535264 research-article2014

JIVXXX10.1177/0886260514535264Journal of Interpersonal ViolenceInsetta et al.

Article

Intimate Partner Violence Victims as Mothers: Their Messages and Strategies for Communicating With Children to Break the Cycle of Violence

Journal of Interpersonal Violence 2015, Vol. 30(4) 703­–724 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514535264 jiv.sagepub.com

Emily R. Insetta, MD,1 Aletha Y. Akers, MD, MPH,1,2,3 Elizabeth Miller, MD, PhD,1,3 Michael A. Yonas, DrPH, MPH,4 Jessica G. Burke, PhD, MHS,6 Lindsay Hintz, MD,5 and Judy C. Chang, MD, MPH1,2

Abstract Children whose mothers are victims of intimate partner violence (IPV) are at increased risk of adverse health and psychosocial consequences, including becoming victims or perpetrators of violence in their own relationships. This study aimed to understand the role mothers may play in preventing the perpetuation of violence in their children’s lives. We performed semistructured interviews with 18 IPV victims who are mothers and were

1University

of Pittsburgh, School of Medicine, PA, USA Hospital of UPMC, Pittsburgh, PA, USA 3Children’s Hospital of Pittsburgh of UPMC, PA, USA 4Allegheny County Department of Human Services, Pittsburgh, PA, USA 5Beth Israel Deaconess Medical Center, Boston, MA, USA 6Pitt Public Health, PA, USA 2Magee-Womens

Corresponding Author: Judy C. Chang, Associate Professor of Obstetrics, Gynecology, and Reproductive Sciences and Medicine, University of Pittsburgh, 300 Halket Street, Pittsburgh, PA 15213, USA. Email: [email protected]

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living at the Women’s Center & Shelter of Greater Pittsburgh from July through November 2011. We sought to understand how they communicate with their children about IPV and relationships. These mothers described a desire to explain their IPV experience and offer advice about avoiding violence in relationships. As foundations for these discussions, they emphasized the importance of close relationships and open communication with their children. Although mothers are interested in talking about IPV and relationships and identify communication strategies for doing so, many have never discussed these topics with their children. These mothers need and want an intervention to help them learn how to communicate with their children to promote healthy relationships. Development of a program to facilitate communication between IPV victims and their children could create an important tool to empower mothers to break the cross-generational cycle of domestic violence. Keywords intimate partner violence, domestic violence, teen dating violence, parent– child communication

Introduction The National Intimate Partner and Sexual Violence Survey recently estimated that almost 7 million women are victims of intimate partner violence (IPV) in the United States annually (Black et al., 2011). Among female IPV victims, more than 50% have children in their household (Greenfeld et al., 1998). As many as 15.5 million American children live in families in which IPV has occurred during the past year (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006), and one in four children will be exposed to family violence before the age of 18 (Hamby, Finkelhor, Turner, & Ormrod, 2011). Children whose mothers are victims of IPV are at increased risk for physical, mental, and behavioral problems (Bensley, Van Eenwyk, & Wynkoop Simmons, 2003). These children are more likely to engage in health-compromising behaviors including cigarette smoking, substance use, and high risk sexual activity (Anda et al., 1999; Caetano, Field, & Nelson, 2003; Dube, Anda, Felitti, Edwards, & Williamson, 2002; Hillis, Anda, Felitti, Nordenberg, & Marchbanks, 2000). Family violence is also one of the most consistent predictors of children becoming victims or perpetrators of violence in their own relationships (Cui, Ueno, Gordon, & Fincham, 2013; Jouriles, Wolfe, Garrido, & McCarthy, 2006; McKinney, Caetano, Ramisetty-Mikler, & Nelson, 2009; E. Miller et al.,

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2011; Wolfe, Scott, & Crooks, 2005). Females who have witnessed IPV as children are at three to four times increased risk for becoming victims of emotional IPV and four to six times greater risk for experiencing physical IPV (Bensley et al., 2003). Violence in relationships begins early, and teen dating violence (TDV) is prevalent. In a study of more than 5,000 sixth graders, 42% of students reported being victimized by a boyfriend or girlfriend, and 29% reported TDV perpetration (Simon, Miller, Gorman-Smith, Orpinas, & Sullivan, 2010). For children who have been exposed to violence, supportive and responsive parenting is one of the strongest predictors of thriving despite their adverse experiences (Australia Mental Health Foundation, 2007; Finkelstein et al., 2005; Garmezy, 1991; Graham-Bermann, Gruber, Howell, & Girz, 2009). The nonviolent parent, who is most often the mother (Catalano, 2007; Tjaden & Thoennes, 2000), plays a particularly crucial role in the child’s adjustment. For instance, the Child and Family Traumatic Stress Intervention targeted more than one hundred 7- to 17-year-old youth and their caregivers, 90% of whom were female. The children participating had been exposed to a variety of stressors including motor vehicle accidents, sexual abuse, witnessing violence, physical assaults, injuries, animal bites, or threats of violence. By promoting parent–child communication about posttraumatic stress disorder (PTSD) symptoms and teaching family-based coping skills, the intervention improved symptoms of PTSD in more than one hundred of the children (Berkowitz, Stover, & Marans, 2011). In this study, we specifically sought to explore parent–child communication about IPV and relationships among IPV victims and their children. We focused on understanding the perspectives of mothers who have experienced IPV, because their children are at greatest risk of becoming involved in violence themselves. The focus was to learn from IPV victims (a) the messages they want to convey to their children about relationships, (b) the strategies they employ to do so, and (c) their interest in and thoughts about interventions to develop parent–child communication skills. This formative research is intended to guide the design of interventions to help female IPV victims talk to their children about relationship violence and healthy relationships.

Method Study Design From July through November 2011, we conducted one-on-one interviews with female IPV victims seeking services at the Women’s Center & Shelter (WC&S) of Greater Pittsburgh. Participants were invited to attend one study

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session where they participated in an interview and completed a brief questionnaire. We chose a qualitative approach to avoid approaching the topic with preconceived theories or hypotheses. Individual interviews are particularly appropriate for sensitive issues, such as IPV, to facilitate an understanding each victim’s unique experience and perspective (Giacomini & Cook, 2000).

Eligibility, Recruitment, and Consent We used a purposeful sampling strategy targeting women 18 years of age and older who self-identified as victims of IPV and mothers, defined by ever having given birth to a child who is living. All participants were receiving residential or counseling services at the WC&S. We recruited women who had already accessed IPV resources because they were already accustomed to recalling and discussing their IPV experiences in counseling and group sessions. We planned to exclude women deemed to be developmentally, emotionally, or psychologically incapable of participation, as determined by the WC&S staff’s needs assessment interviews, which are standardly performed by trained staff members upon each victim’s arrival to the shelter. The interviews identify individual needs ranging from housing, childcare, and employment resources to medical, legal, and psychological support. The WC&S staff further assisted with participant recruitment by displaying flyers in the shelter and making a verbal announcement on days when study staff were available for to conduct interviews. We met with each woman who expressed interest to explain the study design and purpose. If she chose to participate, verbal consent was obtained prior to the interview. To protect anonymity and safety, we obtained an IRB waiver for written informed consent. Participants were advised that all responses would be kept confidential unless child abuse was a concern, in which case the WC&S protocol on mandatory reporting was to be followed. A US$25 gift card was offered as compensation for participation. This research was approved by the University of Pittsburgh’s Institutional Review Board (IRB PRO10020163). Each mother took part in a one-time, semistructured, one-on-one interview. The interviewer was one of three female medical students who were well versed in study design and purpose as well as the open-ended, participant-centered interview style. Interviewers encouraged each participant’s free expression of feelings and perspectives. Each interviewer used the same interview guide (Table 1) to provide the topic overview, ground rules, and guiding questions. Questions addressed six topics: (a) relationships with children, (b) perceptions of how violence affected children, (c) communication about violence with children, (d) communication about violence with

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Table 1.  Interview Guide Questions. Relationship with their child/ren   1.  Tell me about your child/ren   2.  What is your relationship with your child/ren like? Perceptions of how the violence affected their child/ren   1. How do you think the children were affected by the abuse you experienced from your partner?   2. What steps have you taken or tried to protect your children from the effects of the violence you experienced from your partner?   3.  How have you tried to address domestic violence with your children? Communication about violence with their child/ren   1. How have you tried to talk to your child/ren about domestic violence in general?   2. What are some of the challenges in talking to your child/ren about domestic violence?   3. What strategies have you used to talk to your child/ren about domestic violence? Communication about violence with adolescent child/ren   1.  What are some of the challenges of talking to a teenager about violence?   2.  How have you talked to your teenager/s about relationships and dating?   3.  How have you talked to your teenager/s about dating violence?   4. What are some strategies that worked for you in talking about dating violence?   5. What skills and help would you need when talking to your teenager/s about dating violence?   6. How would this be different if your children were boys or girls? If we were to design a program that could help women who have experienced domestic violence talk to their children about the violence, about dating and relationships and about protecting themselves from dating violence . . .   1.  What topics would we need to include?   2.  What should we consider when designing this?   3. What would women and teens be likely to use? What would be most useful to women and teens? If we wanted to talk to teenagers about some of the topics that we’ve discussed today:   1.  What would your thoughts be?   2.  How would you feel about your child/ren participating?   3. What advice would you give us about asking women if their children could participate?

teenagers, (e) perspectives about a program for mothers, and (f) perspectives about a program for children to promote talking about violence and

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Table 2.  Characteristics of Study Population (N = 18). Mothers   Age (M±SD)   Race (n)   Black   White    Black + Native American   Other   Marital status (n)    Single, never married   Divorced   Separated   Widowed   Married  Education    Some high school    High school degree or certificate of equivalency   Some college   College degree  Religion   Christian   None Children   Number of children (M±SD)   Mothers with at least one child in home   Age of children (M±SD)

41 ± 8.4 years 11 5 1 1 7 4 4 2 1 2 10 4 2 15 3 4 (±3.5) 61% 16.4 (±8.8)

relationships. After the interview, each participant also completed a brief self-administered, anonymous, pen-and-paper questionnaire that included sociodemographic data. Sociodemographic information included age, race, education, religion, and family structure (Table 2).

Analysis Interviews were digitally audio-recorded, transcribed, and entered into ATLAS.ti, a qualitative data management program that was used to record, document, and organize the results (ATLAS.ti, 1999). Each interview was reviewed by at least two investigators, who independently read the transcripts and assigned codes to phrases or sections of dialogue. Then, they met and compared their coding, which provided an important check on selective

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perception and interpretive bias (Patton, 1999). Using more than one coder was a form of investigator triangulation to ensure consistency and guard against bias (Giacomini & Cook, 2000; Patton, 1999; Pope, Ziebland, & Mays, 2000). Codes were reconciled and compiled into a final coding scheme which was applied to all 18 transcripts, and then thematic trends were identified. Final corroborating steps included (a) presenting and discussing a review of the analysis with a larger group of investigators with experience in IPV research (E.R.I., E.M., A.Y.A., J.C.C., J.G.B., M.A.Y.) and (b) presentation of themes to a group of advocates for IPV victims at the WC&S. Both groups found the presented themes to be plausible, recognizable, and accurate based on their expertise and experience. For data from the sociodemographic questionnaire, SPSS Statistics 21 software was used to calculate frequencies and means (IBM SPSS Statistics for Windows, 2012).

Results Sample Characteristics The study population (Table 2) included 18 female IPV victims ranging from 28 to 56 years of age with an average age of 41 years (±8.4 SD). Of the 18 women who volunteered to participate, none had psychological or developmental needs that warranted exclusion from the study. Length of time receiving residential and counseling services at the shelter varied from less than 1 week to several months. Eleven of the participants were African American. Eight were divorced or separated, while 7 were single and never married. Maternal education ranged from some high school to a college degree; most women had not exceeded high school education. Each mother had between 1 and 11 children. Almost two thirds (61%) of them had at least one child living in their home—those whose children were not living in their home either described having older, grown children; the involvement of child protective services; or voluntarily had other family members raising their children. Children ranged in age from 9 months to 35 years, with an average age of 16 years.

Thematic Overview Women emphasized two primary messages they wanted to share with their children: (a) explaining their past experiences with IPV while emphasizing that violence was not normal or healthy behavior and (b) offering advice about their children’s relationships. To convey these messages, mothers identified two key strategies for communication: (a) establishing positive relationships and (b) encouraging open discussion. Finally, mothers expressed

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great interest in a program to learn to communicate with their children about violence and relationships because (a) they want to have these discussions and (b) they seek help in doing so.

Messages IPV Victims Want to Convey to Their Children Explain IPV experience and highlight that it was not normal.  Mothers were faced with many questions from their children about their IPV experiences. They described their own difficulty in understanding their partners’ behaviors. Thus, they struggled to explain to their children why the abuse occurred, to rationalize their partner’s actions, and to provide reasons they endured the abuse. As one mother described, Like how do you explain why mommy’s boyfriend or why daddy is hitting you? Why are you always crying? Why doesn’t he just love you? If you love somebody, you know what I mean, it wouldn’t be like that. So it’s hard to figure out how to explain that to a child . . . especially to my six year old.

Women expressed worry that their children would accept the behavior they had witnessed as normal interaction between partners and emphasized their desire to counter this message. One participant described how witnessing IPV between her own parents led to her own IPV experience and how she wanted something different for her daughter: It [witnessing IPV between my parents] just made me think that that was like normal. That life. It was like “that’s what they do when they’re angry at you.” Um, maybe I did something wrong, um. You know, blaming myself like it was my fault. If I didn’t say this back, if I had just kept my mouth shut they probably wouldn’t have got hit. It just seemed like a normal way to live, you know? That’s what I’m afraid of for my daughter . . . [I want to] try to help her. It’s like, I understand what you’re going through and you witnessed a lot growing up and it’s not normal. It’s not healthy. It’s not right for someone to put your hands on another person. You know. And we can help each other.

Mothers pointed to their abusers’ substance abuse or mental health issues to emphasize that violence was part of problematic behavior or illness. One mother said, “I think his mental illness actually kind of helped because they understood: This is more than the drinking.” The mothers also expressed high levels of guilt about their children witnessing the abuse and said it was difficult to admit their mistakes. They wished they could apologize to their children by saying, “It’s not your fault. I’m sorry that you had to see it.”

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Offer relationship advice.  In addition to explaining past experiences, mothers wanted to share advice for their children’s future intimate relationships. Their primary message was to teach against perpetrating or accepting abuse. For sons, mothers mainly wanted to teach that physical and nonphysical abuse of women were both wrong, saying, “You don’t hit a woman if you love her, and abusive language is not appropriate—is not acceptable.” Mothers advised their children to leave conflicts if they were feeling angry, or to talk through their disagreements rather than using violence. They warned their children of the consequences of IPV. These included legal consequences, such as being put in jail, as well as grave consequences, including death of the victim or of the perpetrator. For daughters, mothers were mainly concerned about victimization and emphasized the importance of having zero tolerance for violence. Many women wanted to teach the concept, “Love doesn’t hurt.” They wanted to encourage strong personal qualities, such as self-esteem and independence, which would protect children against becoming victims of IPV because “You have to love yourself first.” One mother described how she wanted to instill these values in her daughter: She’s gonna know her value as a woman. Do you know? Like, she’s gonna be raised in a way where she’s not gonna take that. You know, she’s not gonna get caught up in that web. Like her self-esteem’s gonna be high enough to where she’s not gonna settle for less than what she deserves, let’s hope. But that’s what I’m gonna instill in her.

IPV victims also chose to use their own experiences as lessons for their children about relationships, giving advice such as, “You saw what I went through . . . Don’t make bad choices.” In addition to self-esteem, mothers encouraged children to prioritize education and self-sufficiency over intimate relationships. One mother told her daughter she did not need to rush into relationships during her teen years, I told her she got her whole life, you know. You get your career going, be independent, you know. I’ve always put that into it. Be your own woman. Then you could say “say” and “nay” to whatever. Call your own shots.

Despite different messages for sons versus daughters, women did recognize that roles could be reversed with women as abusers and men as the victims. A specific topic mothers wanted to teach both their sons and daughters was the warning signs of a potential abuser, “Because they always, whether they hit you or not, they will always show some type of verbal or mental or

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emotional abuse at the beginning.” These red flags included control, isolation, verbal abuse, a selfish mentality, manipulative behavior, or any act of violence. If children should find themselves as victims of IPV, mothers advised seeking help from authority or their mother. They also encouraged leaving the situation. One mother said, “ . . . just get out. Try it, you know? Because you’d rather be alive than dead.” Apart from teaching against violence, sex was another key topic that mothers emphasized when prescribing dating advice. First, they did not want their daughters to be naïve and “looking for love,” which could lead to risky sexual decisions. Next, they emphasized the consequences of having sex, especially sexually transmitted infections and pregnancy. They wanted their children to understand the responsibility for both genders that comes with pregnancy. A mother of boys described her advice: Abstinence is the best way but if you’re going to do it just protect yourself. There’s a lot of stuff out there. I’ll let them know about the HIV virus, how there’s no cure for it yet and, all the sexually transmitted diseases, you know. I will buy them condoms. I’ll even give the girl the condom, all of that . . . as they get that age and they start dating, sex will be my main concern. You know, I just don’t want them to be going from girl to girl having baby to baby. You know then they gotta worry about the child support on their back and, this one and that one, then you going to say that ain’t your baby when you know you slept with her. You know. I don’t want my kids to deal with that.

Strategies Mothers Use to Communicate These Messages Build mother–child relationship. Whether they had broached conversations about relationships with their children or not, most mothers were able to identify valuable strategies in communicating with children. First, they described the importance of establishing positive relationships, which sometimes had been affected by the abuse and therefore needed to be rebuilt. Many mothers strove to show love and to earn trust. Some described compensating with gifts. One mother described her complex relationship with her kids: Well, honestly it’s been strained because there has been some disappointment on my behalf . . . I’d say in the last year or so, I’ve been making up for those disappointments with like monetary items, gifts, things like that because there is some disappointment. I know that they are disappointed in me and because of that disappointment I know there has been some mistrust between us. We’re getting there; I can tell. We’ve been here for the past two weeks and I can feel that trust coming back and I haven’t felt this in at least a year and a half.

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In their relationships with their children, some women saw themselves as role models. This role modeling was often related to a mother’s victory of escaping her abuse or fighting back against her abuser which demonstrated resilience and self-sufficiency. One woman said it was easy for her to talk to her daughter about avoiding IPV: Mother:  . . . because I tell her when someone’s being mean, you ain’t gotta take it. And me showing her you ain’t gotta take it is proof positive. I could show you better [than] I could tell you . . . Interviewer: Yeah. How do you show her? Mother: We gone. We left. That’s it. And she see that, it’s not, I mean, you can start over and you know you, you know what you need to live, and I show her by examples. We’re here, got a job, find a place. And we still live.

A universal remark by mothers with multiple children was the importance of recognizing the differences between their kids. Mothers had a unique relationship with each child and therefore had to employ distinct communication strategies. Especially important differences were those of gender and age. Mothers offered a wide range of opinions about gender-specific challenges. Some participants preferred communicating with daughters about the IPV, because “[sons] don’t understand what you’re going through.” Others thought it was harder to talk to daughters because they were more likely to be too enamored with their relationship to listen. One mother said, “I’m telling you: the girls, they don’t want to listen. They do not want to listen. If they getting money from a man, anything good that makes their body feel good or—no they don’t want to hear it.” Mothers with young children described wanting to protect their innocence by sharing minimal information about IPV. One mother described that what she wanted for her daughter was to let her be a kid as long as possible. But, because of what’s going on . . . it’s adult issues. You want to separate the kid and the adult issues . . . Explaining it to a child, you know on a child’s level and taking that adultness out of it. That’s the hard part: filtering is the hard part.

Many women said their children seemed to act older than their ages as a result of witnessing abuse. Women differed in their opinions of an appropriate age to begin having discussions about IPV. Some mothers thought violence should be addressed only if the abuse happened when children were at an age when they would remember it, which one mother estimated to be 5 years old. Opinions about the appropriate age to discuss dating was largely

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based on when children started showing interest in intimate relationships, which mothers suggested ranged from 11 to 15 years old. Encourage open communication.  Women built on the foundation of strong relationships with their children to encourage open communication. Mothers wanted to be “honest,” “open,” “up front,” and “100% real” with their children about the IPV. They wanted their children to feel like they could talk to them about anything, including the IPV or their own relationships. Mothers would pursue open discussions by asking their children about their feelings. Some women said they conversed openly with their children, but they knew that was not always the case for other families. One of these participants advised other mothers to learn to talk openly because “if the mother doesn’t know how to communicate, [the kids] are lost too.” Many mothers valued therapists as communication resources for themselves and their children. Mothers said they learned how to express their feelings during therapy and could use those skills to talk to their children. Some women described a therapist as someone the children could talk to if they would not talk to their mothers. Others wanted to have family therapy with their children so that a third party could help them all communicate and then provide professional feedback.

Mothers’ Thoughts About Interventions to Help Them Communicate With Their Children They want to talk to their children about IPV and relationships.  A key motivator for mothers to discuss relationships with their children is concern about their children’s relationships. Among participants whose children were dating, some kids had already become victims or perpetrators of abuse. Some children who were not yet romantically involved were being violent or “acting out” in other ways at home or in school. The majority of mothers expressed fear about their children entering violent dating relationships. They did not want their children to grow up expecting violence as a normal part of relationships. Mothers were primarily worried about IPV perpetration by their sons and victimization of their daughters. One mother described her worry about her son becoming an abuser: “I think that he’s going to grow up thinking that it’s okay to hit women because that’s how they . . . that’s how their father learned how to show love. Like, that’s what he thought love was.” Another mother described her fear about her daughter’s relationships, “Well she’s seen most of what went on. And I’m afraid she’s learned about relationships from what she’s seen . . . Just the control, the violence; I’m afraid she’s learned that that’s what’s normal.”

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Many mothers were fearful about violence in their children’s lives because they had observed the cross-generational pattern of violence in their own lives. Many mothers had witnessed violence between their own parents during childhood. One mother recalled: “Me being a girl and seeing my mother being abused, you know, I followed right in her footsteps.” Due to concern about their children’s relationships, mothers felt protective and wanted to discuss IPV and relationships with their children. One mother said, I want to talk about that stuff because I don’t want them to turn out to be like, you know, hurt anybody. Verbally, physically, mentally, socially, none of that. I don’t want that to happen. And I don’t want them to pass it on to their kids.

Mothers wanted to be involved, meet their children’s boyfriends or girlfriends, and defend their children if necessary. They hoped their children would wait until later in life or after getting an education to start romantic relationships. Mothers identified a variety of advantages to talking about violence and relationships for their own healing, for the maternal–child relationship, and for their children’s future. One participant described the benefits she foresaw if she were to talk to her children about the IPV: We could probably heal. You know, if we were to talk about it, if they were able to talk to me about how they felt or I would talk about how I felt at the time, I think we would be able to heal better—become a stronger family if we were able to do that.

Another woman encouraged her fellow mothers to talk to their children, “When you talk to your kids they’re not going to love you less. They might love you more ’cause you’re explaining it to them, the situation, so they don’t end up like that.” They want help with these discussions.  Despite wanting to talk to their children about these topics, many participants had never addressed IPV or relationships with their children. They expressed their desire for help in talking about these topics. All participants except one said they would be interested in participating in a program to learn to communicate with their children about IPV and relationships. Mothers thought a program would benefit both themselves and their children. They wanted to understand how to “get the conversation started” because it would be helpful to hear what their children had to say. One mother described various communication skills she wanted to learn:

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keeping their attention to what you’re talking about, making sure they understand what you’re talking about, being clear about it, giving them the right information . . . I really don’t know, that’s why I need a program like this to help me to talk to them.

Only one participant in this study said she would not want to take part in such a program. She said, “I wouldn’t participate because I’m not the right person to talk to about it. I’m not good with words or defining how I feel.” She felt like participating would be hypocritical: “I can’t be a facilitator and tell people like, well do this and do this, because everything I’ve tried has been a failure . . . I’m the wrong person to be getting advice from.” Almost all mothers wanted their children to participate in a program to learn about IPV. They said children did not receive enough education about these topics and they thought society lacked awareness of domestic abuse. One participant would not want her 6-year-old participating in a program because a young child may not understand topics like IPV and relationships, but she would definitely allow her 15-year-old to participate. Other participants conjectured about why other mothers would not be comfortable with their children participating. Mothers might want to “keep things hidden” or they could think the program was not needed because “that won’t happen to my daughter.” Overall, the majority of participants were enthusiastic about developing a program, and many even volunteered to help.

Discussion Perspectives from mothers who are IPV victims provide a novel contribution to the literature about parent–child communication. Salient findings are that the IPV victims participating in this study universally want to have discussions with their kids about relationships and also want a program to help them do so. Mothers who are victims of IPV have unique goals for communicating with children because they want to explain the past IPV and also offer relationship advice for the future. These mothers are able to identify strategies such as building close relationships and encouraging open communication. However, they struggle to have these conversations and are interested in learning more about how to prevent violence in their children’s futures. These interviews teach us that broaching conversations about relationships is particularly challenging for IPV victims because they must struggle to answer their children’s questions about their abusive experiences. Mothers often feel guilty and want to apologize to their children for their exposure to violence. Some mothers use their IPV victimization as an example for teaching children to avoid IPV in their own lives.

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Apart from discussing the abuse, many of the messages IPV victims want to teach about relationships match those of nonvictimized parents. A 2011 study by Akers, Yonas, Burke, and Chang conducted focus group discussions with African American parents who did not identify themselves as being involved in IPV. When comparing the perspectives of our population with those of the nonviolent parents, both groups identified concern about their children’s relationships as a motivator for discussion. They similarly sought to teach boys against becoming perpetrators and girls against accepting violence, although mothers in our study were more open to the possibility of gender reversal in violent relationships (Akers et al., 2011). Research supports parental teaching nonaggression and encouraging self-esteem as being inversely associated with children’s risk of TDV. Notably, studies also show that peer influence is equally important in determining risk for TDV; neither study population described awareness of their teens’ friends or mentioned advising their children about selecting nonviolent friends (S. Miller, GormanSmith, Sullivan, Orpinas, & Simon, 2009; Pflieger & Vazsonyi, 2006). In an intervention designed to teach parents how to talk about relationships with their children, it may be important to address the impact of peer influence on children’s behaviors. Unique findings from our study add to the results of the Akers et al. (2011) focus group discussions. In addition to the signs of an abuser described by the nonviolent parents, which included disrespect, yelling, and violence, the IPV victims in our study explained more subtle signs of abuse, such as control and isolation. Moreover, in the Akers study, fathers saw themselves as role models and providers for their children and parents described striving to exemplify healthy, nonviolent relationships. In contrast, IPV victims in our study promoted independence; rather than role modeling healthy relationships, they saw themselves as examples of self-sufficiency when they were able to escape abuse. Contrasting these studies shows that children of IPV victims lack examples of healthy interparental relationships and positive father figures in their lives. Thus, it is important to target interventions toward children of IPV victims who are at high risk of entering violent relationships. Mothers in our study noted two important strategies for communication that have been supported by the literature: close relationships and open communication. However, they also struggle and seek help in these areas. Studies show that mothers whose perceptions of relationships have been affected by being victims of abuse may translate into poor attachment with their children. This inadequate maternal–child bond increases the likelihood that children will enter violent relationships themselves (Levendosky, Lannert, & Yalch, 2012). Helping IPV victims to foster close relationships with their children could help to disrupt the intergenerational cycle of violence.

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Studies confirm that parents who develop open communication, make their teens feel comfortable, and seek their children’s opinions are more effective in communicating with their adolescents about sex (Rosenthal, Senserrick, & Feldman, 2001). Mothers in our study described perceiving their communication with their children was in general good but admitted avoidance of the specific topics of IPV and relationships. While many mothers wanted to protect the innocence of young children, no studies have examined the effect of early discussions about IPV and dating on children’s psyche and behaviors. Research does describe an avoidant approach and low frequency of discussion as indicators of poor communication (Barnes & Olson, 1985; Rosenthal et al., 2001). Therefore, empowering women to overcome avoidance could be an important first step in promoting discussions about IPV. These IPV victims strongly indicated their interest in tools to help them talk to their children, which is consistent with the sentiments of parents who are not involved in IPV (Akers et al., 2011). Improving relationships and conveying knowledge were two primary goals of the mothers in this study. A 2013 review examined the results of 44 interventions focusing on improving parent–child communication about sex in the general population. Results showed that all programs successfully improved parent–child interaction and adolescents’ attitudes and knowledge about sexual health (Wight & Fullerton, 2013). However, only half of studies produced changes in adolescents’ behaviors. These results may reflect the need to consider other factors contributing to behaviors apart from parenting, such as peer influence (S. Miller et al., 2009). The mothers in our study were eager to learn how to communicate about IPV and relationships with their children, and the Child and Family Traumatic Stress Intervention showed that parent–child communication can improve children’s symptoms of PTSD. However, the Child and Family Traumatic Stress Intervention targeted youth exposed to a variety of different stressors from injuries to sexual abuse, and their caregivers were not intimately involved in the traumatic experience (Berkowitz et al., 2011). Importantly, the mothers in our study were victims themselves and described difficulty in approaching discussions about IPV with their children. Our study suggests that mothers who are victims have a specific need for an intervention to help them develop communication with their children. Although many efficacious interventions have been developed for parent– child communication about sexual health (Wight & Fullerton, 2013), few interventions have been designed specifically for communication between IPV victims and their children. One 2005 study showed the greater efficacy of Child–Parent Psychotherapy (CPP) versus typical treatment and case management for the well-being of preschoolers and their mothers after exposure

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to IPV. The CPP intervention focused on a relational process promoting maternal responsiveness to children’s developmental needs and strengthening children’s trust in the mother’s capacity to provide protective care. CPP successfully improved children’s behavior while decreasing both child and maternal traumatic stress symptoms (Lieberman, Van Horn, & Ippen, 2005). In another study from 2007, Graham-Bermann and Miller developed a community-based program to promote emotional health and resilience in IPV victims and their children. They compared no intervention versus a childonly program versus a maternal–child combined program. The combined maternal–child program produced the best improvement in externalizing problems and attitudes about violence for children as well as the greatest reduction in abuse-related traumatic stress for mothers (Graham-Bermann, Lynch, Banyard, DeVoe, & Halabu, 2007; Graham-Bermann & Miller, 2013). Our study builds upon these earlier intervention studies by providing specific suggestions from women who have experienced IPV regarding what components, content, and skills they would want an intervention to include. Incorporating their suggestions and perspectives will allow for the design of mother–child interventions with the ultimate objective to prevent future IPV perpetration and victimization among this vulnerable population of children.

Limitations Our work is a descriptive qualitative study using a purposeful sample population. All participants had escaped abuse and sought help in a women’s shelter. They had also volunteered to participate in a study about mother– child communication. The study design was not meant to produce results that could be generalized to all female victims of IPV with children. Different results would likely be found from interviews with other groups of victims, such as those who have not escaped abuse, who have not sought help from advocacy groups, or who are not interested in exploring mother– child communication. Interviews in a different setting, such as in jails or in emergency departments, would also potentially produce distinct findings. In addition, while 69% of female IPV victims experience violence before age 25 (Black et al., 2011), our study population was older, with a mean age of 41 years. In this regard, our results may not be generalizable to the experiences of younger victims. Finally, we did not specifically assess the nature and severity of the women’s IPV experience, the duration of their IPV relationship, the number of IPV relationships they had had, nor how long since they had last experienced IPV. Potentially, these details could provide a context for those mothers who potentially could benefit from a mother– child intervention. Our study intent was to focus primarily on the women’s

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experiences, thoughts, and needs regarding communication about IPV with their children. Future studies are needed to examine any associations between women’s perceptions, experiences, and described needs regarding IPV communication and other factors such as details of the IPV experiences, whether their children were living with them, or the relationship between children and the IPV perpetrator. Our study reached saturation of themes based on the perspectives of 18 mothers. However, we did not elicit perspectives from their children. Future research may focus on understanding children’s feelings about being exposed to IPV, their perceptions of communication with their mothers, and their views of their own relationships. Future study should also strive to elicit children’s interest in a program to learn about communication with their mothers. Although the mothers in our study strongly indicated their interest in a program, further study is required to elicit specific recommendations from mothers and children for the appropriate design of an intervention.

Conclusion Mothers who have experienced IPV want to share valuable messages with their children, from explaining and apologizing for past abuse to promoting nonviolence in their children’s lives. They identify the importance of establishing relationships with their children and supporting open communication as steps to conveying these messages. Despite knowledge of these communication strategies, IPV victims rarely broach these conversations. Although mothers are interested in discussing IPV and relationships, they need and want an intervention to help them do so. Development of a program to promote communication between IPV victims and their children could create an important tool to empower these women to break the cycle of violence. 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) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Emily R. Insetta is a fourth-year medical student who completed this research as her longitudinal Scholarly Project during her medical school training. She will graduate from the University of Pittsburgh School of Medicine in 2014 and then pursue a residency in internal medicine. Aletha Y. Akers is an assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Pittsburgh. She is a women’s health services researcher whose work seeks to understand the social and contextual factors that influence reproductive health behaviors and outcomes. Her current projects examine the role of parent–adolescent communication on adolescent sexual behaviors. Elizabeth Miller is chief of adolescent medicine at Children’s Hospital Pittsburgh of the University of Pittsburgh Medical Center and associate professor in pediatrics with tenure at the University of Pittsburgh School of Medicine. Trained in medical anthropology as well as internal medicine and pediatrics, her community-partnered research examines the nexus of adolescent and women’s health with gender-based violence.

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Michael A. Yonas specializes in health practice and human services research using novel community-based and partnered research and evaluation methodologies. His research efforts aim to identify and address the social and environmental factors affecting disparities in the health and well-being of vulnerable populations and to inform and conduct interventions with young people and communities. His particular interests include childhood asthma, child welfare, homelessness, and application of principles of community-based participatory research (CBPR). He earned doctorate and masters of public health degrees from the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Jessica G. Burke is an associate professor in the Department of Behavioral and Community Health Sciences at the University of Pittsburgh, Graduate School of Public Health. She is a social scientist who focuses on the context of health disparities. Much of her work is concentrated on HIV, intimate partner violence, adolescent health, and infant health outcomes. Her area of expertise is the utilization of innovative quantitative social epidemiologic and qualitative ethnographic methodologies in the exploration of multiple levels of determinants affecting issues of health. She pioneered the use of the mixed method approach of concept mapping as a participatory public health research tool. She is director of the Community-Based Participatory Research and Practice certificate program, which is designed to provide a comprehensive set of courses that prepare graduate students for a career in community-based participatory research and practice. Lindsay Hintz is a resident physician in the Department of Internal Medicine at BethIsraelDeaconessMedicalCenter, where she is pursuing the Primary Care track. She attended medical school at the University of Pittsburgh, where she became involved in work with survivors of intimate partner violence. Her interests also include behavioral health, communication, and primary care delivery. Judy C. Chang is an associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Pittsburgh. She is a women’s health services researcher whose work has been primarily in the area of violence against women, specifically addressing issues regarding health care screening and interventions for intimate partner violence. She has more recently expanded her expertise to focus on patient–provider communication in women’s health encounters, particularly regarding challenging topics including intimate partner violence, substance use, and mental illness.