Child Abuse & Neglect 38 (2014) 1934–1944

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Child Abuse & Neglect

Subtypes of exposure to intimate partner violence within a Canadian child welfare sample: Associated risks and child maladjustment夽 Andrea Gonzalez a,∗ , Harriet MacMillan a , Masako Tanaka a , Susan M. Jack b , Lil Tonmyr c a Offord Centre for Child Studies, McMaster University, Department of Psychiatry and Behavioural Neurosciences and of Pediatrics, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada b School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada c Injury and Child Maltreatment Section, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 785 Carling, AL 6807B, Ottawa, ON K1A 0K9, Canada

a r t i c l e

i n f o

Article history: Received 2 June 2014 Received in revised form 12 September 2014 Accepted 1 October 2014 Available online 14 November 2014 Keywords: Subtypes of exposure to intimate partner violence Internalizing and externalizing problems Child welfare

a b s t r a c t Children exposed to intimate partner violence (IPV) are at increased risk of experiencing behavioral difficulties including externalizing and internalizing problems. While there is mounting evidence about mental health problems in children exposed to IPV, most of the research to date focuses on IPV exposure as a unitary, homogeneous construct. The purpose of this study was to examine the association between subtypes of IPV exposure on child functioning and presence of harm within a child welfare sample. Given the evidence of the “double whammy” effect, co-occurring IPV exposure was also examined. Using data from the Canadian Incidence Study of Reported Child Abuse and Neglect – 2008 (n = 2,184) we examined whether specific IPV exposure subtypes or their co-occurrence resulted in a greater risk of child maladjustment. Information was obtained from child welfare workers’ reports. Caregiver and household risk factors were also examined. Co-occurring IPV exposure resulted in the greatest risk for reported child maladjustment. Exposure to emotional IPV and direct physical IPV were significantly associated with increased risk of internalizing problems and presence of harm. Caregiver mental health and lack of social support emerged as significant risk factors for behavior problems. This study adds to the evidence that exposure to subtypes of IPV may be differentially related to child functioning. Given that risk factors and child functioning is part of the decision-making framework for case worker referrals, this study provides important preliminary evidence about how the child welfare system operates in practice with respect to sub-types of exposure to IPV. These findings suggest that intervening with children exposed to different types of IPV may require a tailored approach. © 2014 Published by Elsevier Ltd.

夽 The study was funded by the federal, provincial and territorial governments, the Social Sciences and Humanities Research Council, and the Canadian Foundation for Innovation. ∗ Corresponding author. http://dx.doi.org/10.1016/j.chiabu.2014.10.007 0145-2134/© 2014 Published by Elsevier Ltd.

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Introduction Exposure to intimate partner violence (IPV) is a significant public health problem. IPV is defined as actual or threatened physical, sexual, psychological, emotional abuse, economic deprivation, destruction of personal property or stalking by a current or former partner or spouse (WHO, 2013). The 2009 Canadian cycle of the General Social Survey revealed that 6.2%, or approximately 1.2 million people, reported experiencing sexual or physical abuse by their spouse in the last five years. Moreover, 17% of individuals reported having experienced some form of emotional or financial abuse in their current or previous relationships (Statistics Canada, 2011). Children living in these households are at increased risk for exposure to violence. Approximately 33% of abused women in Canada reported their children witnessing IPV (Thompson, Saltzman, & Johnson, 2003), representing an estimated 1 million children. However, these numbers likely do not represent the actual prevalence, given that self-reports are known to underestimate IPV, as are estimates based on official reports to police or other authorities (Johnson, 2005). Furthermore, not all jurisdictions in Canada include exposure to IPV in their child welfare legislation; therefore, many cases remain unreported (Cross, Mathews, Tonmyr, Scott, & Ouimet, 2012). In a large cohort study, of US women, 45.1% reported experiencing more than one type of IPV and that IPV was persistent and severe (Thompson et al., 2006). Taken together, these findings indicate that IPV is a chronic condition affecting the lives of millions of families in North America. Terminology describing children’s exposure to IPV has evolved in the last decade. Early research characterized children “witnessing” IPV, which implied direct observation of violence between adults (MacMillan, Wathen, & Varcoe, 2013). The term, exposure to IPV is broader in scope and includes experiences when children see, hear, are directly involved in (i.e., attempt to intervene) and experience the aftermath of assaults that occur between their caregivers, or are otherwise aware of an incident of abuse or threatening behavior between adults (Edleson et al., 2007; Evans, Davies, & DiLillo, 2008; Gilbert et al., 2009). Exposure to IPV is increasingly recognized as a separate category of child maltreatment (Gilbert et al., 2009), with widespread negative consequences (Carpenter & Stacks, 2009; Holt, Buckley, & Whelan, 2008). To date, research has primarily focused on exposure to IPV as a unitary construct, despite reports that it may not be a homogenous phenomenon (Holden, 2003; Johnson & Ferraro, 2000; Kelly & Johnson, 2008). While the impact of IPV exposure, other maltreatment types and their co-occurrence on child outcomes is established in the literature (Moylan et al., 2010; Sternberg, Baradaran, Abbott, Lamb, & Guterman, 2006), information about differentiating subtypes of IPV exposure is limited. Treating exposure to IPV as a unitary construct may overlook potentially important variability in the type of abuse children are exposed to, as well as the differential impact on child functioning (Jouriles et al., 1998). Information on the impact of exposure to sub-types of IPV on child functioning could lead to more specific predictions regarding consequences and inform the referral and treatment process. Below we review research highlighting the impact of exposure to IPV on child functioning, as well as the impact of exposure to IPV and other forms of maltreatment. Numerous studies have demonstrated that children exposed to IPV are at increased risk for a wide range of psychological, emotional, behavioral, social and academic problems (Cummings, Pepler, & Moore, 1999; Fantuzzo et al., 1991; Harding, Morelen, Tomassin, Bradbury, & Shaffer, 2013; Holt et al., 2008; McFarlane, Groff, O’Brien, & Watson, 2003; Moylan et al., 2010; Zarling et al., 2013). More specifically, IPV exposure among children has been associated with internalizing symptoms, including low self-esteem, depression, anxiety, social withdrawal (Edleson, 1999; Fantuzzo, Boruch, Beriama, Atkins, & Marcus, 1997; Graham-Bermann, 1996), and externalizing symptoms such as aggression, violence and delinquency (Holmes, 2013; Lichter & McCloskey, 2004) and increases in risk-taking behaviors (Bair-Merritt, Blackstone, & Feudtner, 2005). Recent meta-analyses indicated moderate associations between IPV exposure and internalizing and externalizing symptoms and childhood trauma symptoms (Briggs-Gowan, Carter, & Ford, 2011; Evans et al., 2008; Kitzman, Gaylord, Holt, & Kenny, 2003; Sternberg et al., 2006). Importantly, the assumption of differential outcomes depending on subtypes of exposure was supported by Kitzman et al.’s (2003) meta-analysis, which demonstrated that children who witnessed physical IPV fared significantly worse than non-witnesses and children from verbally aggressive homes. Of note, these children were indistinguishable from physically abused children. The Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2008), a nationwide study estimating official reports to child welfare of child abuse and neglect, reported three subtypes of IPV exposure: indirect exposure to physical violence, direct exposure to physical violence, and exposure to emotional violence (PHAC, 2010a, 2010b). According to CIS-2008 findings, of all substantiated cases, exposure to IPV (all sub-types combined) represented 31% of single-category investigations (where IPV was identified as the only type of maltreatment) and another 10% involved IPV exposure co-occurring with another form of substantiated maltreatment (sexual or physical or emotional maltreatment or neglect) (PHAC, 2010a). Data from the CIS-2008 showed that, compared with other maltreatment types (e.g., neglect, emotional maltreatment, physical or sexual abuse) and with IPV exposure co-occurring with other types of maltreatment, investigations of exposure to IPV only were less likely to lead to case worker reports of child functioning concerns (e.g., developmental concerns) and reports of emotional or physical harm to the child (Black, Trome, Fallon, & MacLaurin, 2008; Lefebvre, Van Wert, Black, Fallon, & Trocmé, 2013; Trocmé et al., 2013). To the best of our knowledge, no study to date has examined the impact of specific subtypes of IPV on internalizing and externalizing symptoms in children.

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Co-occurrence of Exposure to IPV and Other Types of Child Maltreatment Research examining the co-occurrence of IPV exposure and child maltreatment shows that children exposed to both types of violence exhibit greater problems than children exposed to either type alone (Finkelhor, Ormrod, & Turner, 2010; Herrenkohl, Sousa, Tajima, Herrenkohl, & Moylan, 2008; Moylan et al., 2010; Sternberg et al., 2006) – termed, the “double whammy effect” (Hughes, Parkinson, & Vargo, 1989). In their mega-analysis, Sternberg et al. (2006) found that the dual exposure group of children (abused + IPV exposure) was 187% more likely to have internalizing problems compared to the no-violence group, 117% more likely than the children exposed to abuse only, and 38% more likely than the IPV exposed group. Risk for externalizing symptoms was dependent on child age, with younger children (aged 4–9 years) exposed to both IPV and abuse at greater risk for externalizing behaviors; however, this did not hold for older children, aged 10–14 years. Earlier findings from the CIS-2008 indicate that co-occurring IPV exposure (IPV exposed + other maltreatment) leads to higher rates of internalizing and externalizing symptoms compared to IPV exposure only, but was similar in prevalence to children exposed to a single form of maltreatment (Lefebvre et al., 2013). Risk for IPV Exposure Numerous risk factors associated with IPV perpetration and victimization have been demonstrated across multiple levels – individual, family, community and societal. These include parental history of childhood maltreatment, drug and alcohol use, unemployment, young age, presence of mental health issues, social isolation, poverty and associated household factors (e.g., overcrowding) (Lamers-Winkelman, Willemen, & Visser, 2012; Tjaden & Thoennes, 2006; Stith, Smith, Penn, Ward, & Trit, 2004). The presence of these risk factors in families with IPV creates an environment of pervasive adversity for the child; where multiple stressors can accumulate and impinge upon the child’s development (Holt et al., 2008). Many of these risk factors for IPV have been independently linked to internalizing and externalizing symptoms in children. In particular, maternal depression (Campbell, Morgan-Lopez, Cox, & McLoyd, 2009; Capaldi, Pears, Kerr, Owen, & Kim, 2012; Cummings & Davies, 1993; Hser et al., 2013), maternal history of maltreatment (Miranda, de la Osa, Granero, & Ezpeleta, 2013; Rijlaarsdam et al., 2014), home overcrowding (Fagan & Najman, 2003; Supplee, Unikel, & Shaw, 2007) and poverty (Hardaway, McLoyd, & Wood, 2012; Slopen, Fitzmaurice, Williams, & Gilman, 2010) have all been independently associated with both internalizing and externalizing symptoms. The primary purpose of this study was to examine child welfare workers’ assessment of risk factors of and child functioning concerns related to exposure to subtypes of parental/caregiver IPV using data from the CIS-2008. More specifically, we explored: (1) the association between subtypes of IPV (single form of exposure to indirect exposure to physical violence, direct exposure to physical violence, and exposure to emotional violence exposure, as well as exposure to multiple types) and child functioning (internalizing and externalizing problems) and presence of harm; and (2) the impact of subtypes of IPV exposure and caregiver and household risk factors on child functioning. We divide the analyses into two parts in order to examine the associations between caregiver and household factors and IPV subtype exposure, and then examine the effects of subtypes of IPV exposure and other childhood risk factors on child functioning using multivariate regression analyses. Because of the evidence related to the “double whammy effect,” to test this effect within the IPV subtypes, we created four mutually exclusive IPV exposure groups – three single-form exposure subtypes and one co-occurring IPV exposure subtype (exposed to two or more subtypes of IPV) – to be used in analyses. Given that this information contributes to the decisionmaking framework for referrals, this study has the potential to provide important preliminary evidence about how the child welfare system operates in practice with respect to sub-types of exposure to IPV and reflects the assumptions of workers in the field. Methods This study uses data from the CIS-2008 – the third nationwide study of reported child abuse and neglect across Canada. The CIS-2008 was designed to provide a profile of children and families receiving child welfare services across Canada, using a standardized set of definitions and forms. It involved a multi-stage sampling design where a sample of 112 child welfare sites was selected from 412 child welfare organizations across Canada (PHAC, 2010a). Cases within these sites were sampled over a three-month period (October 1, 2008 to December 31, 2008). Child welfare investigations that met the study criteria resulted in a final sample of 15,980 investigations. These included instances in which there were concerns that a child may have been abused or neglected, as well as situations where there were no specific concerns about previous maltreatment, but where the risk of future maltreatment was under investigation (PHAC, 2010a). Information was collected directly from front line child welfare workers using a three-page, data collection form, the CIS Maltreatment Assessment Form. The National CIS-2008 Steering Committee comprised the research team and national experts in maltreatment, provided input into the design and implementation plans, including the data collection instruments. The CIS Maltreatment Assessment Form was designed to capture standardized information from child welfare workers on the results of their investigations. It consisted of an Intake Face Sheet, a Household Information Sheet, and two Child Information Sheets. Test–retest reliability was examined for a wide range of variables, such as characteristics of the alleged maltreatment, the household, caregivers, children, maltreatment history, and service-related variables (Knoke, Trocmé, MacLaurin, & Fallon, 2009). The majority of items on the CIS-2008 form showed good to excellent test-retest reliability. Prior to data collection,

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Table 1 Definitions of variables. Variable Substantiation of maltreatment

Child functioning concerns Emotional harm

Physical harm Primary caregiver risk factors

Overcrowding Runs out of money Household hazards

Definition Workers indicated the level of substantiation in the investigation. Categorical with three levels: substantiated, suspected or unfounded. An allegation of maltreatment was considered substantiated if the balance of evidence indicated that abuse had occurred. An allegation was considered suspected if the worker did not have enough evidence to substantiate maltreatment, but maltreatment could not be ruled out. An allegation was unfounded if the balance of evidence indicated that maltreatment had not occurred Workers were asked to rate issues related to the child’s level of functioning. Concerns were grouped into two domains: internalizing or externalizing. Concerns could be noted by workers or not noted Workers indicated whether the child showed signs of mental or emotional harm (e.g., bedwetting, nightmares, or social withdrawal) resulting from the investigated maltreatment incident(s). Harm was either noted or not noted Workers indicated whether or not there was physical harm (e.g., broken bones, bruises/cuts/scrapes, head trauma, or burns and scalds) as a result of the investigated maltreatment. Harm was either noted or not noted We included the following primary caregiver risk factors: mental health issues, alcohol abuse or solvent/drug use, few social supports and history of foster care or group home. Presence of risk factors were either noted or not noted by workers Workers were asked to identify whether or not the child and family lived in overcrowded housing condition or whether the household was made up of multiple families Workers indicated whether the family regularly runs out of money for basic necessities (e.g., food, clothing) Workers indicated whether there was at least one household hazard (e.g., accessible weapons, accessible drug paraphilia, drug trafficking or production in the home, access to such things as poisons, fire implements or electrical hazards or health hazards, such as no heating)

site researchers coordinated training and case selection at each CIS-2008 site (PHAC, 2010a, 2010b). The case selection phase consisted of an initial training session, introducing the child welfare workers to the forms and procedures. Workers then completed the form based on information from a selected case vignette. These forms were then discussed, and any discrepancies were reviewed to ensure proper interpretations. Each worker was provided with a CIS-2008 Guidebook (PHAC, 2010b), which included detailed definitions of all study items and procedures. Information regarding the primary type of maltreatment investigated, as well as the level of substantiation for that maltreatment was collected. Data describing child, caregiver, household and investigation-related factors were also collected. Child welfare workers completed the assessment forms at the point when workers finished their written report of the investigation; typically within 6 weeks of the referral. Thirty-two specific forms of maltreatment could be identified, which were then re-categorized into five main categories of maltreatment – sexual abuse, physical abuse, emotional maltreatment, neglect, and exposure to IPV. Up to three forms of maltreatment were reported as primary, secondary and tertiary forms of maltreatment. For each type of maltreatment listed, case workers assigned a level of substantiation. The CIS uses a three-tiered classification system for maltreatment investigations: substantiated, suspected or unfounded (see Table 1). Risk-only investigations were classified as instances where no allegation of maltreatment was made, or no specific incident of maltreatment was suspected at any point during the investigation. For the purpose of this paper we did not include risk-only investigations, but only included maltreatment investigations. Research Ethics Board approval for the CIS-2008 protocol was obtained from the University of Toronto, McGill University and the University of Alberta Ethics Committee. We obtained permission for the secondary use of the data for this study from the Public Health Agency of Canada. Measures Exposure to IPV was classified and defined in the CIS-2008 as the following: (1) indirect witness to physical violence (“indirect”): included situations where the child overheard, but did not see the violence between intimate partners; or saw some of the immediate consequences of the assault (e.g., injuries to the mother); or the child was told of, or overheard conversations about the assault; (2) exposure to emotional violence (“emotional”): which included situations in which the child was exposed directly or indirectly to emotional violence between intimate partners. This included witnessing or overhearing emotional abuse of one partner by another; and (3) direct witness to physical violence (“direct”): the child was physically present and witnessed the violence between intimate partners. For the dependent variables, a checklist was developed by child welfare workers and researchers to reflect the types of child functioning concerns which may be identified during an investigation (PHAC, 2010a, 2010b). Although utilization of a validated instrument, such as the Child Behaviour Checklist would be ideal, it is not typically used in child welfare settings, nor was its use feasible within the context of the CIS due to time constraints and participant burden. Workers noted a concern if problems had been confirmed by a diagnosis and/or directly observed by the investigating child welfare worker or another worker, or disclosed by the parent or child, as well as issues that they suspected were problems but could not fully verify at the time of the investigation. All child functioning items on the checklist showed moderate to excellent test–retest reliability (Knoke et al., 2009). For these analyses, child functioning concerns were dichotomized into two categories: noted (the concern was suspected or confirmed) and not noted (no or unknown). Child functioning were recoded into three main categories (see Table 1): (1) internalizing problems (at least one of the following: depression, anxiety, suicidal thoughts

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or self-harming behaviors) (0 = not noted, 1 = noted); (2) externalizing problems (at least one of the following: aggression, running away, attention deficit disorder [ADD/ADHD], drug or solvent abuse (e.g., prescription or illicit drugs), or alcohol abuse) (0 = not noted, 1 = noted) (PHAC, 2010a, 2010b); and finally, (3) in investigations resulting in substantiated or suspected maltreatment, child protection workers noted whether mental or emotional harm to the child was evident (0 = not noted, 1 = noted). The past six months was the reference time frame. Primary caregiver and household risk factors were collected using the Household Information Sheet, which detailed information on up to two caregivers living in the household at the time of referral (see Table 1). Risk factors were dichotomized into noted (suspected or confirmed) versus no problem noted (0 = none, 1 = suspected/confirmed). Primary caregiver risk factors included: substance abuse (alcohol or drug), mental health issues, lack of social support, and history of foster care/group home involvement. Household factors included: home overcrowding, household running out of money for basic necessities (e.g., food or clothing), and safety, defined as the presence of one or more household hazards. Child gender and age were also examined. Analysis Risk-only investigations were excluded in these analyses since the focus was on investigation of reports of exposure to IPV reports. Given that the age range for mandatory reporting varies by jurisdictions, the analysis sample included only children 15 years of age or younger. To avoid overlap with the effects of other forms of maltreatment, such as emotional maltreatment, neglect, physical or sexual abuse, we included only those cases where exposure to IPV was the sole reason for the investigation. For the analyses, we grouped our sample into four mutually exclusive and collectively exhaustive categories: exposure to (1) “indirect” only, (2) “emotional” only, (3) “direct” only, and (4) “co-occurring IPV exposure”. The “co-occurring IPV exposure” category was created to assess the double whammy effect of children who were exposed two or more types of IPV. Using bivariate logistic regression, we estimated the extent to which child internalizing and externalizing problems and presence of harm were each associated with subtypes of IPV exposure, caregiver risk factors and household characteristics. In the first set of bivariate logistic analyses, we examined child functioning with three IPV exposure subtypes (“emotional” only, “direct” only, and “co-occurring IPV exposure”) as the dummy-coded independent variable, using “indirect” only as the reference group. We chose this reference group, as previous studies have indicated that indirect exposure to IPV was related to fewer child functioning difficulties compared to direct exposure to physical IPV (Kitzman et al., 2003). In the second set of analyses, which consisted of two steps, in order to inform our multivariate analysis, we first estimated the association between IPV exposure subtype and caregiver risk factors and household characteristics. In the multivariate logistic model, we estimated each of the three child outcomes depending on IPV exposure subtypes, caregiver risk factors, household characteristics and child factors (age and sex) to examine the effect of each variable on the outcome, while controlling for all other variables in the model. To obtain the most parsimonious multivariate model, we did not include caregiver and household variables, which were not significant in the first step. In all models, odds ratios (OR) and 95% confidence intervals (95% CI) are reported. All models were run in Sudaan (SUDAAN for Windows, release 7.5.3, Research Triangle Institute, Research Triangle Park, NC), which makes variance adjustments for correlated data resulting from a survey’s design. The nesting variables were agency and family. Results Excluding risk-only investigations and children over age 15 reduced the sample from 15,980 to 11,807. Of these, 2,184 (18.5%) investigations involved exposure to IPV as the sole reason for the investigation. Table 2 shows the IPV exposure subtypes. Single forms occurred most frequently: direct exposure to physical violence only, followed by exposure to emotional violence only and indirect exposure to physical violence only. Table 2 also presents sample characteristics. Half the sample (50%) consisted of girls, the average age of the children was 6.05 (SD = 4.45) and 63.9% were white. Child welfare workers noted internalizing problems in 9.8% of cases and externalizing problems in 9.7% of cases. Emotional or physical harm was noted by caseworkers in 18.4% of the children for whom exposure to IPV was substantiated. Table 3 presents the bivariate logistic regressions examining the association between IPV exposure subtypes with internalizing, externalizing problems and presence of harm in children. As noted previously, indirect exposure to physical violence only served as the reference group, therefore, all statements of likelihood refer to a comparison with that IPV exposure subgroup. The odds of internalizing problems was greater in children exposed to emotional violence only (OR, 2.10, 95% CI 1.20–3.68), direct physical violence only (OR, 1.76, 95% CI 1.00–3.08), and those exposed to co-occurring IPV (OR, 2.49, CI 1.42–4.30). Exposure to emotional violence only (OR, 1.73, CI 1.03–2.90) and exposure to co-occurring IPV (OR, 2.37, CI 1.40–4.01) conferred significantly higher odds for externalizing problems compared to children exposed to indirect physical violence only. Exposure to emotional violence only, direct exposure to physical violence only and exposure to co-occurring IPV were each associated with, respectively, a twofold, threefold and fourfold greater risk of emotional or physical harm. As shown in Table 4, the odds of having a caregiver with mental health issues was approximately two times greater in children exposed to emotional violence only, directly exposed to physical violence only, or co-occurring IPV compared to those with indirect exposure to physical violence only. Lack of social support was significantly associated with greater odds of direct exposure to physical violence only and exposure to co-occurring IPV. Neither caregiver substance use nor

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Table 2 Sample characteristics. Risk variables

All children N = 2,184

Exposure to IPV subtypes Direct exposure to physical violence only (n) Exposure to emotional violence only (n) Indirect exposure to physical violence only (reference group) (n) Co-occurring IPV exposure Direct exposure to physical violence + exposure to emotional violence (n) Indirect exposure to physical violence + direct physical violence (n) Indirect exposure to physical violence + exposure to emotional violence (n) Exposure to all three subtypes (n) Total co-occurring IPV exposure Caregiver risk factors Mental health issues (n) Lack of social support (n) Substance abuse (n) History of foster care/group home (n) Household risk factors Regularly runs out of money (n) Overcrowding (n) At least one household hazard present (n)

30.0% (656) 25.5% (556) 18.5% (403) 11.6% (254) 8.3% (181) 1.9% (41) 4.2% (93) 26% (569) 18.9% (412) 32.6% (711) 21.2% (464) 8.3% (181) 9.1% (198) 5.6% (119) 4.8% (104)

Table 3 Bivariate logistic regressions of child outcomes by IPV exposure subtype. Internalizing OR (95% CI) Subtypes of IPV exposure Indirect physical only (reference) 2.10 (1.20–3.68) Emotional only Direct physical only 1.76 (1.00–3.08)* Co-occurring 2.47 (1.42–4.30)** * ** ***

Externalizing OR (95% CI)

Presence of harm OR (95% CI)

1.73 (1.03–2.90)* 1.59 (0.95–2.68) 2.37 (1.40–4.01)**

2.23 (1.33–3.74)** 2.85 (1.74–4.66)*** 4.15 (2.52–6.84)***

p < .05. p < .002. p < .0001.

Table 4 Bivariate logistic regressions of IPV exposure subtypes by caregiver and household risk factors (N = 2,184).

Caregiver risk factors Mental health Social support Substance use History of foster care Household risk factors Runs out of money Overcrowding Household hazard

Emotional only OR (95% CI)

Direct physical only OR (95% CI)

Co-occurring OR (95% CI)

1.75 (1.07–2.85)** 0.83 (0.55–1.25) 0.68 (0.42–1.10) 0.88 (0.43–1.78)

1.77 (1.11–2.84)** 1.47 (1.01–2.15)* 1.02 (0.66–1.57) 1.28 (0.65–2.50)

2.16 (1.33–3.51)*** 1.89 (1.28–2.77)** 1.41 (0.90–2.21) 1.38 (0.70–2.71)

0.98 (0.48–2.03) 1.09 (0.36–3.29) 0.96 (0.33–2.74)

1.27 (0.65–2.51) 3.11 (1.19–8.12)** 1.70 (0.68–4.26)

2.77 (1.44–5.32)** 3.46 (1.27–9.39)** 1.43 (0.55–3.76)

*

p < .05. p < .02. *** p < .001. Indirect exposure to physical violence only is the reference group. **

history of foster care/group home placement was significantly associated with IPV exposure subtype. The odds of direct exposure to physical violence only and exposure to co-occurring IPV were significantly elevated in households deemed as overcrowded (Table 4). In addition, the characteristic of households that ran out of money for basic necessities was associated with an almost three-fold increase in the odds of exposure to co-occurring IPV. Presence of any household hazard was not significantly associated with IPV exposure subtype. In the final multivariate analysis (see Table 5), we examined the effects of exposure to IPV subtypes and caregiver and household risk factors on each of three child functioning when all variables were entered into the model simultaneously. Exposure to emotional IPV only was associated with greater odds of internalizing problems and presence of emotional or physical harm and approached significance for externalizing problems even when accounting for other risk factors. Exposure to direct physical IPV only was significantly associated with greater odds of harm to the child, was not significantly associated with externalizing problems, and approached significance for internalizing problems. Co-occurrence of multiple IPV subtypes was significantly associated with increased odds for all child problems. With respect to caregiver risk factors, mental health issues and lack of social support were both associated with greater odds for all child outcomes. No significant associations

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Table 5 Multivariate logistic regressions of internalizing and externalizing disorders, and presence of emotional or physical harm in children on IPV exposure subtypes, caregiver and household risk factors and covariates (N = 2,184). Internalizing OR (95% CI) Fixed effects −4.64 (0.32) Intercept b (se) IPV exposure subtypes Indirect physical only (reference) Emotional only 2.10 (1.12–3.94)* Direct physical only 1.80 (0.96–3.38) Co-occurring 2.58 (1.39–4.80)** Caregiver risk factors Mental health 1.65 (1.05–2.57)* Social support 1.89 (1.26–2.83)** Household risk factors Runs out of money 1.36 (0.76–2.40) Overcrowding 0.86 (0.35–2.40) Child variables 0.78 (0.55–1.10) Female 1.22 (1.18–1.26)*** Age * ** ***

Externalizing OR (95% CI)

Presence of harm OR (95% CI)

−3.73 (0.31)

−3.43 (0.29)

1.76 (0.97–3.17) 1.63 (0.89–2.98) 2.16 (1.21–3.84)**

2.48 (1.37–4.49)*** 3.31 (1.89–5.59)*** 3.78 (2.12–6.72)***

1.67 (1.11–2.51)* 1.95 (1.33–2.86)***

1.77 (1.21–2.58)** 1.64 (1.16–2.34)**

1.56 (0.97–2.49) 0.70 (0.28–1.77)

1.05 (0.60–1.83) 0.97 (0.47–2.00)

0.28 (0.19–0.41)*** 1.15 (1.11–1.19)***

1.00 (0.78–1.28) 1.09 (1.07–1.13)***

p < .05. p < .02. p < .001.

were found with either of the household risk factors, although household running out of money approached significance for externalizing problems. Notably, the likelihood of internalizing and externalizing problems and the presence of emotional or physical harm increased with the age of the child. Female sex was a protective factor for externalizing problems; no other child sex effect was found. Discussion Findings from this study provide new evidence for the link between exposure to IPV subtypes, family risk factors and internalizing and externalizing problems and the presence of emotional and/or physical harm in a child welfare sample. Our results suggest the importance of awareness about children’s IPV exposure subtype, in addition to well-established risks, including other family risk factors, age and child outcome. First, we found an association between three risk factors – co-occurring IPV exposure, caregiver mental health and lack of social support – and all three child outcomes. The relevance of caregiver mental health and social support as important predictors and mediators of child externalizing and internalizing problems has previously been recognized (Goodman & Gotlib, 1999; Koverola et al., 2005; Min, Singer, Minnes, Kim, & Short, 2013), but IPV exposure may also have an important role. Previous research has shown that both caregiver mental health and social support are related to parenting quality (Belsky, 1984; Webster-Stratton & Hammond, 1988), which in turn affects child development (Davies & Cummings, 1994; Harding et al., 2013; Herwig, Wirtz, & Bengel, 2004; Zarling et al., 2013). To the best of our knowledge, this is the first study examining associations between IPV exposure subtypes and child functioning problems. We found that children exposed to co-occurring IPV were an considered at greater odds of internalizing and externalizing problems and mental or physical harm, compared to children with indirect exposure to physical IPV only. This provides preliminary support for the “double whammy” effect within the context of IPV sub-types. To date, literature supporting the “double whammy” effect has focused exclusively on the presence of child maltreatment and IPV exposure (Hughes et al., 1989). Results from this study indicate that children exposed to multiple types of IPV may fare worse compared to children exposed to a single form of indirect exposure to physical IPV. Importantly, a number of family risk factors tended to cluster with co-occurring IPV exposure. Specifically, caregiver mental health problems, lack of social support, household running out of money, overcrowding were all significantly associated with greater odds of co-occurring IPV. These findings suggest that children exposed to multiple types of IPV, may also live in a pervasively adverse environment due to the other risk factors present in the home. Second, we found that exposure to emotional violence only was significantly associated with all child outcomes in bivariate associations; however, when effects of other caregiver and household risk factors were included in the model, only internalizing problems and presence of harm remained significant. These findings are consistent with the family conflict literature which links hostile and angry marital interaction patterns to internalizing and externalizing problems in children (Davies & Cummings, 1994; El-Sheikh, Keiley, Erath, & Dyer, 2013; Katz & Gottman, 1993). High emotional conflict households are related to parent–child relations, as well as the child’s sense of emotional security, which in turn affects their abilities to regulate emotions (Crockenberg & Langrock, 2001; Davies & Cummings, 1994). Surprisingly, and in contrast to Kitzman et al.’s (2003) meta-analysis, we found that exposed to direct physical violence only was significantly associated with increased risk of emotional or physical harm compared to reports of indirect exposure to physical violence; however, child functioning problems were not significantly different between the two groups when other risk factors were adjusted for. Unlike previous studies, our reference group consisted of children with indirect exposure to physical violence only. It may be that children

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who are indirectly exposed, and directly exposed to physical violence are at similar risk for behavioral problems and in fact, not distinguishable from one another in a child welfare sample. Finally, in our full model, we found that caregiver mental health and lack of social support were significantly associated with increased risk for all child functioning outcomes even when IPV sub-types were included. Many of the risk factors associated with IPV victimization are also linked to child behavioral problems (Graham-Bermann, Gruber, Howell, & Girz, 2009). Previous research has shown that in general, a single stressor has little effect on a child, but the accumulation of adverse factors greatly increased the likelihood of negative impact on a child’s development (Appleyard, Egeland, van Dulmen, & Sroufe, 2005; Ferguson, Cassells, MacAllister, & Evans, 2013; Rutter, 1993). It has been suggested that a child is differentially affected depending on the co-occurrence, type and severity of violence within the home, as well as the existence of other risk factors present in the child’s environment. It is the combination of these factors, which may produce greatest negative impact on children exposed to IPV (Rossman, Hughes, & Rosenberg, 2000). Consistent with previous research (Evans et al., 2008; Moylan et al., 2010), we did not find associations with gender and child outcomes with the exception of externalizing problems: males were at an increased risk compared to females. Males are generally at greater risk for externalizing problems including ADHD, conduct disorder and oppositional defiant disorder (Carlson, Tamm, & Gaub, 1997; Gershon, 2002; Loeber, Burke, Lahey, Winters, & Zera, 2000). In terms of age differences, although it was reported that younger children are at greatest risk of exposure to IPV (Carpenter & Stacks, 2009; Trocmé et al., 2013), we found that older children were at increased risk for all child outcomes. This may not be surprising, given that the internalizing and externalizing problems were collapsed across a number of behaviors some of which would not be endorsed for the youngest children, e.g., drug or alcohol use. Despite this limitation, our findings are congruent with Sternberg et al.’s (2006) findings that older children (ages 10–14) were at greatest risk of externalizing disorders. We were unable to ascertain the duration of exposure to IPV due to the cross-sectional nature of the data; however, it is possible that children have been exposed to IPV for a number of years. These findings correspond with a recent study suggesting that aggressive behaviors in children exposed to IPV (before age 3) may not manifest until school age (Holmes, 2013). Children who are exposed to IPV in early childhood may initially exhibit less aggressive behavior due to adaptation and protective mechanisms designed to avoid physical harm to themselves (Holmes, 2013). With continued exposure, IPV children may gradually increase their aggressive behaviors when they begin to interact regularly with peers and adults outside of the home. It is the timing, nature and continuity of exposure to violence, which lays the foundation for later adverse outcomes (Rutter, 1993). Despite the strengths of the CIS in assessing exposure to IPV subtypes and risks associated with childhood outcomes in a child welfare sample, this study has some limitations. First, CIS estimates included only cases that were open for investigation by the child welfare worker and therefore did not include incidents not reported to child welfare, screenedout reports, or internal reports on already open cases and the data was cross-sectional. Second, although the CIS-2008 assessed 32 categories of maltreatment subtypes, exposure to IPV was limited to indirect and direct physical violence and emotional violence. Other subtypes of IPV, such as sexual violence were not included. Future research should expand on the categories of subtypes to examine differential effects. Third, the data collected included assessments provided by the investigating child welfare worker and were not independently verified. Therefore, multifaceted constructs, such as criteria to meet classification categories for internalizing and externalizing problems may not be consistent with recognized scores in clinically relevant ranges. Furthermore, these data do not include any self-report measures by family members, or verified diagnoses from healthcare professionals. However, methodological issues in assessing psychological adjustment in child IPV exposure are not exclusive to child welfare cases (Clements, Oxtoby, & Ogle, 2008). Child welfare workers were trained by the research team to ensure a high standard of consistency in the application of study definitions (Trocmé et al., 2013). Despite these limitations, the current study’s findings are highly relevant within the child welfare context given that welfare workers are the front line workers interacting with families their referrals to relevant sources (e.g., child mental health care providers) are based on their suspicions or confirmation of child problems and difficulties that the child may be experiencing. The child functioning checklist within the CIS is a documentation of problems known to the investigating child welfare worker – therefore, it is likely to underestimate the occurrence of some child functioning problems. It also does not assess the full range of mental health outcomes which are associated with exposure to IPV, e.g., posttraumatic stress disorder. A more systematic assessment would likely lead to the identification of a higher frequency of problems than reported here. Given our relatively low rates of reported child difficulties, we acknowledge that internalizing and externalizing problems were likely under-reported in this sample. In their mega-analyses, Sternberg et al. (2006) reported that even in the highest risk group, abused children exposed to IPV, only 28–50% of children demonstrated clinically significant behavior problems. The majority of children scored in the non-clinical range across abuse type, age and gender. This raises the question about a substantive level of resilience in the face of violence; however, it is possible that some problems may emerge later on. Some children may have developed coping skills and may not exhibit signs of behavioral or emotional problems in the shortterm. Protective factors are not adequately captured in most studies, including the CIS. Longitudinal studies examining both risk and resiliency factors are imperative to increase our understanding of developmental patterns in children exposed to violence. Despite the limitations outlined above, the current study provides new and important information about the risk of exposure to IPV subtypes and adverse child outcomes that will likely be exacerbated with increasing age. Future studies should examine exposure to IPV subtypes as a predictor of child outcome and follow participants into adolescence and early adulthood to accurately determine the long-term impact of exposure to IPV.

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In the majority of cases, child welfare workers did not indicate child functioning problems at the time of the investigation; however, for those exposed to co-occurring IPV there was the greatest risk for adjustment problems. These are also the families where the greatest number of caregiver and household risk factors cluster and can be potential targets for intervention; in particular for intervening early with primary prevention initiatives. In addition, we found that children exposed to emotional violence were at greater risk than formerly reported in the literature. This is especially notable given that they represent approximately 26% of children exposed to IPV in this sample. This raises the possibility that child welfare workers may be more aware of adverse consequences related to exposure to physical IPV, but may be less informed regarding the sequelae of exposure to emotional IPV. Evidence-based interventions for IPV are still in formative stages; therefore, practitioners seeking referral sources are faced with limited choices (Feder, Wathen, & MacMillan, 2013; Holt et al., 2008; Parys, Verhamme, Temmerman, & Verstraelen, 2014). Children and families can best be supported through a variety of interventions. This can include safety planning strategies for children (MacMillan et al., 2013; Miller, Howell, Hunter, & Graham-Bermann, 2012), or interventions which link families to resources that address individual and family adversity, including inadequate housing, parental mental illness and lack of social support, among others. Identifying approaches to reducing risk are also important. For example, research consistently demonstrates that a secure relationship to a competent and caring adult in the family or in the community is an important factor in alleviating the impact of violence on children (Gewirtz & Edleson, 2007; Masten, 2001; Stover, Meadows, & Kaufman, 2009). Interventions focusing on attachment and parenting, such as ChildParent Psychotherapy (Lieberman, Van Horn, & Ippen, 2005) or Project Support (Jouriles et al., 2009) may strengthen critical relations to improve child outcomes. In addition, interventions, such as the Kids’ Club Program (Graham-Bermann, 2011), or trauma-focused cognitive behavioral therapy (Cohen, Mannarino, & Iyengar, 2011), which target processes underlying competencies, such as cognitive functions, social skills and self-regulation, could facilitate healthy development in the context of violence. For the children and their families exposed to multiple risk factors, multilevel interventions (e.g., domestic violence advocates, social service and mental health agencies and family counseling) – are likely to be the most effective in preventing and ameliorating the effects of violence (Gerwitz & Edleson, 2007). While advocacy-based interventions and services provided by women’s shelters and community-based domestic violence programs address some of these issues, rigorous research evaluating the effectiveness of such programs is lacking (Gewirtz & Edleson, 2007; Wathen & Macmillan, 2013). Implementing a preventive approach, for example, by providing services to populations at risk of IPV before it occurs or escalates is ideal. For example, the Nurse Family Partnership (NFP), an evidence-based nurse home intervention providing regular home visits to at-risk women during pregnancy and throughout the first two years postpartum, has been successful in reducing child maltreatment and child injuries (Olds, Sadler, & Kitzman, 2007). Although not specifically designed to address IPV, two trials have shown a reduction of IPV (Eckenrode et al., 2004; Mejdoubi et al., 2013); one in the US and a second in the Netherlands. Currently, an augmented IPV intervention within the NFP has been developed and is being evaluated in the US and Canada (Jack, Ford-Gilboe, Wathen, & the NFP IPV Research Team, 2012; Olds et al., 2013). More research and development of evidence-based intervention programs is needed. In sum, key intervention efforts should be aimed at promoting healthy development in young children. Given the current findings, a tailored approach, involving a thorough assessment of risk and protective factors, severity, type and length of exposure to different types of IPV warrants further attention and investigation. While the focus of interventions may vary, a common underlying theme should be the provision of resources to families and children which support safety, stability and healthy child development. Acknowledgements Data used in this publication are from the Canadian Incidence Study of Reported Child Abuse and Neglect, and are used with the permission of the Public Health Agency of Canada. The study was funded by the federal, provincial and territorial governments of Canada, the Social Sciences and Humanities Research Council of Canada, and the Canadian Foundation for Innovation. The analyses and interpretations presented in this work do not necessarily reflect the opinions of the abovementioned sponsors. 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Subtypes of exposure to intimate partner violence within a Canadian child welfare sample: associated risks and child maladjustment.

Children exposed to intimate partner violence (IPV) are at increased risk of experiencing behavioral difficulties including externalizing and internal...
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