training session was scheduled with a trainer from the Family Violence Prevention Fund on reproductive control and related counseling techniques.

Future Directions

In the last 10 years, research on IPV and reproductive health has expanded in both breadth and depth from studying the association among IPV and reproductive health outcomes to identifying mechanisms of influence and empirically based screening practices. Evidence for mechanisms of influence, including birth control sabotage, pregnancy manipulation, health care monitoring, and partner refusal to use a condom (Levenson, 2009; Miller, 2007; Williams, Larsen, & McCloskey, 2008; Wingood & DiClemente, 1997) support an expanding role for reproductive health professionals. Future directions for research should include a focus on the ways to reduce pregnancy risks associated with partner control or coercion of birth control such as the provision of long acting contraceptives. We will be considering how to integrate general IPV screening questions with questions focused on reproductive control. Partner control over condom use also presents challenges for new interventions to reduce STI and HIV infections.

In our practice, we believe that universal IPV screening should be implemented in all reproductive health care settings using standardized, empirically tested screening instruments and response protocols. While significant strides have been made in understanding how IPV affects sexual and reproductive health, providers need to be aware that this is a prevalent health care issue that requires universal screening and appropriate follow-up assessment and referral.  This includes improvements in youth-friendly services for teen dating violence and health care, and expanded education and outreach services to immigrant communities with specialized expertise in language and cultural barriers.

PPNYC has also made recent efforts to increase coordinated community responses between health care professionals and IPV specialists by convening an initial discussion group of interdisciplinary providers across New York City. Screening for IPV is only as helpful as the response that follows.  Health care providers can discuss health care needs and safety plans specifically for reducing the risk of reproductive health problems, but bridging social service providers and health care providers is needed to coordinate a full range of services for clients experiencing abuse. Making a referral is not as helpful as facilitating access for a survivor between well-trained health care and social service providers knowledgeable about partner violence. To promote such relationships, increased cross-training is needed about the specific connections between physical and sexual violence, reproductive coercion, and reproductive health, including relationship dynamics that:  inhibit the use of condoms, interfere with birth control methods and lead to unwanted pregnancy; monitor or restrict access to health care; and  impact pregnancy continuation and termination.

Finally, the public must be aware of the range of behaviors associated with partner violence and its effects on reproductive health. Health care recipients who do not have knowledge about the connection between relationship dynamics and reproductive health problems, including increased risk for sexually transmitted infections and HIV, unwanted pregnancy, miscarriage, and urinary tract infections, may not understand why they are being screened for IPV by a reproductive health provider nor be able to take advantage of health care options that may be helpful.  There is a need for more provider training, but also for public campaigns and health center waiting room visual materials to increase knowledge and understanding about the link between reproductive health and intimate partner violence.

Table 2. Examples of questions on the provider survey
Please indicate how much you agree or disagree with each statement

We acknowledge that you follow the PPNYC protocol on partner violence. We would like to know whether you agree or disagree that each factor below makes it more difficult to discuss partner violence with patients.

For the following items, please indicate how much you would like more professional development on each of the topics below.

References

Colarossi, L. G., Breitbart, V., Betancourt G. (2009a). Screening for Intimate Partner Violence in Reproductive Health Settings: An Evaluation Study. Biannual meeting of the Family Violence Prevention Fund, New Orleans, LA.
Colarossi, L. G., Breitbart, V., Betancourt G. (2009b). Provider Barriers to Screening for Partner Violence in Reproductive Health Clinics: A Mixed Method Study. Biannual meeting of the Family Violence Prevention Fund, New Orleans, LA.
Hathaway, J.E., Willis, G., & Zimmer, B. (2002). Listening to survivors’ voices: Addressing partner abuse in the healthcare setting.  Violence Against Women, 8(6): 687-719.
Levenson, R. R. (2009). Male reproductive control of women who’ve experienced intimate partner violence in the United States:  An unexplored dimention. Biannual meeting of the Family Violence Prevention Fund, New Orleans, LA.
Miller, E. Male partner pregnancy-promoting behaviors and adolescent partner violence: Findings from a qualitative study with adolescent females, Ambulatory Pediatrics, 2007; 7(5):360-366.
Owen-Smith, A., Hathaway, J., Roche, M., Gioiella, M.E., Whall-Strojwas, D. & Silverman, J.   (2008). Screening for domestic violence in an oncology clinic: Barriers and potential solutions.  Oncol Nurs Forum, 35(4): 625-633.
Rickert, V.I., Davidson, L.L., Breitbart, V., Jones, K., Palmetto, N.P., Rottenberg, L., Tanenhaus, J., Steven, L. (2009).  A randomized trial of screening for relationship violence in young women.  Journal of Adolescent Health, 45, 163-170.
Trabold, N. (2007). Screening for Intimate Partner Violence within a health care setting: A systematic review of the literature.  Social Work and Health Care, 45, 1-18.
Williams, C. M., Larsen, U., and McCloskey, L. A. (2008).  Intimate partner violence and women’s contraceptive use.  Violence Against Women, 14(12), 1382-1396.
Wolfe, D. A., Reitzel-Jaffe, D., Wekerle, C., Grasley, C., Straatman, A. (2001). Development and validation of the conflict in adolescent dating relationships inventory, Psychological Assessment, 13, 277-293.
Zeitler, M.S., Paine, A.D., Breitbart, V., Rickert, V.I., Olson, C., Stevens, L., Rottenberg, L., Davidson, L.L. (2006). Attitudes about intimate partner violence screening among an ethnically diverse sample of young women. Journal of Adolescent Health, 39, 119.el-119.e8.