Issues in Comprehensive Pediatric Nursing, 2014; 37(4): 212–234 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.947444

BEHAVIORAL FUNCTIONING OF CHILDREN OF ABUSED WOMEN WHO SEEK SERVICES FROM SHELTERS OR THE JUSTICE SYSTEM: NEW KNOWLEDGE FOR CLINICAL PRACTICE

Nina M. Fredland, PhD, RN1, Judith McFarlane, DrPH, FAAN2, John Maddoux, MA1, Brenda K. Binder, PhD, RN1, and Nora Montalvo-Liendo, PhD, RN, FAAN3 1

College of Nursing, Texas Woman’s University, Houston, Texas, 2Parry Chair in Health Promotion & Disease Prevention, College of Nursing, Texas Woman’s University, Houston, Texas, and 3College of Nursing, Texas A&M Health Science Center-McAllen Campus, Bryan, Texas

Millions of women worldwide are victims of partner violence annually and their children are at-risk for psychological and physical dysfunctions. A total of 300 children (ages 18 months to 16 years), whose abused mothers sought safe shelter or a protection order for the first time, were studied. Data revealed internalizing behaviors, such as depression and externalizing behaviors, such as bullying decreased 4 months after mothers obtained help. Children’s scores from the shelter group indicated more dysfunction. Although no direct program was offered to the children studied, routine child care presents opportunities for nurses in pediatric settings to assess mothers for abuse and intervene with guided referrals and safety information that may promote better child functioning. Keywords: Child behavioral functioning, Intimate Partner Violence, Child Exposure to Violence, Internalizing Behaviors, Externalizing Behaviors

The World Health Organization (WHO) has called for a global response to interpersonal violence. Global estimates of children exposed to violence against a parent or caregiver in the home range from 133 to 275 Received 1 April 2014; revised 17 July 2014; accepted 18 July 2014

Correspondence: Nina Fredland. E-mail: [email protected]

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million (United Nations Children’s Fund et al., 2009) For more than a decade, the World Health Organization (WHO) has encouraged researchers, scientists, and advocates to delineate and identify causal factors, and test global intervention models with the intent of widely applying effective measures for safety and wellbeing (Krug et al., 2002). Within the broad scope of violence, family violence remains a pervasive public health problem worldwide (WHO, 2012). Family violence spans generations, socioeconomic, racial, and ethnic groups. Evidence suggests that children exposed to intimate partner violence (IPV), a form of family violence, are at increased risk for developing emotional, behavioral, physiological, cognitive, and social problems (Johnson & Lieberman, 2007; Overlien, 2010; Zerk et al., 2009) both as children and as adults (Felitti, et al., 1998; McFarlane et al., 2006). Furthermore, these children are at even greater risk for developing mental health problems, such as post-traumatic stress disorder (PTSD) (Graham-Bermann et al., 2012) as well as growth and development delays (Jouriles et al., 2000). Global studies on children who witness abuse perpetrated against their mothers show that the abuse negatively impacts a child’s mental and physical health (Hirst, 2012; Lamers-Winkelman et al., 2012; Meltzer et al., 2009). Negative Outcomes for Children Exposed to Family Violence Increasing evidence suggests that children and adolescents growing up in urban poverty are more likely than those growing up in more affluent environments to experience traumatic events that interfere with normal development and may progress to ‘‘complex symptoms of traumatic distress at disproportionate rates’’ (Collins et al., 2010, p. 11). Children tend to be more traumatized by witnessing violence in their own homes than by witnessing less personal violence in the street such as community or gang violence (Osofsky, 1999). Every year in the United States alone, an estimated one million children arrive at shelters with their mothers seeking safety from abusive household situations (Jouriles et al., 2000). These children of violent homes experience detrimental effects; yet, receive little or no counseling or coping assistance (Jouriles et al., 2001). Additionally, children exposed to violence have the potential to become victims or perpetrators of interpersonal violence later in life either as older teens or adults (Whitfield et al., 2003). Negative Child to Child Violence Related Behavior Family violence effects extend beyond an individual child. Externalizing behaviors, including physical fighting and bullying, appear to be

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acceptable ways to handle difficult situations at home and at school (Fredland, 2005; Fredland et al., 2008). Nationally representative surveys such as the Youth Risk Behavior Surveillance Survey, conducted periodically in U.S. middle and high schools, consistently report high numbers (32.8%) of boys and girls who admit physically fighting (CDC, 2012). In the classic study by Nansel and associates, more than five million youth (29%) admitted experiencing some form of bullying behavior (Nansel et al., 2001). Recent findings report 20.1% of students experience some form of bullying behavior at school and 16.2% admit being bullied electronically and fighting (CDC, 2012). Recent advances in social media provide a platform for cyber bullying, an indirect form of abuse. Furthermore, 28.5% of school age youth consistently reported daily feelings of sadness and hopelessness over a 2-week period and stated that their mood interfered with their normal activities. Recognizing that such child behaviors and feelings may be attributable to a variety of issues, these data underscore the need for recognition and advocacy to support healthy child development, behavior and functioning. Behavioral Dysfunctions for Children Exposed to Family Violence Boys exposed to domestic violence tend to exhibit more externalizing behaviors, such as hostility and aggression (Binder et al., 2013; Hazen et al., 2006; Yates et al., 2003) while girls display more internalizing behaviors, such as withdrawal (Yates et al., 2003). However, some studies report older girls demonstrate more violent and aggressive behaviors than boys (Cummings et al., 1999; Holt et al., 2008). The child’s age at first exposure to mother’s abuse by her intimate partner is linked to whether the behavior problem is internal or external and mediated by the dose of exposure. Children exposed, first as preschoolers, are more likely to exhibit internalizing problems of depression and anxiety and less likely to have externalizing behaviors of anger and hostility as compared with school-age children (GrahamBermann et al., 2009; Sternberg et al., 2006). Interventions for Children Exposed to Family Violence Research is lacking in effective intervention models to prevent negative outcomes related to witnessing violence, especially intimate partner violence in the home. However, appropriate and timely interventions have been shown to be effective in addressing children’s externalizing behaviors (i.e., bullying, and aggressive behaviors) and internalizing behaviors (i.e., deprssive and anxious states) (Feinfield & Baker, 2004; Grossman et al., 1997). Specifically, researchers report children’s

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externatilizing and internalizing scores on the Child Behavior Checklist (CBCL) improved post intervention (Graham-Bermann et al., 2007). Graham-Bermann and colleagues intervened with mother-child dyads and the improvement was observed in children whose mothers received the intervention. Additionally, Jouriles and colleagues, recruited children and mothers (post-shelter experience) and found evidence that a program with an emphasis on social learning principles was effective in reducing behavioral problems in the children exposed to IPV (Jouriles et al., 2001). The success of the program in diminishing children’s externalizing and agresssive behaviors was attributed to building parenting skills. Therefore, improving the behavioral functioning of children exposed to violence is a critical step towards the overall well-being of the entire family. Most intervention studies for children who are exposed to domestic violence have focused on children of mothers who reside in shelters for abused women (Baus et al., 2009; Jouriles et al., 2001; McDonald et al., 2006). All studies identified were formal intervention studies, applied in addition to standard shelter services. No evidence to improve outcomes for children was found after their abused mothers reached out for services, such as safe shelter residence or a protection order. We seek to add evidence for outcome effectiveness on child behavior following an abused mother’s decision to reach out to community services for the first time. The overall intent of this research is to determine the best time for intervening to boost child functioning in a postive direction. We feel this outcome information on child behavior may be applicable to children of abused mothers, and inform practice for nurses and others working in pediatric settings; thus, leading to appropriate referral services for safety and wellbeing. In addition, we hope to add to the evidence related to the following questions: Do these assistance safety actions alone result in more positive functioning for the child? Is length of time an abused mother stays at a shelter with her children associated with differencial outcomes? Is receipt or non-receipt of a protection order (PO) against a perpetrator associated with differential outcomes of child wellbeing? To prevent the negative outcomes of domestic violence on children, evidence is needed on the joint effect of safety actions taken by abused mothers on the functioning of the mother and her children. STUDY PURPOSE The purpose of this study is to examine the differential behavioral outcomes over time of children of abused mothers who seek safe shelter or protection orders for the first time and are therefore seeking

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formal assistance to deal with the abuse. This research is part of an ongoing prospective study to assess the long term effects on maternal and child functioning following assistance seeking. These initial findings (entry to the study and 4 months later) will inform heath care professionals about child outcomes post maternal help-seeking. Age and gender implications will be analyzed as to child behavioral outcomes, specifically related to internalizing and externalizing behaviors. To our knowledge there have been no studies that considered child functioning outcomes following their abused mother’s use of safe shelter or justice services for the first time. The aim, scope, and methodology of the full prospective study, including detailed procedures, eligibility criteria, and interview schedule are reported elsewhere (McFarlane et al., 2012). Research Questions Four research questions to address the study purpose are: 







What is the outcome of days at shelter (defined as less than the median stay of 21 days compared to greater than the median stay of 21 days) by time (entry to the shelter and 4 months later) on child functioning (measured as internalizing, externalizing, and total problematic behaviors)? What is the outcome of a protective order (received compared to not received) by time (application for the order and 4 months later) on child functioning (measured as internalizing, externalizing, total problems)? What are differences in child functioning at entry compared to 4 months for women entering a shelter and mothers applying for a PO by children’s age and gender? Are there changes in proportions of children in clinically significant ranges of behavioral functioning across internalizing, externalizing, and total problem scores?

METHODS Design A cohort observational prospective design is followed with repeated measures at 4 months following entry into the study. Setting The study is occurring in a large urban metropolis in the United States with a population exceeding four million. Five shelters designated for abused women with a collective bed capacity of 400 for women and

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their children serve the population along with a central District Attorney’s Office for processing of protection orders (POs) along with offering safety information and referral assistance to community resources. Population and Sample Size Determination Our eligible population is English and Spanish speaking abused women seeking a shelter for abused women or justice services, specifically a protection order, for the first time who had never used shelter services or applied for a protection order in the past and who also had at least one child between the ages of 18 months and 15 years who live with the mother at least 50% of the time. (If the mother had more than one child within the age range of 18 months to 15 years, one child was selected at random.) Ages 18 months to 15 years were selected to allow for following the youngsters for 3 years and maximum stability of the child functioning measure. Sample size was determined with G-power. Considering two independent samples (i.e., sheltered women and protection order applicants) with a conservative effect size of 0.40, a power of 0.90, and alpha of 0.05, 135 women were needed in each group. Allowing for attrition, we set the sample at 150 women and 150 children in each group for a total of 300 women and 300 children. If the woman had more than one child between the ages of 18 months and 15 years, each child was given a number according to birth order and a die was rolled to select one child at random to be followed in the study. Procedures Following Internal Review Board (IRB) approval at Texas Woman’s University, recruitment began at five local shelters for abused women and the District Attorney’s (DA) Office. Trained researchers, bi-lingual in English and Spanish, approached all women entering the shelter or applying for a protection order and established eligibility criteria. If the women were eligible, the women were taken to a private room and invited to participate in the study. After signing informed consent and completion of the 60-minute interview, all 300 women were offered $30 cash. Two native Spanish and English speakers completed an independent forward and backward translation of all questionnaires from English to Spanish and back to English. The interview could be completed in 60 minutes in both languages. The researchers recorded the woman’s responses using hard copy questionnaires during a private interview setting.

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Recruitment, eligibility screening, and entry into the study continued daily for 13 months at the 5 shelters and Monday through Friday at the DA’s Office. Over the 13 months, 330 women met eligibility criteria. A total of 19 eligible women refused to participate, usually due to a lack of time, and 11 women were missed (i.e., left the shelter or DA’s Office before the study could be explained). A total of 300 women (e.g., 150 at the shelters and 150 at the DA’s office) met eligibility criteria and agreed to participate in this study. The women were re-interviewed at 4 months and offered $40 compensation. The temporal sequencing of 4 months was selected for repeated measures to allow for maximum stability of the child functioning measure and limit recall bias. Instrument Standard demographic questions measuring age, gender, socioeconomic status, education, and employment, as well as current and past relationship with the abuser were collected at entry into the study. Income and poverty level data were categorized according to the United States Department of Health and Human Services (USDHHS) guidelines. The Child Behavior Check List (CBCL), an internationally standardized and widely used instrument, was used to measure child functioning (Achenbach, 1991; Achenback & Rescorla, 2000, 2001) at entry into the study and 4 months later. Two parent report versions of the instrument are available: One is appropriate for children 18 months to 5 years old and has 100 items; and, the other version is applicable for 6 to 18 year olds and has 113 items. As a result of the norming of the CBCL, women had to be the mother of at least one child in this age range to be eligible for inclusion in the study, and that child would also not exceed the normed age range of the CBCL during the timeframe of the study. The Child Behavior Check List (CBCL) is administered to parents, who rate the various behaviors according to presence and frequency on a 3-point scale (0 ¼ ‘‘not true,’’ 1 ¼ ‘‘somewhat or sometimes true,’’ and 2 ¼ ‘‘very true or often true’’). Parents are asked to recall behavior over the past 2 months for the young child and 6 months for six and older children. Items include statements such as being ‘‘cruel to animals,’’ ‘‘physically attacks people,’’ and ‘‘doesn’t want to sleep alone.’’ The 6–18 year old measure includes behaviors such as ‘‘bully behavior,’’ ‘‘vandalism,’’ and ‘‘prefers being with older children.’’, The Child Behavior Check List consists of two subscales: internalizing and externalizing, particularly salient to this study, and total problems score. Normed mean scale scores are categorized as normative, borderline (non-referred), and clinical (referred) samples of children.

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These categorized levels are based on standardized scores, which were normed for both age and gender, and, as such, specific cut offs for clinical severity vary by age and gender. Raw scores were utilized as continuous measures of each of the domains of the Child Behavior Check List. The Child Behavior Check List has had extensive psychometric testing with English and Spanish samples and is generally accepted as valid and reliable (Achenback & Rescorla, 1991, 2000). Time to complete the Child Behavior Check List is approximately 15 minutes. Scoring by researchers followed manual instructions. Data Analysis Prior to conducting the primary analyses, preliminary analyses were conducted to obtain descriptives of the sample, test the assumptions of parametric statistics, and to test simple relationships among variables of interest. Next the statistical assumptions of normality, homogeniety of variance, independence, equal group sizes, etc. were tested. The obtained data meet the assumptions of statistical tests utilized in primary analysis (i.e., repeated measures ANOVA, crosstabulations with Pearson’s chi square). Additionally, simple relationships were tested for potential covariates to be included in primary analysis. To measure differences in child behavioral functioning (e.g., Internalizing, Externalizing, Total Problems) across groups (shelter compared to PO), a series of two (time [baseline, four- months]) by 2 (group [PO, shelter]) by 2 (child gender [boy, girl]) by two (age [1.5–5 years, 6–18 years]) repeated measures Analysis of Variance (ANOVA) tests were conducted. Repeated measures ANOVAs were utilized in order to control for individual differences in outcome measures overtime, as well as to provide both within and between subject differences of main and interaction effects. Effect sizes of all ANOVAs conducted were measured as partial eta square (pZ2). Eta square values of pZ2 ¼ 0.01 indicates a small effect size; and pZ2 ¼ 0.06 indicates a medium effect size; and, pZ2 ¼ 0.14 indicates a large effect size. In order to test for differences in proportions of children in the clinical range of scores, cross tabulations with Pearson’s chi square and Cramer’s V were calculated. All analyses were conducted using SPSS v. 19.0, and the significance level of all tests was 0.05. RESULTS Descriptives of the final sample are outlined in Table 1. Abused mothers who participated in this study had ages ranging from 18 to 52 years old (M ¼ 30.65; SD ¼ 7.64), with the age of the selected child ranging from

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Table 1. Descriptives of final sample

Age of woman Child age (years) Children 1.5–16 years Months in abusive relationship People living in household Age of child (months) Number of children in household

Race White Black Spanish or Hispanic Other/Multi-Racial Ethnicity Hispanic Non-Hispanic Currently in an intimate relationship No Yes Currently in relationship with abuser No Yes Graduate from high school or GED? No Yes Child gender Male Female

n

M

SD

Min

Max

300 299 300 297 298 298 300

30.65 6.88 1.93 83.59 3.64 82.56 1.93

7.64 4.23 1.09 62.86 1.60 50.81 1.10

18 1.5 1 0 1 18 1

52 16.42 7 300 9 197 7

n

%

32 78 170 20

11.7 26 56.7 7.7

170 130

56.7 43.3

251 49

83.7 16.3

190 110

63.3 36.7

101 199

33.7 66.3

152 148

50.7 49.3

1.5 to 16.42 years old (M ¼ 6.88, SD ¼ 4.23). Participants reported an average of 3.64 (SD ¼ 1.60) people living in their household, and that there was an average of 1.93 (SD ¼ 1.09) children living in the home. As also shown, the majority of the sample identified as being Spanish or Hispanic (n ¼ 170, 56.7%). The greatest percentage of the sample identified Spanish or Hispanic as their ethnic background (n ¼ 137, 45.7%), followed by Black (n ¼ 78, 26.0%) and White (n ¼ 32, 10.7%). A large majority of the sample reported that they are not currently in a romantic relationship (n ¼ 251, 83.7%), as well as are not currently in a relationship with the abuser (n ¼ 190, 63.3%). Most participants reported that they had completed secondary school education or the equivalent. Demographic information about the index child is also presented in Table 1.

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Child Function by Days at Shelter In order to test the main effect of total days spent at a shelter on child functioning, a within subjects repeated measure ANOVA was conducted. There was not a significant main effect of number of days spent at a shelter (i.e., less than 21 day, greater than 21 days) on internalizing, externalizing, or total problem scores, all p values 40.05. Furthermore, none of the interaction effects of time by days at shelter were significant, all p values 40.05. Child Functioning by Protection Order Received In order to test the main effect of whether or not a protection order was received on child functioning, a within subjects repeated measure ANOVA was conducted. There was not a significant main effect of receiving a PO on internalizing, externalizing, or total problem scores, all p values 40.05. Furthermore, none of the interaction effects of time by days at shelter were significant, all p values 40.05. Child Functioning by Time In order to test the main effect of time on child functioning, a within subjects repeated measures ANOVA was conducted. There was a significant effect of time on internalizing, F (1, 290) ¼19.52, p50.001, Z2 ¼ 0.063, externalizing, F (1, 290) ¼ 5.52, p ¼ 0.019, Z2 ¼ 0.019, and total problems, F (1, 290) ¼ 17.68, p50.001, Z2 ¼ 0.057. Across all measures, scores were lower at 4 months compared to baseline, and effect sizes were moderate, indicating that time accounted for a significant and moderate amount of the variance explained in child outcomes. See Table 2 for a summary of means by time. Child Function by Group, Time, Gender, Age In order to test the interaction effects of time, group, child age, and gender, a repeated measure of 2 (group) x 2 (time) x 2 (gender) x 2 (age group) ANOVA was conducted, see Tables 3 and 4. There was a significant main effect of group on internalizing scores, F (1, 282) ¼ 8.41, p ¼ 0.004, Z2 ¼ 0.029. Children whose mothers sought support through a protection order from the District Attorney’s office, had significantly lower internalizing scores (Mbaseline ¼ 10.77, SDbaseline ¼ 8.53; M4mo ¼ 8.51, SD4mo ¼ 7.36) compared to children of mothers who sought support of a safe shelter (Mbaseline ¼ 13.09, SDbaseline ¼ 9.66; M4mo ¼ 11.32, SD4mo ¼ 9.08). Similarly, there was a

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Table 2. Main effect of time by child functioning

Internalizing Baseline 4 Month Externalizing Baseline 4 Month Total Problems Baseline 4 Month

n

M

SD

291 291

11.90 9.94

9.14 8.40

291 291

14.48 13.40

10.84 10.83

291 291

43.44 38.28

27.59 26.73

F

p

eta-squared

19.52

50.001

0.063

5.52

0.019

0.019

17.68

50.001

0.057

significant main effect of group on externalizing scores, F (1, 282) ¼ 12.41, p50.001, Z2 ¼ 0.042. Children in the shelter group had significantly higher externalizing scores (Mbaseline ¼ 16.81, SDbaseline ¼ 11.48; M4mo ¼ 15.43, SD4mo ¼ 11.44) compared to all children in the protection order group (Mbaseline ¼ 12.26, SDbaseline ¼ 9.77; M4mo ¼ 11.36, SD4mo ¼ 9.77). Lastly, there was a significant effect of group on total problem scores, F (1, 282) ¼ 15.08, p50.001, Z2 ¼ 0.051. Children of women who sought services via safe shelter services had significantly higher total problem scores (Mbaseline ¼ 49.18, SDbaseline ¼ 28.93; M4mo ¼ 43.77, SD4mo ¼ 27.42) compared to children of women who sought protective services through the DA’s office (Mbaseline ¼ 38.01, SDbaseline ¼ 25.27; M4mo ¼ 32.80, SD4mo ¼ 24.84) regardless of the effect of time. There was a significant main effect of gender on internalizing, F (1, 282) ¼ 5.89, p ¼ 0.016, Z2 ¼ 0.020, externalizing, F (1, 282) ¼ 9.63, p ¼ 0.002, Z2 ¼ 0.033, and total problems, F (1, 282) ¼ 12.42, p50.001, Z2 ¼ 0.042. Boys had higher internalizing scores (Mbaseline ¼ 13.18, SDbaseline ¼ 9.89; M4mo ¼ 10.66, SD4mo ¼ 8.90) compared to girls (Mbaseline ¼ 10.58, SDbaseline ¼ 8.16; M4mo ¼ 9.08, SD4mo ¼ 7.69) regardless of the effect of time. Boys had significantly higher externalizing scores (Mbaseline ¼ 16.13, SDbaseline ¼ 10.93; M4mo ¼ 14.82, SD4mo ¼ 10.92) compared to girls (Mbaseline ¼ 12.79, SDbaseline ¼ 10.56; M4mo ¼ 11.83, SD4mo ¼ 10.49). Boys had higher total problem scores (Mbaseline ¼ 48.50, SDbaseline ¼ 28.74; M4mo ¼ 42.53, SD4mo ¼ 28.17) compared to girls (Mbaseline ¼ 38.31, SDbaseline ¼ 25.57; M4mo ¼ 33.67, SD4mo ¼ 24.31). There was also a significant effect of child age on externalizing scores, F (1, 282) ¼ 26.68, p50.001, Z2 ¼ 0.095. As shown in Table 3, children between the ages of 1.5 and 5 years had higher externalizing

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Table 3. Means and standard deviations for baseline and 4 month child outcomes by gender Boy

Girl

N

Baseline

4 Month

N

Baseline

4 Month

Internalizing1 1.5–5 years

70 76

11.13 (7.88) 10.24 (9.78) 10.66 (8.90)

73

6–18 years

13.59 (10.34) 12.82 (9.51) 13.18 (9.89)

10.38 (8.17) 10.79 (8.20) 10.58 (8.16)

9.14 (7.15) 9.01 (8.25) 9.08 (7.69)

20.26 (10.11) 12.33 (10.31) 16.13 (10.93)

17.69 (9.91) 12.17 (11.19) 14.82 (10.92)

15.99 (11.09) 9.51 (8.94) 12.79 (10.56)

14.84 (11.11) 8.75 (8.88) 11.83 (10.49)

52.53 (26.68) 44.79 (30.21) 48.50 (28.74)

45.51 (24.84) 39.79 (30.84) 42.53 (28.17)

40.70 (26.46) 35.86 (24.56) 38.31 (25.57)

36.66 (25.64) 30.59 (22.63) 33.67 (24.31)

All ages

146

Externalizing2 1.5–5 years

70

6–18 years All ages

76 146

Total problems3 1.5–5 years

70

6–18 years

76

All ages

146

71 144

73 71 144

73 71 144

1

Main effect of time ¼ F (1, 282) ¼ 18.58, p50.001, Z2 ¼ 0.062, Main effect of gender ¼ F (1, 282) ¼ 5.89, p ¼ 0.016, Z2 ¼ 0.020, Main effect of age ¼ F (1, 282) ¼ 0.00, p ¼ 0.949, Z250.001, Time by Gender ¼ F (1, 282) ¼ 5.89, p ¼ 0.016, Z2 ¼ 0.020, Time by Age ¼ F (1, 282) ¼ 0.002, p ¼ 0.960, Z250.001, Time by Gender by Age ¼ F (1, 282) ¼ 0.08, p ¼ 0.778, Z250.001; 2Main effect of time ¼ F (1, 282) ¼ 5.89, p ¼ 0.016, Z2 ¼ 0.020, Main effect of gender ¼ F (1, 282) ¼ 9.63, p ¼ 0.002, Z2 ¼ 0.033, Main effect of age ¼ F (1, 282) ¼ 2.98, p ¼ 0.086, Z2 ¼ 0.010, Time by Gender ¼ F (1, 282) ¼ 0.20, p ¼ 0.653, Z2 ¼ 0.001, Time by Age ¼ F (1, 282) ¼ 0.1.79, p ¼ 0.182, Z2 ¼ 0.006, Time by Gender by Age ¼ F (1, 282) ¼ 1.43, p ¼ 0.233, Z2 ¼ 0.005. 3Main effect of time ¼ F (1, 282) ¼ 17.48, p50.001, Z2 ¼ 0.058, Main effect of gender ¼ F (1, 282) ¼ 12.42, p50.001, Z2 ¼ 0.042, Main effect of age ¼ F (1, 282) ¼ 2.98, p ¼ 0.086, Z2 ¼ 0.010, Time by Gender ¼ F (1, 282) ¼ 0.34, p ¼ 0.563, Z2 ¼ 0.001, Time by Age ¼ F (1, 282) ¼ 0.002, p ¼ 0.960, Z250.001, Time by Gender by Age ¼ F (1, 282) ¼ 0.59, p ¼ 0.443, Z2 ¼ 0.002

scores than children between the ages of 6 and 18. As summarized in Tables 3 and 4, there were no significant interactions between time, group, age, and gender on child outcomes scores, all p values 4.05, indicating that child outcomes does not appear to change differently for various combinations of these factors.

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Table 4. Means and Standard deviations of child outcomes by group PO (n ¼ 149)

Internalizing

1

Externalizing2 Total problems3

Shelter (n ¼ 141)

Baseline

4 Month

Baseline

4 Month

F

p

10.77 (8.53) 12.26 (9.77) 38.01 (25.27)

8.51 (7.36) 11.36 (9.77) 32.80 (24.84)

13.09 (9.66) 16.81 (11.48) 49.18 (28.93)

11.32 (9.08) 15.43 (11.44) 43.77 (27.42)

8.41

0.004

12.41

50.001

15.09

50.001

1

Main effect of time ¼ F (1, 282) ¼ 17.48, p50.001, Z2 ¼ 0.058, Main effect of group ¼ F (1, 282) ¼ 8.41, p ¼ 0.004, Z2 ¼ 0.029, Time by Group ¼ F (1, 282) ¼ 0.19, p ¼ 0.664, Z2 ¼ 0.001; 2Main effect of time ¼ F (1, 282) ¼ 5.87, p ¼ 0.016, Z2 ¼ 0.020, Main effect of group ¼ F (1, 282) ¼ 12.41, p50.001, Z2 ¼ 0.042, Time by Group ¼ F (1, 282) ¼ 0.26, p ¼ 0.610, Z2 ¼ 0.001; 3Main effect of time ¼F (1, 282) ¼ 17.48, p50.001, Z2 ¼ 0.058, Main effect of group ¼ F (1, 282) ¼15.09, p50.001, Z2 ¼ 0.051, Time by Group ¼ F (1, 282) ¼ 0.03, p ¼ 0.867, Z250.001

Children in Clinically Significant Distress Finally, Table 5 presents frequencies and percentages of the CBCL internalizing, externalizing, and total behavior problems according to three behavioral ranges: normative, borderline clinical, and clinical for all 300 children at entry and 4 months after their mothers reached out for services. If the children improved more than 6% over the 4 months, their behavior significantly improved at the p50.05 level. Dramatic improvement occurred over the short 4 month time period. Some 11% of children moved out of the clinical range for internalizing behaviors at 4 months and almost 10% moved into normative behaviors. For total behavior problems, almost 8% of the youth moved out of the clinical range. No significant differences from entry to 4 months were recorded for children’s externalized behaviors. Summary of Results Overall, these findings suggest that regardless of group (i.e., shelter versus protection order), age, gender, days at shelter, or whether or not a mother received a protection order, children’s functioning improved significantly between initial contact and 4 months. Furthermore, compared to girls, boys tended to have higher levels of behavioral dysfunction at entry, and these differences were maintained at 4 month follow up. Lastly, children whose mothers sought support through safe shelters had higher levels of behavioral dysfunction compared to those

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Table 5. Frequencies and Percentages of CBCL Clinical Values All Ages Total Baseline

Internalized Normative Borderline Clinical Externalized Normative Borderline Clinical Total Problems Normative Borderline Clinical

4 Month

n

%

n

%

178 29 93

59.3 9.7 31.0

203 29 59

69.8 10.0 20.3

190 33 77

63.3 11.0 25.7

190 29 72

65.3 10.0 24.7

185 19 96

61.7 6.3 32.0

194 26 71

66.7 8.9 24.4

Percentage differences across time 46.0, significantly different, p50.05.

whose mothers sought support from a protection order at both entry and at 4 month follow up. DISCUSSION Overall for the study group of 300 abused mothers reaching out for services for the first time, significant decreases in their children’s internalizing, externalizing, and total problem scores were measured at 4 months compared to entry data even though no direct program was offered to the 300 children studied. Children from the shelter group had higher scores for all three areas compared to children of mothers, who applied for a protection order. However, no differential clinical impact was noted for children behaviors according to length of shelter stay or receipt or non-receipt of a protection order. Stated another way, children of abused mothers who stayed at the shelter longer than 21 days showed no greater improvement in child functioning at 4 months compared to children who stayed less than 21 days. Since the national median length for abused women staying at a shelter is 21 days, 21 days was chosen as the median for our study (National Network to End Domestic Violence, 2007). Similarily, children of women who received a protection order, showed no greater improvement in functioning compared to mothers who did not receive the order of protection. Therefore, we measured no differential effect and both research questions one and two are negative.

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Behavioral functioning significantly improved at 4 months for children in both the shelter group and the protection order group. The change was most dramatic for internalizing child behaviors such as anxiety and depression with a medium effect size of 0.62. Children with internalizing clinically significant or borderline behaviors showed improved scores (or normalized scores) regardless of type of assistance intervention sought, when examining child functioning across time and clinical behavior levels (i.e., clinical, normative, and borderline). When comparing the two groups (i.e., shelter vs. protection order), at 4 months after abused mothers sought assistance for the first time, children in the shelter group had significantly more internalizing and externalizing behaviors compared with children whose mothers sought services through the justice system. Although the children residing at the shelter had more dysfunctional behaviors, their internalizing behaviors improved no matter how long they remained at the shelter. One explanation may be that the children’s behaviors reflect positive changes in the mothers’ mental health once they have acknowledged the abusive relationship, been validated, and sought help for the abuse. Johnson et al. (2011) describe a physically and emotionally safe environment as the first phase after abused women access shelter services. The premise is that the mothers are no longer as overwhelmed and frightened once they have reached out to establish physical safety for themselves and their children. Therefore, accessing services provides a respite from the abusive situation. Further, they and their children are no longer exposed to abuse, which most likely has a profound influence on child functioning. Although externalizing behaviors did improve for all children in the study from entry to 4 months, the shelter group children had significantly more acting out behaviors than children whose mothers sought services from the justice system. This was particularly significant for the younger boys at the shelter. The finding of younger male children exhibiting more external behavioral problems compared to girls and older boys is similar to gender findings in the literature (Cummings et al., 1999; Hazen et al., 2006; Holt et al., 2008;Yates et al., 2003). One explanation for this finding could be that young boys may engage in modeling of their fathers’ behavior, who among this population is often the mother’s abuser. Unlike the internalizing behaviors, there was not a significant relationship between externalizing clinical behaviors and time. Stated another way, internalizing behaviors decreased dramatically for all children over time; however, externalizing behaviors did not decrease with the same magnitude. One explanation may be that abused mothers may suffer from depression, PTSD, or emotional numbing and lack the

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ability or skills to effectively modify aggressive behaviors in her children (Johnson et al., 2011). This may be especially true with respect to the very young boys, more prone to emulate the aggressive and violent behavior they potentially witness used against their mothers. Effective parental guidance and discipline is a labor-intensive task that requires much energy and consistency from the mother—energy and skills the abused mother may not have following a shelter stay or application for a protection order. The finding that behavioral dysfunctions of children exposed to partner violence against their mothers improves dramatically following their mothers reaching out for services offers evidence for health providers to provide opportunities for abused women to disclose abuse and be offered guided referral. Implications for Best Child Care Practice Implications within the context of this study for pediatric nurses and other health care professionals clearly indicate the need for screening at family and well child visits to identify those children acting out with externalizing behaviors such as aggression towards siblings, fighting at school, or bullying behavior that may indicate they are in chaotic domestic situations. Key groups of health care professionals have issued position statements and guidelines urging those caring for women and children to seize the opportunity to identify women in need of assistance related to domestic abuse. The American College of Obstetricains and Gynecologists, Committee on Health Care for Underserved Women recognizes intimate partner violence as a significant publuic health issue that affects millions of women and this group has deemed such situations preventable (American College of Obstetricains and Gynecologists, 2012). The committee opinion is that medical doctors should screen all women at routine obstetrical and gynecological visits for intimate partner violence. Further, a systematic evidence review on screening for family and intimate partner violence was prepared for the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (Nelson et al., 2004). The objective was to examine existing evidence related to screening procedures in primary care settings. The evidence was limited as to the effectiveness of the screening effort interventions and directed interventions were lacking in all areas. The Academy on Violence and Abuse (AVA), a multidisciplinary organization whose mission is to promote health education and research to prevent, recognize, and treat the negative health effects of exposure to violence, addresses competencies for health professionals in various disciplines to combat this epidemic problem (Ambuel et al., 2011).

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The National Association of Pediatric Nurse Practitioners (NAPNAP) has issued a position statement on the rights of children and adolescents to high quality, culturally appropriate mental and physical healthcare (NAPNAP, 2007). Inherent in their position is that pimary care settings and school-based settings are ideal for prevention opportunities and screening for early identification of mental health issues based on the reality that mental and behavioral health disorders affect more that 15 million children and adolescents and often lead to serious disabling morbidity and moratlity. The Centers for Disease Control and Prevention (CDC) recognized partner violence as a serious, preventable public health concern that affects millions. Prevention of partner violence, defined as ‘‘. . . physical, sexual, or psychological harm caused by a current or former partner or spouse,’’ was identified as a public health goal in tandem with the focus of promoting healthy relationship formation (CDC, Public Health Grand Rounds, 2012). Supported by new guidelines covered under the Affordable Care Act and already in effect, partner violence screening and counseling is considered preventive health services and a necessary part of annual well-woman checkups to identify at-risk women (IOM, 2011). Futures Without Violence, formerly Family Violence Prevention Fund, offers resources, training opportunities, and a toolkit to assist health care professionals implement the preventive screening measures and counseling of at-risk and abused individuals (Futures without Violence, http://www.futureswithoutviolence.org). Clearly, pediatric nurses and nurse practitioners as well as physicians, social service providers, and other health care professionals in primary care are uniquely positioned to intervene on behalf of abused women and their children. Children and families are routinely seen in ambulatory practice settings, pediatric settings, and school-based clinics. Nurses and other health care professionals should commit to assess for abuse and skillfully intervene when indicated in a manner that ensures the safety of the women and children as well as an adequate fit with services provided. Interventions to Interrupt Violence and Protect Child Functioning When a positive screen for intimate partner violence is uncovered, interventions implemented within the context of the well-child visit or other health visit would first include immediate safety and community agency referral information for the mother. Information for supportive parenting of the child would include information about age appropriate behavior, techniques of behavior modification, and age-appropriate discipline. During the health care visit the pediatric nurse may have

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opportunities to role model positive techniques aimed at correcting problem child behaviors. Referrals for positive parenting and support groups may be available in the community or these much needed programs can be offered in partnership with schools of social work, nursing, and medicine. Programs directed at helping children process the violence in their lives are also indicated. For example, arts-based programs that use visual arts, role play, and interactive theater methods have been shown to be effective (Fredland et al., 2008). Finally, the study’s findings support empowering abused mothers who reach out for services and enhancing parenting resources. All approaches must be careful not to further victimize women attempting to leave an abusive situation; but support them in their first attempt to leave the unhealthy situation. Providing them with support, validation, and ways to enhance their parenting skills can build survivor confidence and prevent a return to abusive situations or negative consequences for mothers and children. Limitations The strength of this study lies in the detailed child functioning data collected at entry and at four months on children of abused mothers who seek assistance through the justice and shelter systems for the first time. The reliable, internationally standardized and widely used CBCL is also a strength of the study. However, the methodology employed in this study may be limited as follows: First, abused mothers’ reports of child behavior may be influenced by the positive feelings associated with relief from the abusive environment and reaching out for help since only 4 months have elapsed since seeking assistance for the abusive situation (reflective perhaps of a ‘‘honeymoon’’ period). Second, witnessing and negative child functioning may be underreported because the data are based on self-reported perceptions of mothers about their children, which often tend to be underestimated by mothers and may have been impacted either positively or negatively by the mother’s mental health. Additionally, underreporting likely results from the fact that the study participants reached out for the first time either through the justice department or the shelter system, and many abused women with children do not reach out for help. Future studies need to sample from the general population and not be limited to English and Spanish speakers. Subsequent follow-up over time is needed to determine the long-term impact of the two models of care for intimate partner violence. Lastly, one limitation of this study is the potential of confounding variables such as the impact of pre-existing childhood mental or physical problems,

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which may impact child functioning. As such, further research utilizing more advanced statistical methods, such as structural equation modeling, may be needed to more comprehensively understand the complex nature of human behavior and dysfunction. CONCLUSION The behavioral functioning of children of abused mothers, who reach out for first time assistance either through safe shelter or the justice system, appears to dramatically improve over a 4-month period, irrespective of length of stay at the shelter or receipt or non-receipt of a protection order. The fact that there was no differential effectiveness related to length of shelter stay (less than or more than the mean of 21 days) has implilcations for intervening early in the shelter stay especially with first-time out reachers. The fact that there was no differential effect whether or not the protective order was received also confirms the powerful effect of taking the first step to seek help. Internalizing behaviors improved appreciablly more than externalizing behaviors. Male children of abused women in the shelter group continue to exhibit more externalizing behavior problems 4 months after leaving the shelter compared to children of abused women in the protection order group, placing those male children at higher risk for future delinquency, hostility, and aggression. Evidence for identification and immediate actions of referral and consistent follow-up are supported by these findings. In conclusion, this research documents the strong positive impact on behavioral functioning of children exposed to domestic violence following their mother’s disclosure of partner abuse and receipt of services. Although no direct program was offered to the 300 children studied, we feel the findings underscore the importance of seizing opportunities to assess mothers for abuse in pediatric settings and when appropriate intervening with safety and referral information. This strategy has the potential to mitigate the negative effects of domestic violence on children and improve overall child functioning. PAPER PRESENTATIONS Baseline and four month comparison data was presented on June 17, 2013 at the 19th Nursing Network for Violence Against Women International Conference, University of British Columbia, Vancouver, BC and at the 24th International Nursing Research Congress, Bridge the Gap between Research and Practice through Collaboration in Prague, Czech Republic, July 24, 2013.

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ACKNOWLEDGMENTS We appreciate the unflagging assistance and support of the administrators and staff of the five shelters in Harris County and the Chief and staff of The Harris County District Attorney’s Office, Family Criminal Law Division. We acknowledge funding by The Houston Endowment. DEDICATION We dedicate the findings of this research to the 300 women and children who shared and continue to share their story, pain and survival. DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. REFERENCES Achenbach, T. M. (1991). Manual for the child behavior checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry. Achenback, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA preschool forms & profiles. Burlington, VT: University of Vermont, Department of Psychiatry. Achenback, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Department of Psychiatry. American College of Obstetricians and Gynecologists, Committee on Healthcare for Underserved Women. (2012). Intimate partner violence. Committee Opinion, No. 518, February 2012. Ambuel, B., Downing, D., Jelley, M., Lenahan, P., Lewis-O’Connor, A., MeGraw, M., Mouden, L., Tent, K., Wherry, J., Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (2011). Competencies needed by health professionals for addressing exposure to violence and abuse in patient care. Eden Prairie, MN: Academy on Violence and Abuse. Baus, A. Malone, J. C. Levendosky, A. A., & Dubay, S. (2009). Longitudinal treatment effectiveness outcomes of a group intervention for women and children exposed to domestic violence. Journal of Child & Adolescent Trauma, 2, 90–105. Binder, B., McFarlane, J., Maddoux, J., Nava, A., & Gilroy, H. (2013). Children in distress: Functioning of youngsters of abused women and implications for child maltreatment prevention. Child Care in Practice, 19, 237–252. Centers for Disease Control and Prevention. (2012). Youth Risk Behavior—United States Surveillance, 2012. Morbidity and Mortality Weekly Report Surveillance Summaries, 61. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf. Centers for Disease Control and Prevention, Public Health Grand Rounds. (June 19, 2012). Breaking the silence—Public health’s role in intimate partner violence

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