Secondary prevention of intimate partner violence: a randomized controlled trial.

BACKGROUND: Despite the recognition of intimate partner violence (IPV) against women as a global health issue associated with significant morbidity and mortality, evidence-based treatment strategies for primary care settings are lacking. OBJECTIVE: To assess the comparative safety behaviors, use of community resources, and extent of violence following two levels of intervention. METHODS: A randomized, two-arm, clinical trial was completed in urban public primary care clinics with 360 abused women who assessed positive for physical or sexual abuse within the preceding 12 months. Two interventions were tested: a wallet-sized referral card and a 20-minute nurse case management protocol. Outcome measures were differences in the number of threats of abuse, assaults, danger risks for homicide, events of work harassment, safety behaviors adopted, and use of community resources between intervention groups over a 24-month period. RESULTS: Two years following treatment, both treatment groups of women reported significantly (p <.001) fewer threats of abuse (M = 14.5; 95% CI 12.6, 16.4), assaults (M = 15.5, 95% CI 13.5, 17.4), danger risks for homicide (M = 2.6; 95% CI 2.1, 3.0), and events of work harassment (M = 2.7; 95% CI 2.3, 3.1), but there were no significant differences between groups. Compared to baseline, both groups of women adopted significantly (p <.001) more safety behaviors by 24 months (M = 2.0; 95% CI 1.6, 2.3); however, community resource use declined significantly (p <.001) for both groups (M = -0.2; 95% CI -0.4,-0.2). There were no significant differences between groups. DISCUSSION: Disclosure of abuse, such as what happens with abuse assessment, was associated with the same reduction in violence and increase in safety behaviors as a nurse case management intervention. Simple assessment for abuse and offering of referrals has the potential to interrupt and prevent recurrence of IPV and associated trauma.

Behaviors of children following a randomized controlled treatment program for their abused mothers.

OBJECTIVE: To determine if a treatment program offered to abused mothers positively affects the behaviors of their children. METHODS: A randomized, two-arm, clinical trial was used to measure child behavior at 6, 12, 18, and 24 months following the application of two levels of abuse treatment services to abused mothers: (1) abuse assessment and receipt of a wallet-size referral card, or (2) abuse assessment, receipt of a wallet-size referral card, and nurse case management sessions. The setting was public primary care clinics. The participants were 233 women who reported physical or sexual abuse within the preceding 12 months, and who had at least one child, ages 18 months to 18 years, living with them. Outcome measures were scores on the Child Behavior Checklist (CBCL) at baseline, 6, 12, 18, and 24 months. CBCL scores for a clinically-referred sample of children served as a comparison group. RESULTS: All children improved significantly (p < .001) on CBCL scores from intake to 24 months, regardless of which treatment protocol their mother received. By 24 months, the majority of children and adolescents had scores significantly less than the referred norms. Children ages 18 months to 5 years showed the most improvement and teenagers showed the least improvement. CONCLUSIONS: Disclosure of abuse, such as that which happens during abuse assessment, was associated with the same improvement in child behavior scores as a nurse case management intervention. Routine abuse assessment and referral have the potential to positively improve the behavioral functioning of children exposed to domestic violence.

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

Children exposed to intimate partner violence against their mothers are at increased risk for emotional, behavior, physiological, cognitive, and social problems. To compare the behavioral functioning of children exposed to intimate partner violence before and 1 year after their mother received treatment, 206 Black, White, and Hispanic children, age 18 months to 18 years, were administered the Child Behavior Checklist. Behavior problems of all children significantly improved 1 year following treatment of their mother. When compared with a clinically referred sample of youngsters, scores of children of abused mothers were not significantly different before their mothers received treatment but most scores were significantly different after their mothers were treated. Screening and a treatment for abused women can have a positive effect on the behavior of their children.

Prevalence of partner violence against 7,443 African American, White, and Hispanic women receiving care at urban public primary care clinics.

Given inconclusive findings regarding racial/ethnic differences in risk for intimate partner violence (IPV), this study will estimate annual prevalence and severity of IPV and associated risk factors of homicide among a multiethnic population of English- and Spanish-speaking African American, White, and Hispanic women receiving public primary health care. A personal interview survey was conducted using three measurement instruments including a brief two-question screen. The sample consisted of 7,443 women, aged 18-44 years, receiving care at urban, primary health care clinics in southern Texas. White women disclosed abuse at a rate of 8.9%, followed by African American women at 6.0% and Hispanic women at 5.3%. More abuse was reported by White and African American women compared to Hispanic women. Use of a brief two-question screen provides racial/ethnic specific surveillance data for patient care programming and can track progress toward decreasing violence against women.

Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white, and Hispanic children.

OBJECTIVE: To compare the behaviors of black, white, and Hispanic children who were 18 months to 18 years of age and exposed to intimate partner violence with an age- and ethnically similar sample of children who were not exposed to violence and to compare both exposed and nonexposed children to normative samples. METHODS: As part of a study on treatments for abused women in primary care public health clinics and Women, Infants and Children clinics in a large urban area, 258 abused mothers completed the Child Behavior Checklist (CBCL) on 1 of their randomly selected children between the ages of 18 months and 18 years. An ethnically similar sample of 72 nonabused mothers also completed the CBCL. The CBCL is a standardized instrument that provides a parental report of the extent of a child's behavioral problems and social competencies. The CBCL consists of a form for children 18 months to 5 years and a version for ages 6 to 18 years. The CBCL is orally administered to a parent, who rates the presence and frequency of certain behaviors on a 3-point scale (0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true). The time period is the last 6 months for the child 6 to 18 years of age and 2 months for the child 18 months to 5 years of age. Examples of behaviors for the child age 6 to 18 years include "gets in many fights," "truancy, skips school." Examples of behaviors for the child 18 months to 5 years of age include "cruel to animals," "physically attacks people," and "doesn't want to sleep alone." Both forms of the CBCL consist of 2 broadband factors of behavioral problems: internalizing and externalizing with mean scale scores for national normative samples as well as clinically referred and nonreferred samples of children. Internalizing behaviors include anxiety/depression, withdrawal, and somatic complaints. Externalizing behaviors include attention problems, aggressive behavior, and rule-breaking actions. Behavior scales yield a score of total behavioral problems. Scores are summed and then converted to normalized T scores. T scores >or=60 are within the borderline/clinical referral range-higher scores represent more deviant behavior. Multivariate analyses of variance (MANOVAs) were used to determine whether children from abused mothers differed significantly in their internalizing behaviors, externalizing behaviors, and total behavior problems from children of nonabused mothers. One sample t tests were used to compare children from abused and nonabused mothers to the matched clinically referred and nonreferred normative sample. Four pair-wise comparisons were considered: 1) children from abused women to referred norm, 2) children from abused women to nonreferred norm, 3) children from nonabused women to referred norm, and 4) children from nonabused to nonreferred norm. The internal, external, and total behavior problem T scores were dichotomized into a referral status: nonreferred = T score < 60, referred = T score >or= 60. Frequencies and percentages were used to describe the distribution of referral status among the children from the abused and nonabused women, and chi(2) tests of independence were used to determine whether the groups were significantly different. RESULTS: No significant differences in demographic characteristics between children from the abused women and nonabused women were observed. The sample consisted of a large number of Hispanic children (68.9%) and slightly more girls (53.6%), and nearly half (45.2%) had annual household incomes <10,000 dollars. Means, standard deviations, and results from the MANOVAs performed on internal, external, and total behavior problem scores between children from abused and nonabused women revealed no significant differences (F[3,139] = 1.21) for children ages 18 months through 5 years. Results from the MANOVA performed for ages 6 through 18 years revealed a significant group difference (F[3,183] = 3.13). Univariate tests revealed significant group differences for internalizing behavior (F[1,185] = 6.81), externalizing behav = 6.81), externalizing behavior (F[1,185] = 7.84), and total behavior problems (F[1,185] = 9.45). Overall, children of abused mothers had significantly higher internalizing (58.5 +/- 12.1), externalizing (55.5 +/- 12.4), and total behavior problems (57.6 +/- 12.3) scores than the internalizing (52.9 +/- 13.7), externalizing (49.7 +/- 10.6), and total behavior problems (51.0 +/- 13.0) scores exhibited for children of nonabused mothers. Most comparisons of children from the abused women to the referred and nonreferred norms are significant. The mean internal, external, and total behavior problem scores from children of abused women were significantly higher than the nonreferred norms and significantly lower than the referred norms. In contrast, all comparisons for children from nonabused women were not significantly different from the nonreferred norms. CONCLUSIONS: Children, ages 6 to 18 years, of abused mothers exhibit significantly more internalizing, externalizing, and total behavior problems than children for the same age and sex of nonabused mothers. In addition, the mean internalizing behavior score for boys 6 to 11 years of age as well as girls and boys 12 to 18 years of age of abused mothers were not significantly different from the clinical referral norms. Internalizing behaviors of anxiety, withdrawal, and depression are consistent with suicidal risk. The association of a child's exposure to intimate partner violence and subsequent attempted and/or completed suicide demands research. Our data demonstrate that children of abused mothers have significantly more behavioral problems than the nonclinically referred norm children but also, for most children, display significantly fewer problems than the clinically referred children. These children of abused mothers are clearly suspended above normal and below deviant, with children ages 6 to 18 being at the greatest risk. If abused mothers can be identified and treated, then perhaps behavior problems of their children can be arrested and behavioral scores improved. The American Academy of Pediatrics Committee on Child Abuse and Neglect recommends routine screening of all women for abuse at the time of the well-child visit and implementation of a protocol that includes a safety plan for the entire family. Clinicians can use this research information to assess for intimate partner violence during child health visits and inform abused mothers of the potential effects on their children's behavior. Early detection and treatment for intimate partner violence against women has the potential to interrupt and prevent behavioral problems for their children.