The Process of Reporting and Receiving Support Following Exposure to Intimate Partner Violence During Childhood.

554289 research-article2014

JIVXXX10.1177/0886260514554289Journal of Interpersonal ViolenceHowell et al.

Article

The Process of Reporting and Receiving Support Following Exposure to Intimate Partner Violence During Childhood

Journal of Interpersonal Violence 2015, Vol. 30(16) 2886–2907 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514554289 jiv.sagepub.com

Kathryn H. Howell, PhD,1 Åsa K. Cater, PhD,2 Laura E. Miller-Graff, PhD,3 and Sandra A. Graham-Bermann, PhD4

Abstract While a significant body of research suggests that exposure to intimate partner violence (IPV) during childhood has severe and long-lasting consequences, little is known about how children cope with witnessing IPV, including who they tell about the violence, whether they receive support after disclosing, and the association between childhood disclosure and adulthood mental health. The current study examines these issues in 703 Swedish young adults who endorsed witnessing IPV during childhood. In this sample, 57% reported that they had ever confided in someone about the witnessed violence. The primary reason given for not disclosing was the belief that no one could do anything about it, which was endorsed by 41% of the young adults who kept the violence concealed. Individuals who disclosed the violence were most likely to tell a friend and least likely to 1University

of Memphis, TN, USA University, Sweden 3University of Notre Dame, IN, USA 4University of Michigan, Ann Arbor, MI, USA 2Örebro

Corresponding Author: Kathryn H. Howell, Assistant Professor, Department of Psychology, University of Memphis, 356 Psychology Building, Memphis, TN 38152-3230, USA. Email: [email protected]

Downloaded from jiv.sagepub.com at Stockholm University Library on November 14, 2015

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use an anonymous hotline. Young adults with higher levels of depression were less likely to have disclosed IPV during their childhood. Individuals’ use of formal reporting outlets was endorsed infrequently, with only 5.2% recalling that they had personally reported the violence or someone else had reported it on their behalf. If such reports were filed, it was most likely to the police. These formal reports typically resulted in participants feeling that the problem continued anyway or that they were believed, but no changes were made. Given the infrequent use of formal reporting services, results suggest that for this sample, reporting outlets for IPV exposure may be underutilized and may not be perceived as beneficial. Keywords disclosure, Sweden, IPV, witnessed violence Intimate partner violence (IPV), defined as the presence of physical, sexual, psychological, or emotional abuse by a current or former partner (Centers for Disease Control and Prevention, 2006), has been observed in a wide range of cultures. When examined worldwide, the lifetime prevalence of IPV varies quite significantly, with yearly rates of physical and sexual violence as low as 3% in Serbia and Montenegro to 54% in Ethiopia (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). While few studies have examined the lifetime prevalence of IPV in Sweden, one national study found it to be as high as 35% (Lundgren, Heimer, Westerstrand, & Kalliokoski, 2001). Based on research in both North America and Europe, when IPV occurs at home, the vast majority of children either directly witness or overhear it taking place (Christensen, 1990; Fantuzzo & Fusco, 2007). Recent estimates from the United Nations indicate that approximately 275 million children worldwide are exposed to IPV each year (United Nations Children’s Fund [UNICEF], 2005). Given that such exposure has been consistently linked to a range of negative emotional and behavioral sequelae that extend from childhood into adulthood, exposure of children to IPV has become a pressing public health concern worldwide (e.g., Dube, Anda, Felitti, Edwards, & Williamson, 2002; Kitzmann, Gaylord, Holt, & Kenny, 2003). To date, however, few studies have specifically examined the experience of Swedish children who witness IPV. In Sweden, exposing a child to IPV is not criminalized by law; however, if children directly witness IPV, this is taken into consideration when making penalty decisions for perpetrators (The Swedish Penal Code, 2010). Beyond legal involvement, children exposed to IPV in Sweden are eligible for


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support from social service agencies, but to receive this aid the experiences and needs of these children must be shared with social service providers. Therefore, as is consistent with policies in the United States, any individual who works for an agency affiliated with children (such as a school or hospital) is required to report to social services if they suspect that a child may be at risk of harm (Sweden Social Services Act 14:1). Given that children typically do not show physical signs of witnessing violence in the home, their exposure is often only brought to awareness when they disclose to a trusted individual or authority figure. Disclosure is defined as revealing one’s beliefs and feelings about upsetting events through speech or writing (Pennebaker, 2000). Studies examining the disclosure of traumatic events have found that the reaction of others to the disclosure influences the extent to which the disclosure is deemed helpful or harmful (Ullman, 2011). Such research suggests that the source to which individuals disclose is especially influential in effecting perceptions of the disclosure process. Individuals may disclose to a variety of sources, including close friends, family members, and formal agencies, such as the police or health care professionals. With regard to victimized women, research has indicated that many women feel they would like to discuss violence exposure with health professionals, but far fewer health professionals feel comfortable managing such disclosures (Taylor, Bradbury-Jones, Kroll, Dipl-Psych, & Duncan, 2013). In terms of the mental health effects of disclosure, adults who share about their difficult and traumatic experiences in a supportive psychotherapy setting exhibit less traumatic stress and more insight, again highlighting the importance of the outlet for the disclosure (Cohen, Mannarino, Murray, & Igleman, 2006; Farber, Berano, & Capobianco, 2006). Studies of disclosure by children are rare and focus primarily on victims of childhood sexual abuse (Berliner & Conte, 1995). While only half of sexually abused children report disclosing their experiences, most often to their mothers, those who do are more likely to be girls and older than non-disclosers (Sauzier, 1989). Still, a number of factors contribute to disclosure, including the child’s relationship to the perpetrator (e.g., a family member or peer), the extent of threat, and feelings of self-blame (Finkelhor, Ormrod, & Turner, 2007). The only study to examine disclosure longitudinally in youth exposed to IPV was conducted in the United States and focused on a relatively narrow age range of children. This study of preschool-aged children participating in an IPV group therapy program (Graham-Bermann, Kulkarni, & Kanukollu, 2011) found that approximately half of the children spontaneously disclosed their thoughts and beliefs about IPV during a group therapy session, and those who disclosed during the therapy program had significantly less depression and anxiety post intervention. They were also significantly more likely


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to show positive change in their beliefs as to the acceptability of violence by the end of the therapy program, relative to non-disclosers. Taken together, this small body of research suggests that there is variability in the impact of disclosing, but potential mental health benefits associated with disclosure seem to exist, particularly if the disclosure is made in a therapy setting. The factors that prompt some children to disclose while others remain silent are still not fully understood. Although studies on the disclosure process in Swedish samples are more limited in number, one study of physically abused children found that only 1 in 10 youth who experienced this form of abuse had, on his or her own volition, revealed to a teacher, coach, or equivalent professional that he or she was victimized (Statens Offentliga Utredningar [SOU], 2001). Researchers reported that for every physical assault that was revealed to a professional, there were at least two more that remained unidentified (SOU, 2001). Although police reports of child physical abuse have increased in recent years in Sweden, Annerbäck, Wingren, Svedin, and Gustafsson (2010) found that only 7% of violence-exposed children told an authority figure about their experience. Some research indicates that it is more common for youth to disclose their experiences to a same-aged peer. For example, Priebe and Svedin (2008) found that the rate of disclosing sexual abuse among high school seniors was 81% for girls and 69% for boys when disclosure options included telling a friend. Based on qualitative interviews with 19 children in Norway, Solberg (2007) found that the premises for children to reveal/disclose their experiences of IPV were that they had an opportunity to disclose, a goal with the disclosure, and an individual to tell. Although this research is promising, to date no studies in Sweden have examined the process of children disclosing about witnessed IPV or the associations between disclosure and mental health.

The Current Study Given the potential instrumental and mental health benefits of disclosing identified in the literature, there is a clear need to examine the specific reasons that lead some children to disclose their experiences with IPV. The current study uses retrospective reports of Swedish adults’ disclosure following childhood exposure to IPV. Although there are legitimate concerns regarding recall and bias in using cross-sectional, retrospective data, this preliminary study has the potential to call attention to the nuanced details and interpretations of the disclosure process. Therefore, the current study aims to examine the following research questions in a sample of Swedish young adults exposed to IPV during childhood: (a) What is the frequency of disclosing childhood


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exposure to IPV informally to confidantes and in a formal report to authorities? (b) In an informal disclosure, who is most likely to be told about the violence? (c) What agency is most likely to receive a formal report of violence exposure? (d) What are the associations between adulthood mental health and retrospective reports of childhood disclosure? Based on prior research, we hypothesize that the overall rate of disclosure will be low, but participants will be more likely to disclose informally to a trusted confident as opposed to making a formal report to authorities. Furthermore, we hypothesize that disclosing, whether informally or formally, will be associated with lower levels of psychopathology in adulthood, as measured by symptoms of depressed mood, anxiety, and posttraumatic stress (PTS).

Method Participants Participants were drawn from a large, nationally representative and randomly selected sample of 2,500 individuals who reported on early experiences of abuse and neglect as well as psychosocial functioning in young adulthood. This larger study, known as the Retrospective Study of Young People’s Experiences (RESUME; Cater, Andershed, & Andershed, 2014), was conducted in 2011 and included young adults between the ages of 20 and 24 who were identified from the Swedish national inhabitant register. Random selection was constrained to proportional draws based on gender and county of residence. Of the 2,500 selected adults, those reporting any exposure to verbal, emotional, or physical aggression between caregivers in their home during childhood, as evidenced by responding in the affirmative to any item on the Childhood Exposure to Domestic Violence (CEDV) scale, were extracted for analysis in the current study (n = 703; 28% of the larger sample). Of these participants, 69.7% reported witnessing multiple forms of aggression. Individuals in the current study ranged in age from 20 to 24 (M = 22.15, SD = 1.38), and 58% were female. The most commonly reported type of exposure among the 703 participants was to verbal aggression between adults in the home, with 100% of the current study participants witnessing verbal disagreements, 80.5% witnessing disparaging comments between parents, and 58.3% witnessing arguments in which the child was the topic. Psychological aggression was also witnessed in the form of parents destroying objects on purpose (39.7%); one adult stopping another from doing something, like eating or sleeping (32.4%); and hurting a family pet (6.5%). Physical aggression was the form of IPV that children were least likely to be exposed to, with 23.5% witness to parents


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being physically injured, 9.8% witness to threats with a weapon, and 3.4% witness to parents being physically attacked with a weapon.

Procedure Following approval by the regional ethical review board in Uppsala, Sweden, potential study participants were randomly pulled from the national inhabitant register and contacted via telephone by a Swedish survey and marketing company. This company was commissioned by the research team and then trained in the interviewing protocol that was relevant to the study. This survey company was responsible for all participant recruitment and the administration of all study measures. Interested individuals were scheduled for an interview that took place at a time and location convenient for the participant. Interviews were typically conducted at the participant’s home, in a public place such as a library, or in the survey company office. Based on random selection from the national inhabitant register, 25,750 individuals were initially identified as potential participants, of which 20,827 had a registered telephone number. Of those with registered numbers, 16,372 did not answer the recruiter’s first call, did not want to hear information about the study, asked the recruiter to contact them another time, or could not be informed for other, less common reasons. Of the remaining 4,455 potential participants, 1,955 individuals could not be reached at the time of the interview, were in a geographical location that made the interview impossible to conduct, or could not be interviewed for other, less common reasons, which resulted in a final sample of 2,500 participants in the RESUME study. Comparison of the answers to a subset of items from the questionnaire by 30 randomly selected individuals who chose not to participate in the RESUME study indicated that there was no evidence of bias or skew in the final sample of 2,500 participants. At the interview, after obtaining informed consent from study participants, interviewers gathered basic demographic information, such as age, education, and relationship status, via a brief structured interview (5-10 min). Study participants then completed an electronically administered questionnaire about their history of violence exposure and perpetration, as well as their current psychosocial functioning. This self-report survey took approximately 1 hr to complete, and the interviewers were present to answer any questions. Following completion of the survey, interviewers debriefed study participants and provided resources for mental health services. Participants received monetary compensation.


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Measures Demographics. Demographic data were collected during a brief semistructured interview in which information about the participant’s sex, age, and education was gathered. IPV exposure. Retrospective accounts of childhood exposure to IPV were gathered using a modified version of the Childhood Exposure to Domestic Violence (CEDV) scale (Edleson, Shin, & Armendariz, 2008). This 10-item measure evaluates children’s exposure to verbal, physical, and psychological aggression in the home. Adaptations were made to the measure to enhance consistency across sections of the overall survey and to reduce the time needed to complete the entire survey. First, the phrase “when you were a child” was added to the beginning of each of the 10 items to make the questionnaire appropriate for retrospective reporting. Second, questions were changed to be gender neutral (e.g., “father” was changed to “your parent or someone else who took care of you”) to better account for bidirectional or mother-only violence perpetration. Third, the original scale asks about witnessed violence as a follow-up question (e.g., “and you saw or heard what happened and the consequences of it, like someone got hurt, something broke, or the police arrived),” but the current study collapsed this into the body of each question. As an example, the original question “How often has your mom’s partner threatened to use a knife, gun, or other object to hurt your mom?” plus the follow-up question related to exposure was altered in the present study to the following: When you were a child, how often did someone (one of your parents or someone else who took care of you) threaten to use a knife, gun or other object to hurt the person who took care of you (your other parent or someone else), and you saw or heard what happened and the consequences of that (e.g., someone got hurt, something broke, or the police came)?

These modifications produced a retrospective, briefer, and gender-neutral version of the CEDV that was more suited to a survey of this magnitude without losing any relevant content inherent in the original items. For each question, participants indicated whether they had witnessed this type of violence “never” (1), “sometimes” (2), “often” (3) or “almost always” (4), resulting in a scale range of 10 (no violence) to 40 (very frequent violence). Internal reliability for this modified measure was (α) = .87 and relatively consistent with the original measure (α) = .78 administered to American samples (Edleson et al., 2008). Following the completion of the measure, participants were asked to


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recall their age (in years) when they first witnessed any IPV and their age (in years) when they last witnessed any IPV. Based on these reports, total duration of recalled IPV exposure was calculated by subtracting age at first exposure from age at last exposure. Disclosure of witnessed violence. Participants completed additional retrospective self-report questions related to IPV exposure. First, they were asked if, and when (i.e., at the time the violence occurred or at a later date), they ever told someone about the witnessed IPV. If they ever disclosed about any of their IPV exposure, participants selected from a list of potential individuals to confide in, including siblings, friends, parents, other relatives, a familiar adult, a professional, or a romantic partner. Then, participants were asked (yes/no) if they felt supported or taken seriously when they disclosed. Participants who did not tell someone about the violence were asked why they made the decision not to disclose. Next, they were asked to select from a list, which included mother, father, siblings, teacher, or someone else, anyone who might have known the violence was happening, even if a direct disclosure was not made. A second set of follow-up questions examined formally reporting IPV exposure (i.e., to an agency or organization rather than in the context of an interpersonal relationship). Participants were asked whether a formal report was ever made, either self-initiated or by another person on their behalf, and then selected from a list of potential reporting agencies (e.g., the police, social services, school staff, health care professionals, coaches, and an anonymous hotline). Participants then reported the results of the notification. Response choices included that they were ignored or not believed, believed but nothing happened, actions were taken but the violence continued, or actions were taken and the violence ceased. Finally, participants were asked how they felt about the outcome of the report. Response options included that it was what they needed/wanted, it was partially helpful, it was not at all what they wanted, or they could not recall the outcome. All questions assessed the totality of experiences with disclosure during childhood across all IPV incidents and time periods. Depressive and anxiety symptoms. Current symptoms of depressed mood and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). This measure has been validated on both patient samples and the general population in Scandinavian countries, with established validity, specificity, and reliability (Bjelland, Dahl, Haug, & Neckelmann, 2002). This self-report measure includes seven items associated with symptoms of depression that may have occurred over the past week


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(e.g., “I feel as if I am slowed down”). Items are rated on a 4-point scale with response choices of 0 = not at all, 1 = not very often, 2 = quite often, and 3 = very often. Reliability in the present study for the depression subscale was α = .69. Current symptoms of anxiety were examined using the Anxiety subsection of the HADS (Zigmond & Snaith, 1983). The seven questions associated with anxiety over the past week (e.g., “I feel tense or wound up”) are also evaluated on a 4-point scale, with response options of 0 = not at all, 1 = not very often, 2 = quite often, and 3 = very often. In the present study, reliability for the anxiety subscale was α = .79. PTS symptoms. The presence and severity of PTS symptoms were evaluated using the 22-item Revised Impact of Event Scale (IES-R; Weiss, 2007; Weiss & Marmar, 1997). The questions correspond to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) criteria for posttraumatic stress disorder (PTSD) and capture symptoms in the domains of re-experiencing, avoidance, and arousal that have occurred over the past week. The psychometrics of the IES-R have been evaluated in Swedish samples, indicating good specificity and concordance with clinical diagnostic interview data for PTSD (Sveen et al., 2010). All items are rated on a 5-point scale (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely). In the present study, the internal reliability (α) for the total scale was .96.

Results Young adults recalled that the average duration of IPV exposure during childhood was 8 years (SD = 5.48) and the average age at first exposure was 7.21 years (SD = 3.61). A slight majority (56.6%) of participants reported that they informally confided in a trusted person about their experiences with IPV exposure during childhood. Timing of the disclosure was variable, with 40.2% doing so when the violence occurred and 59.8% disclosing at a later date. Individuals who shared about ever witnessing IPV were most likely to tell a friend (53.2%) and least likely to tell a close or familiar adult (7.1%). See Figure 1 for a graphical depiction of who was told about the violence. According to participants, the process of disclosing was beneficial, as 95.3% of the individuals who disclosed to a trusted person felt they were taken seriously and 72.0% believed they received needed help and support. Independent samples t tests revealed a significant difference in disclosing based on the frequency of witnessed violence, t(701) = 2.85, p = .005, with participants who disclosed to a trusted person witnessing more frequent IPV (M = 14.10, SD = 4.37) as compared with participants who did not disclose (M = 13.17,


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Howell et al. 60% 50% 40% 30% 20% 10% 0%

Figure 1. Rates of informal disclosure of witnessing intimate partner violence.

SD = 4.18). In addition, chi-square analysis revealed that participants who disclosed to a trusted person were more likely to be female than male (65% vs. 35%, respectively), χ2(1, N = 703) = 21.57, p < .001. Of the 43.4% of young adults who did not disclose about any of their IPV experiences, the primary reason given for keeping the violence private was the belief that no one could do anything about it, endorsed by 41.4% of participants, followed by the belief that IPV was not serious or wrong (28.1%). Participants gave a wide variety of explanations for not disclosing (shown in Figure 2). Despite electing not to directly tell anyone about the witnessed violence, 68.5% of these young adults believed that someone was aware of their IPV exposure. Most participants thought that a family member knew; 27.7% thought a sibling likely knew, 20.9% thought their mother knew, and 2.3% reported that their father likely knew they witnessed IPV. Next, the mental health of young adults who ever disclosed to a confidante was compared with the mental health of those who kept the IPV private using a series of one-way ANCOVAs with gender and violence frequency included as covariates. These variables were included as covariates because chi-square analysis and independent samples t tests indicated differences in disclosing to a confidante based on gender and violence frequency. There was a significant effect of recalled childhood disclosure on depression during adulthood after controlling for the effect of gender and violence frequency, F(1, 699) = 11.53,


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45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

Nobody could do anything

I did not I didn't want I was scared I was No one I promised think it was my friends threatened would not to tell wrong to find out by the believe me perpetrator

Figure 2. Explanations for not disclosing intimate partner violence exposure.

p = .001. Follow-up pairwise comparisons were conducted and the results showed that participants who recalled disclosing to a confidante during childhood had significantly lower depression levels as adults (M = 3.05, SD = 0.14) compared with participants who kept the IPV exposure private (M = 3.80, SD = 0.16), controlling for the effects of frequency of witnessed violence and gender. Furthermore, the covariate, violence frequency, was significantly related to the participant’s depression, F(1, 699) = 13.91, p < .001. Rates of general anxiety and PTS in adulthood were comparable between the disclosure and non-disclosure groups. Participants’ use of formal reporting outlets, such as the police or a social service agency, was endorsed infrequently, with only 5.2% indicating that they had ever personally reported the violence or that someone else had reported the violence on their behalf. This was evenly split between reporting 1 time (2.7%) and reporting 2 or more times (2.5%). Independent samples t tests revealed a significant difference in formal reporting based on the frequency of witnessed violence, t(626) = 3.52, p = .001, with making a formal report associated with more frequent IPV (M = 16.33, SD = 5.15) as compared with not making a formal report (M = 13.40, SD = 4.15). No gender differences were identified with regard to formal reporting. If IPV exposure was reported, then these reports were most likely to be filed with the police (44%). See Figure 3 for rates of reporting to other formal agencies or services. Following a formal report, participants recalled that they typically felt the problem continued anyway (31%) or that they were believed but no changes


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50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

Police

Social Services

Healthcare Worker

School Staff

Anonymous Hotline

Figure 3. Rates of formal reporting of intimate partner violence exposure.

were made (31%), with only 17.9% stating that the formal report led to a cessation of witnessing IPV. In reflecting on the outcome of the report, 41% of individuals felt that it was “not at all what they wanted” to have happen. In all, 27% stated that it was “helpful in some ways” and another 27% could not recall the outcome of the notification. Only 5.4% stated that the outcome of the report was what they “needed, wanted, or desired.” Next, the mental health of young adults who made a formal report or had one made on their behalf was compared with the mental health of those who did not make such a report using a series of one-way ANCOVAs with violence frequency included as a covariate. Violence frequency was included because independent samples t tests indicated differences in formal reporting based on violence frequency. Notably, there was a significant effect of formal reporting on PTS after controlling for the effect of violence frequency, F(1, 625) = 3.88, p = .039. Follow-up pairwise comparisons were conducted and the results showed that participants who reported to an authorized agency had significantly higher mean levels of PTS as adults (M = 0.97, SD = 0.13) compared with participants who did not make such a report (M = 0.71, SD = 0.03), controlling for the effect of frequency of witnessed violence. Furthermore, the violence frequency covariate was significantly related to the participant’s PTS, F(1, 625) = 39.50, p < .001. Rates of general anxiety and depression were comparable between the formal report versus the no formal report groups.


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Discussion This study aimed to expand the fledgling literature on the process and implications of disclosing exposure to IPV during childhood. While the crosssectional and retrospective procedures used in this study require preliminary and cautionary interpretation of results, the findings call attention to an important, but neglected, area of research regarding not only who was told about the violence, but also the timing and reactions to this disclosure. This study goes beyond simply assessing if a child discussed the violence by delving into the process of disclosing and the associations between recalled childhood disclosure and mental health during young adulthood. Findings indicate that roughly half of young Swedish adults retrospectively reported confiding in someone about the interparental violence they witnessed during childhood. This rate is in line with studies of childhood sexual abuse (Sauzier, 1989; Saywitz, Goodman, Nicholas, & Moan, 1991) and with the only other study to examine IPV disclosure among youth (Graham-Bermann, Kulkarni, & Kanukollu, 2011). Given that the average length of violence exposure was 8 years, this finding suggests that many children are chronically exposed to IPV and are unable or unwilling to reveal their experiences. This may enhance feelings of isolation or embarrassment that perpetuate keeping IPV a family secret. While past literature highlights great variability in the effects of disclosure, one consistent finding is that a lack of safe and secure outlets for appropriate disclosure may be associated with the pronouncement of negative mental health effects (Easterling, Antoni, Fletcher, Marguiles, & Schneiderman, 1994; Pennebaker, 2000). Furthermore, it may limit access to service organizations that provide support and needed intervention for high-risk children. Although there are multiple empirically supported interventions for children exposed to IPV, including Kids’ Club, Project Support, and Child–Parent Psychotherapy (Graham-Bermann, Lynch, Banyard, DeVoe, & Halabu, 2007; Jouriles et al., 2009; Lieberman, Van Horn, & Ippen, 2005), the failure to identify exposure precludes access to services. Gender differences emerged in the likelihood of IPV disclosure, with more females than males retrospectively recalling that they disclosed about the violence to a trusted confidante. This finding suggests a need for additional exploration with regard to how male and female children may be socialized differently to discuss difficult events, how comfortable children of each gender feel in sharing personal experiences, and how the number or quality of available confidantes may vary as a function of gender. In addition, violence frequency emerged as an influential factor in differentiating individuals who disclosed from those who did not, with young adults who


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recalled disclosing to a confidante, as well as to a formal agency, witnessing more frequent IPV. It may be that as the frequency of violence in the home increases, children feel more distressed and compelled to seek comfort from trusted individuals. It may also be that more frequent violence signals to children that they need assistance and support in grappling with chronic IPV. Although these cross-sectional and retrospective data preclude any causal associations, these findings call attention to the importance of examining individual characteristics of the child and environmental factors associated with the violence in understanding the process of disclosing IPV exposure. The reasons young adults gave for not disclosing provide important insight into commonly held attitudes and beliefs about IPV. For example, nearly 30% of participants stated that they did not reveal the violence because it was not “serious or wrong.” This concerning finding is consistent with previous research that has identified a relatively high level of acceptability of IPV in some European countries (Gracia & Herrero, 2006; Jonzon, Vung, Ringsberg, & Krantz, 2007). Although a large percentage of the sample endorsed the belief that what they had experienced was acceptable, many others chose not to disclose because they believed that nothing could be done about IPV. These opinions call for increased country-wide efforts and public health campaigns to reduce the stigma associated with IPV and to provide individuals with appropriate outlets to discuss their experiences with violence. For those individuals who chose to reveal their exposure to IPV, results were mixed as to perceptions of the helpfulness of this disclosure, which was primarily driven by the individual who was told about the violence. Disclosure was reportedly quite cathartic for participants who shared their experiences with a close friend or family member, with most individuals believing they were appropriately supported and received needed help. This may initially seem counterintuitive, as many informal disclosures were made to peers who were likely not empowered to directly end the violence. Yet, it may be that openly talking about the experience of living with violence in the home and expressing thoughts and feelings about this hardship allow the individual to feel heard and less isolated, potentially leading to enhanced empowerment. The experience of disclosure was quite different when a formal reporting agency was used, such as the police or social services. First, these agencies were rarely sought out by violence-exposed individuals either through selfinitiated reports or through others on their behalf, suggesting that such organizations are underutilized and are not viewed as especially favorable, a finding consistent with previous research in Sweden (Annerbäck et al., 2010; SOU, 2001). It may be that these agencies need to take additional steps to train personnel and enhance their approachability for violenceexposed populations, given research indicating that professionals may feel


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inadequately equipped to manage disclosures (Taylor et al., 2013). Thus, children’s options for reporting should be enhanced to better match what they find supportive and healing. For example, it may be useful for the police to more often come to locations, such as schools or youth centers, in which children feel more comfortable discussing their personal experiences. In addition, shoring up relationships between service agencies and targeted relevant adults, including teachers or coaches, may increase the likelihood that these individuals will disclose on the child’s behalf. It may also be that the low percentage of formal reports recalled by participants reflects their lack of knowledge about reports made by others on their behalf in which no action was taken by the authorities. Thus, it is possible that the true percentage of formal reporting is underestimated in this study. These results should be interpreted with caution because only a small number of participants (n = 40) endorsed making a formal disclosure, so implications are speculative and limited based on the sample size. With regard to associations between mental health and disclosing, it was found that, after controlling for violence frequency and gender, young adults with higher levels of depression were less likely to have disclosed to a trusted confidante about their IPV during their childhood. Given that the primary reason for not disclosing was the belief that nothing could be done about the violence, it may be that non-disclosers feel a greater sense of helplessness or hopelessness, which may have been associated with depressed mood. Furthermore, nearly 70% of non-disclosers reported that they believed someone else knew about the IPV, even though it was not discussed directly. This may suggest an environment of silence and isolation during childhood, in which families did not talk openly about their feelings or experiences, which may be associated with eventual depressed mood. Given that this is a cross-sectional and retrospective study, there are a number of alternative explanations for this identified association, including that emotionally healthy young adults reflect on their childhood experiences more positively or that young adults currently experiencing depressed mood recall childhood events as more debilitating or isolating. Such an array of explanations highlights the preliminary nature of these findings and the importance of future longitudinal research to clarify relationships between childhood and adulthood experiences. Findings related to PTS again point to the importance of who was told about the violence. After controlling for violence frequency, young adults with higher levels of PTS were more likely to have made a self-initiated or other-initiated formal report about their IPV during their childhood. This may be due to the response and outcomes of these formal reports, as over 60% of respondents felt the problem continued despite the formal report and over


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40% believed that the consequences of making a formal complaint were not at all what they wanted. Although not available in the present study, it would be especially useful to explore if these differences in outcome were associated with self-initiated versus other-initiated reporting. It may be that rather than confronting the problem of IPV exposure, participants felt dismissed or stifled, which could contribute to avoidance or secondary traumatization. This hypothesis is supported by research indicating that the reaction to disclosure moderates the extent to which disclosure negatively affects mental health (Ullman, 2011). Violence frequency was also an influential factor with regard to PTS symptomatology, suggesting that more frequent violence was associated not only with the likelihood of making a formal report, but also with the expression of PTS. Previous research has consistently identified a direct association between IPV exposure and the expression of PTS, which has been reaffirmed in this study (Levendosky, Huth-Bocks, Semel, & Shapiro, 2002; Margolin & Gordis, 2000). Given the cross-sectional and retrospective study design, these findings may alternatively suggest that young adults who are actively experiencing higher levels of PTS may recall childhood experiences with IPV and with formal reporting agencies as more harsh, distressing, and unhelpful as compared with their emotionally healthy peers. Last, the small number of participants who recalled engaging with formal reporting services limits the interpretability of findings and highlights the preliminary nature of these results, which need to be reexamined with a larger sample using a longitudinal approach.

Limitations Although this study brought attention to an under-examined topic and utilized a nationally representative sample to assess key processes associated with violence exposure in Sweden, there were a number of limitations that should be acknowledged. First, the retrospective, cross-sectional study design and reliance on self-report measures may lead to recall and response biases. For example, a participant’s mental and emotional health in adulthood may have colored his or her reflections on childhood events and may have contributed to selective recall or the distortion of childhood experiences and feelings. Beyond the impact of current socioemotional functioning, the challenges of recollecting childhood events that may have transpired more than a decade earlier are significant and could be biased by a number of relevant factors, including other meaningful life experiences, ongoing relationships, temporal inaccuracies, and basic memory decay, all of which should be carefully considered when interpreting study results. Furthermore, some items included the response option of “could not recall,” which was utilized by a substantial


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minority of participants and may reflect some of the challenges in remembering childhood experiences. It is also possible that some participants felt compelled to provide an answer even though they could not accurately remember childhood events, which could have skewed study findings. All of these complications in cross-sectional, retrospective data collection, in conjunction with the small number of participants who endorsed certain items related to formal disclosures, suggest that findings from this preliminary study should be interpreted with caution. In addition, a potential measurement limitation is the lack of a standardized or systematic scale to evaluate disclosure. Of particular concern is that questions about disclosure were asked with regard to the totality of violence exposure, which limits the interpretations that can be drawn about participants who had chronic exposure to IPV, as these individuals may have made multiple disclosures over the course of childhood and their experiences of disclosure may have been variable. The current assessment of disclosure was unable to detect such variability, as it asked participants to draw from their total experience rather than querying about specific incidents. Furthermore, when evaluating relationships between young adult functioning and disclosure during childhood, it is important to keep in mind that other potentially traumatic events, not accounted for in the present study, may have influenced mental health. In addition, some relevant demographic information, including participant’s race/ethnicity, was not collected, which makes comparative analyses with other international populations more challenging. Finally, information on the participant’s number of siblings, extended family members, and individuals living with the participant during childhood was not gathered and such information could affect patterns of disclosure or outcomes associated with the disclosing process.

Clinical Implications and Future Research Directions A variety of practical implications emerge based on the findings from this study. Specifically, these results suggest that there is a need for improvement within the Swedish social service system with regard to opportunities for children to disclose IPV or for the IPV to be disclosed on their behalf. The common belief among participants who did not disclose was that nothing could be done about the violence, which may indicate existing (or perceived) problems in access to services for these families. In different parts of the country, particularly the more rural areas, new programs and/or ways to reach out to children exposed to IPV should be developed, which may promote better formal services for these at-risk children and families. In addition to the development of more formalized reporting structures, facilitating informal disclosures may also confer benefit for children exposed


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to IPV. The school environment may be an especially important place to bolster knowledge about the ramifications of IPV exposure, and to provide training to school staff about how to manage disclosures of violence, as all children in Sweden have mandated schooling from the age of 7 to 16, which falls in line with the common age range of IPV exposure for this sample. Such initiatives might also consider educating students about what to do if peers disclose that they are exposed to violence in the home. Finally, it may be useful to educate non-exposed confidantes on how to go about making reports on the behalf of their peers. A number of directions for future research emerge based on these study findings. Future studies should attempt to examine disclosure patterns during childhood, with particular emphasis on the attitudes and beliefs associated with deciding to disclose. This would bypass concerns with retrospective reporting and facilitate a richer and more nuanced examination of the decision-making process for children. It would also be beneficial for future research to assess the individual who the child chose to disclose to, as this might provide useful data on how recipients manage their response and allow for follow-up after a disclosure has been made. Given the role of social services in protecting children, conducting outcome evaluations of psychoeducational initiatives will be an important part of tracking whether increased disclosure and services have made a substantial impact on child and family well-being. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financially supported by the National Board of Health and Welfare in Sweden. The findings and conclusions in this manuscript are those of the authors only.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Annerbäck, E. M., Wingren, G., Svedin, C. G., & Gustafsson, P. A. (2010). Prevalence and characteristics of child physical abuse in Sweden: Findings from a population-based youth survey. Acta Paediatrica, 99, 1229-1236. Berliner, L., & Conte, J. R. (1995). The effects of disclosure and intervention on sexually abused children. Child Abuse & Neglect, 19, 371-384.


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Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic Research, 52, 69-77. Cater, Å. K., Andershed, A-K., & Andershed, H. (2014). Youth victimization in Sweden: Prevalence, characteristics and relation to mental health and behavioral problems in young adulthood. Child Abuse & Neglect, 38, 1290-1302. Centers for Disease Control and Prevention. (2006). Preventing intimate partner violence, sexual violence, and child maltreatment. Retrieved from http://www.cdc. gov/ncipc/pub-res/research_agenda/07_violence.htm Christensen, E. (1990). Children’s living conditions: An investigation into disregard of care in relation to children and teenagers in families of wife maltreatment. Nordisk Psykologi, 31(42), 161-232. Cohen, J. A., Mannarino, A. P., Murray, L. K., & Igleman, R. (2006). Psychological interventions for maltreated and violence-exposed children. Journal of Social Issues, 62, 737-766. Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Williamson, D. F. (2002). Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: Implications for health and social services. Violence and Victims, 17(1), 3-17. Easterling, B. A., Antoni, M. H., Fletcher, M. A., Marguiles, S., & Schneiderman, N. (1994). Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus activation. Journal of Consulting and Clinical Psychology, 62, 130-140. Edleson, J. L., Shin, N., & Armendariz, K. K. J. (2008). Measuring children’s exposure to domestic violence: The development and testing of the Child Exposure to Domestic Violence (CEDV) Scale. Children and Youth Services Review, 30, 502-521. Fantuzzo, J., & Fusco, R. (2007). Children’s direct sensory exposure to substantiated domestic violence crimes. Violence and Victims, 22, 158-171. Farber, B. A., Berano, K. C., & Capobianco, J. A. (2006). A temporal model of patient disclosure in psychotherapy. Psychotherapy Research, 16, 463-469. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Polyvictimization and trauma in a national longitudinal cohort. Development and Psychopathology, 19, 149-166. Gracia, E., & Herrero, J. (2006). Acceptability of domestic violence against women in the European Union: A multilevel analysis. Journal of Epidemiology & Community Health, 60, 123-129. Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L., & Watts, C. H. (2005). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence. The Lancet, 368, 12601269. Graham-Bermann, S. A., Kulkarni, M., & Kanukollu, S. (2011). Is disclosure therapeutic for children following exposure to traumatic violence? Journal of Interpersonal Violence, 26(5), 1056-1076.


2905

Howell et al.

Graham-Bermann, S. A., Lynch, S., Banyard, V., DeVoe, E., & Halabu, H. (2007). Community-based intervention for children exposed to intimate partner violence. Journal of Consulting and Clinical Psychology, 75(2), 199-209. Jonzon, R., Vung, N. D., Ringsberg, K. C., & Krantz, G. (2007). Violence against women in intimate relationships: Explanations and suggestions for interventions as perceived by healthcare workers, local leaders, and trusted community members in a northern district of Vietnam. Scandinavian Journal of Public Health, 35, 640-647. Jouriles, E. N., McDonald, R., Rosenfield, D., Stephens, N., Corbitt-Shindler, D., & Miller, P. C. (2009). Reducing conduct problems among children exposed to intimate partner violence: A randomized clinical trial examining effects of Project Support. Journal of Consulting and Clinical Psychology, 77, 705-717. Kitzmann, K. M., Gaylord, N. K., Holt, A. R., & Kenny, E. D. (2003). Child witnesses to domestic violence: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 339-352. Levendosky, A. A., Huth-Bocks, A. C., Semel, M. A., & Shapiro, D. L. (2002). Trauma symptoms in preschool-age children exposed to domestic violence. Journal of Interpersonal Violence, 17, 150-164. Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 1241-1248. Lundgren, E., Heimer, G., Westerstrand, J., & Kalliokoski, A.-M. (2001). Captured Queen: Men’s violence against women in “Equal Sweden” a prevalence study. Umea, Sweden: Crime Victim Compensation and Support Authority. Margolin, G., & Gordis, E. B. (2000). The effects of family and community violence on children. Annual Review of Psychology, 51, 445-479. Pennebaker, J. W. (2000). The effects of traumatic disclosure on physical and mental health: The values of writing and talking about upsetting events. In J. M. Violanti, D. Paton, & C. Dunning (Eds.), Posttraumatic stress intervention: Challenges, issues and perspectives (pp. 97-114). Springfield, IL: C. C. Thomas. Priebe, G., & Svedin, C. G. (2008). Child sexual abuse is largely hidden from the adult society: An epidemiological study of adolescents’ disclosures. Child Abuse & Neglect, 32, 1095-1108. Sauzier, M. (1989). Disclosure of child sexual abuse: For better or worse. Psychiatric Clinics of North America, 12, 455-469. Saywitz, K. J., Goodman, G. S., Nicholas, E., & Moan, S. F. (1991). Children’s memories of a physical examination involving genital touch: Implications for reports of child sexual abuse. Journal of Consulting and Clinical Psychology, 59, 682-691. Solberg, A. (2007). Hur förhåller sig barn till våld i hemmet? [How do children respond to violence in their home?]. In Eriksson (Ed.), Barn som upplever våld. nordisk forskning och praktik [Children who experience violence: Nordic research and practice] (p. 25-37). Stockholm, Sweden: Gothia Publishers.


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Statens Offentliga Utredningar [Government Official Reports]. (2001). Barnmisshandel: Att förebygga och åtgärda [Child abuse: Prevention and treatment]. In Slutbetänkande av Kommittén mot barnmisshandel, Statens Offentliga Utredningar [Final Report of the Committee on Child Abuse, Government Official Reports] (p. 72). Stockholm, Sweden: Fritzes Publisher. Sveen, J., Low, A., Dyster-Aas, J., Ekselius, L., Willebrand, M., & Gerdin, B. (2010). Validation of a Swedish version of the Impact of Event Scale-Revised (IES-R) in patients with burns. Journal of Anxiety Disorders, 24, 618-622. Taylor, J., Bradbury-Jones, C., Kroll, T., & Duncan, F. (2013). Health professionals’ beliefs about domestic abuse and the issue of disclosure: A critical incident technique study. Health & Social Care in the Community, 21, 489-499. The Swedish Penal Code. (2010). Government of Sweden, Section 370, Article 29.2. Retrieved September 14, 2013. Ullman, S. E. (2011). Is disclosure of sexual traumas helpful? Comparing experimental laboratory versus field study results. Journal of Aggression, Maltreatment & Trauma, 20, 148-162. United Nations Children’s Fund. (2005). Behind closed doors: The impact of domestic violence on children. New York, NY: UNICEF Child Protection Section. Weiss, D. S. (2007). The Impact of Event Scale: Revised. In J. P. Wilson & C. S. Tang (Eds.), Cross-cultural assessment of psychological trauma and PTSD (pp. 219238). New York, NY: Springer. Weiss, D. S., & Marmar, C. R. (1997). The Impact of Event Scale-Revised. In J.P. Wilson & T.M. Keane (Eds.), Assessing Psychological Trauma and PTSD:A Practitioner’s Handbook (pp. 399-411). New York, NY: Guilford Press. Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.

Author Biographies Kathryn H. Howell, PhD, is an assistant professor in the Department of Psychology at the University of Memphis. She received her PhD from the University of Michigan Clinical Psychology program and completed a 2-year postdoctoral fellowship in the clinical child and adolescent track of the University of Michigan Department of Psychiatry postdoctoral training program. Her research centers on young children exposed to potentially traumatic events, such as family violence and parental loss. She examines pathways to risk and resilience in these children. She is also a licensed psychologist with health service provider designation in the state of Tennessee. Åsa K. Cater, PhD, is an associate professor in the School of Law, Psychology and Social Work at Örebro University in Sweden. As a trained social worker, she has previously worked in a residential institution supporting teenage girls with psychosocial problems. Her research is primarily aimed at understanding the experiences of children whose mothers have been abused by an intimate partner. In her research, she also examines children’s victimization to other forms of violence and neglect, as well as disrupted child–parent relationships. More recently, her research has included how


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welfare institutions can meet the growing support needs of children exposed to intimate partner violence. Laura E. Miller-Graff, PhD, is an assistant professor of psychology and peace studies at the University of Notre Dame. Her research examines the developmental effects of exposure to violence in childhood with a particular focus on children who have multiple traumatic exposures. She investigates resulting patterns of resilience and psychopathology, including the development of posttraumatic stress symptoms. In addition to basic research on the effects of violence on development, her work also seeks to identify effective intervention practices for children and families affected by violence. Sandra A. Graham-Bermann, PhD, is professor of psychology and psychiatry at the University of Michigan, where she researches how different forms of violence affect children’s adjustment. Over the past 23 years, she has developed new measures of children’s fears and worries, traumatic stress, attitudes and beliefs about violence, family stereotyping, and conflict in sibling relationships. With support from national agencies and state and local foundations, she has designed and evaluated interventions for women and children exposed to domestic violence using randomized control trials. Author of more than 70 peer-reviewed publications, she is co-editor of How Intimate Partner Violence Affects Children: Developmental Research, Case Studies, and Evidence-Based Treatment (2011, APA Books). As director of the Child Violence and Trauma Lab in the Department of Psychology, she and her team of postdoctoral fellows, graduate students, and honors students study the behavioral and emotional adjustment of children exposed to family violence and trauma and interventions designed to assist them. These interventions have been adopted for use in 28 states and 5 countries.


Children's exposure to intimate partner violence.

Children's exposure to intimate partner violence: Impacts and interventions.

Ethnoracial Variation in Women's Exposure to Intimate Partner Violence.

Screening for intimate partner violence during pregnancy.

Childhood maltreatment and intimate partner violence in dissociative disorder patients.

Lesbian intimate partner violence.

Intimate partner violence interventions.

Types of adolescent exposure to violence as predictors of adult intimate partner violence.

Lasting effect of intimate partner violence exposure during preschool on aggressive behavior and prosocial skills.

Parent-child warmth as a potential mediator of childhood exposure to intimate partner violence and positive adulthood functioning.

Intimate partner violence during pregnancy: maternal and neonatal outcomes.

Lifetime Exposure to Intimate Partner Violence and Proinflammatory Cytokine Levels Across the Perinatal Period.

Intimate partner violence and maternal educational practice.

Gender, psychopathy factors, and intimate partner violence.

Intimate Partner Violence. The gynaecologist's perspective.

Intimate partner violence during pregnancy in Urmia, Iran in 2012.

The effect of an evidence-based intervention on women's exposure to intimate partner violence.

Intimate partner violence and HIV: embracing complexity.

Informal social control and intimate partner violence.

Intimate partner violence and mental health.

Intimate partner violence and children's memory.

Mechanisms of Alcohol-Facilitated Intimate Partner Violence.

AWHONN Position Statement. Intimate partner violence.

Physical intimate partner violence in northern India.