• Describe the nature and scope of the problem known as “domestic violence
• Discuss what is being done by the healthcare system to deal with this problem
• Identify and explain how the legal system has responded to the problem
• Identify steps healthcare professionals can take to deal with domestic violence victims

Today, domestic violence is recognized as a serious societal problem in the United States. Yet, children in families in which such violence occurs have remained largely invisible as victims. Concern about children's exposure to domestic violence is increasing, however, in light of a growing body of knowledge regarding the prevalence and effects of childhood exposure to domestic violence. Research suggests that between 3.3 million and 10 million children in the United States are exposed to domestic violence each year. And more than a decade of empirical studies indicates that this exposure can have significant negative effects on children's behavioral, emotional, social, and cognitive development. (The term domestic violence typically refers to violence between intimate partners, including marital partners, cohabiting partners, and former partners, as well as non-cohabiting dating couples.)

Families affected by domestic violence touch all service systems and live in every community. Children exposed to domestic violence are in our schools, day-care centers, health care institutions, child welfare systems, and other agency settings. Law enforcement personnel have contact with children exposed to domestic violence through on-site police responses to domestic violence calls. Virtually every branch of our court system handles cases involving domestic violence. Though domestic violence cuts across the economic spectrum, poor families are more likely to be affected. In fact, many families in which domestic violence is present struggle with multiple problems, including poverty, substance abuse, and exposure to other forms of violence. For example, current research indicates that in 30% to 60% of families experiencing either domestic violence or child maltreatment, the other form of violence is also present.

In response to the growing awareness of the potential harm to children exposed to domestic violence, a wide range of agencies and service providers are developing intervention policies and practices. Professional organizations, including the National Council of Juvenile and Family Court Judges, the American Bar Association, the American Medical Association, and the American Psychological Association, have published intervention recommendations, convened task forces, commissioned reports, or sponsored conferences to address this problem. Community-based domestic violence organizations, many of which have served battered women and their children for more than two decades, have expanded their children's services to provide more comprehensive responses. Through cross-agency collaborations, innovative pilot programs are being implemented at various sites throughout the country to offer mental health services to children exposed to domestic violence and improve law enforcement responses to domestic violence incidences in which children are present. Policymakers are devoting increased attention to this issue, and several states have passed legislation, especially in the family law area, designed to improve outcomes for children exposed to domestic violence.

Though many of these approaches hold promise, few programs have been evaluated. It is difficult to find funding for intervention programs in this field, and even more difficult to obtain adequate funding for thorough evaluations. Yet, without this research, policymakers cannot determine which interventions yield the best results, and service providers do not have the quantitative information they need to improve programs and justify their long-term support.

This course summarizes the current knowledge to date regarding the prevalence and effects of childhood exposure to domestic violence. The course describes current responses to this problem by the multiple service systems with which children exposed to domestic violence have contact, and addresses what we know about how well these responses work.

The course also discusses federal and state laws that affect these children and their families, proposes recommendations for improvements to these interventions, and explores strategies to prevent domestic violence. Despite the limitations in current research regarding the efficacy of programs for children exposed to domestic violence, the potential harms to these children necessitate action. Sweeping policy changes are premature, given our limited understanding of their potential impact. However, short of such changes, there is much work that can be done to improve interventions for children affected by domestic violence.

Researchers agree that millions of children are exposed to domestic violence each year; however, there is no consensus regarding the specific number of children affected. The often-cited figures of 3.3 million and 10 million are estimates derived from methodologically limited studies. This absence of trustworthy statistics on the prevalence of child exposure to domestic violence affects the ability of policymakers, practitioners, and advocates to argue for and design effective interventions and policies for this population

One promising approach to improving understanding about the prevalence of childhood exposure to domestic violence is to use data gathered by professionals in close contact with domestic violent incidences (such as law enforcement officers). Several researchers have illustrated the value of such data. They describe a multi-city research project in which investigators created a sample of study cases using domestic violence misdemeanors. Results indicated that children, particularly those under the age of five, were disproportionately present in households experiencing domestic violence, and that these homes were more likely to have other risk factors present as well, such as poverty, substance abuse, low educational achievement of the principal care provider, and single-female heads of household. Though this study shows the potential of using data gathered by professionals close to the violent incident, it was not a national study and did not include all types of domestic violence cases.

Exposure to domestic violence can have serious negative effects on children. These effects may include behavioral problems such as aggression, phobias, insomnia, low self-esteem, and depression. Children exposed to domestic violence may demonstrate poor academic performance and problem-solving skills, and low levels of empathy. Exposure to chronic or extreme domestic violence may result in symptoms consistent with posttraumatic stress disorder, such as emotional numbing, increased arousal, avoidance of any reminders of the violent event, or obsessive and repeated focus on the event. Retrospective studies indicate that there may also be negative effects in adulthood, including depression, low self-esteem, violent practices in the home, and criminal behavior.

The effects of domestic violence can vary tremendously from one child to the next. The family situation, community environment, and the child's own personality may either strengthen the child's ability to cope or increase the risk of harm. For example, studies indicate that children exposed to both domestic violence and child maltreatment typically show higher levels of distress than children exposed only to domestic violence. Additional research is needed to determine if the presence of other stressors such as poverty, homelessness, substance abuse, and exposure to community violence exacerbate the negative effects of exposure to domestic violence.

Not all children exposed to violence suffer significant harmful effects. Based on research concerning children's resilience in the face of community violence and war, it is likely that the most critical protective factor for a child is the existence of a strong, positive relationship between the child and a competent and caring adult. Children exposed to violence need to be able to speak openly with a sympathetic adult about their fears and concerns, and also, ideally, have someone intervene to improve the situation.

Most children rely on one or both parents to provide nurturing support in the face of crises and emotionally challenging situations, but ongoing exposure to violence can sometimes hamper the parents' abilities to meet these needs. Parents living with chronic violence may feel emotionally numb, depressed, irritable, or uncommunicative, and thus may be less emotionally available to their children.

In cases of domestic violence, in which one parent is a victim of the violence and the other is the perpetrator, children may be even less able to turn to their parents for support and reassurance. The limited research to date on resilience and exposure to domestic violence indicates that maternal functioning, particularly as it relates to the mother's emotional availability, may be critical to children's ability to cope with the exposure. Yet, battered mothers may be less emotionally available to their children because they are preoccupied with the violence and trying to stay safe, and/or because they are experiencing depression. Their parenting practices may be compromised in other ways as well.

Studies of battered women's patterns of affectionate or aggressive conduct toward their children either reveal no differences when compared with control groups, or suggest that battered women may use more punitive child-rearing strategies or exhibit aggression toward their children. The limited research to date on the relationship between battering fathers and their children indicates that these fathers may be less available to their children, less likely to engage in rational discussions with their children, and less affectionate than fathers who are not violent. Still, more research on the effects of domestic violence on parenting is needed. Because the battered parent can be a critical support for the child, and because children often have ongoing contact with the batterer, services must be available to help parents improve their interactions with their children.

If parents experiencing domestic violence are unable to meet their children's needs, a relationship with a caring adult who is closely connected to the child's home or school can be helpful. Children with good social and communication skills are more likely to be successful at developing these relationships than children who do not have these skills. Further study is needed to identify which social supports are most helpful to children exposed to domestic violence, and in which situations. With better research, practitioners can shape prevention and intervention strategies to boost the protective factors that promote children's positive coping.

RECOMMENDATION

• Research is needed that advances the current understanding of the prevalence and effects of childhood exposure to domestic violence, and the impact of resilience and risk factors, so that policymakers and practitioners can design interventions sufficient to address the size, nature, and complexity of the problem.

Families affected by domestic violence utilize the services of health care, child welfare, mental health, and law enforcement agencies, as well as the courts and community-based domestic violence programs. Interventions for children in these families vary from system to system and from program to program within each system. Current services reach only a small percentage of the number of children exposed to domestic violence, and are typically not designed with the specific needs of these children in mind. Though specially designed services for children exposed to domestic violence are limited, innovative programs within each of these systems do exist. Currently, little is known about the effectiveness of these programs in improving outcomes for the children they serve.

Community-based domestic violence services emerged from the battered women's movement of the 1970s and 1980s. Early services focused primarily on providing shelter and advocacy to battered women. However, because most of the battered women utilizing these programs brought their children with them, many of these programs began providing services to the children as well. There are now more than 2,000 community-based domestic violence programs, and more than 1,300 provide shelter. Approximately half of all shelter residents are children. A 1997 survey shows that 72% of all shelters currently offer some type of children's services. These services range from childcare to recreational activities to health care to mental health counseling, though the number of shelters offering each type of service is unknown.

Innovative shelter programs that specifically address childhood exposure to domestic violence include group counseling sessions for the children and special parenting classes for the battered mothers.29 Another promising approach is the use of child advocates who help child residents access the benefits and services they need, ensure that legal protections are in place for the children, and provide training to shelter staff on child development and the impact of domestic violence on children.

Despite the array of services offered through shelters, most children affected by domestic violence do not have access to these services. Shelter programs are chronically under-funded and unable to meet the demand for services. Many battered women do not utilize shelters, either by choice or because these services are not available. Additionally, many shelters do not allow adolescent boys to enter as residents. Despite increases in recent years in the number of battered women accessing legal advocacy, counseling, and support groups through nonresidential programs, these services are less available to children. Identifying children through their contact with other public systems will increase their access to services only if a wide range of children's programs, in addition to those offered through shelters, is available. Community-based domestic violence programs are beginning to work collaboratively with other agencies to develop more comprehensive responses to mothers and children affected by domestic violence.

RECOMMENDATION

• Stable public funding sources are needed to support comprehensive and coordinated community-based services for battered women and their children, as well as program evaluations and replication of effective interventions.

Research indicates that between 4% and 30% of women entering emergency departments are suffering from a domestic violence injury. In the early 1990s, in recognition of the high health costs associated with domestic violence, key professional health care organizations developed guidelines for identifying and responding to domestic violence. As a result, many health care institutions have established domestic violence screening and assessment protocols, although it is unclear to what extent health care professionals use them. Studies indicate, for example, that only a little more than half of the women who enter emergency rooms for domestic violence related trauma either discuss their domestic violence experiences or are questioned about them by health care professionals, although many would disclose if asked. Because so many battered women have frequent contact with the health care system, it provides a critical venue within which to reach battered women and their children.

In order for screening and assessment protocols to be used effectively, health care professionals need ongoing training about domestic violence and the use of the protocols.

Once women and children affected by domestic violence are identified, health care professionals must be able to either provide them with or refer them to appropriate services. Some health care institutions have routine screening for domestic violence and offer specialized domestic violence services in-house, such as safety planning and support groups for battered women or therapeutic interventions for the children.

RECOMMENDATION

• Because the majority of children exposed to domestic violence do not have access to services through traditional avenues such as battered women's shelters, new strategies for identifying and serving these children in other venues, such as health care institutions, must be developed.

Mental Health System

Mental health system approaches to children exposed to domestic violence range from crisis interventions to individual, group, and family therapy programs. Crisis interventions can include mental health professionals providing on-site counseling in the home following a domestic violence incident, or immediate assistance to a child who is having trouble adjusting to shelter life. Group programs can offer children a safe venue in which to talk about the violence, improve self-esteem, and develop safety skills. Individual therapy is indicated for children who show extreme symptoms, though approaches vary. Some programs emphasize the development of social problem-solving skills that are often impaired by chronic exposure to domestic violence. Others employ therapy techniques used to treat posttraumatic stress disorder. Family therapy approaches may include counseling for mother and child, and referrals to other family support services. Because of the potential dangers, few family therapy programs include batterers. Those that do will only work with batterers who have done extensive work to change their violent behavior.

It is not known how many mental health programs for children exposed to domestic violence have been established, or how many children participate in them. Children exposed to domestic violence may receive mental health services without being assessed and treated for exposure to domestic violence. Although the American Psychological Association has recently focused attention on childhood exposure to domestic violence, and some mental health professionals have, for years, provided special services to battered women and their children, most mental health professionals do not receive training in identifying, assessing, or treating children exposed to domestic violence. Funding for mental health interventions is limited, and often only supports short-term treatment that will not adequately address the long-term symptoms these children may exhibit, or the myriad of other stressors in these children's families. Crime-victim programs in several states provide funding so that children exposed to domestic violence, as well as adult victims, can receive long-term mental health treatment. Other innovative programs combine more traditional mental health services with housing and job assistance.

As mentioned above, research indicates that there is a high co-occurrence in families of child abuse and domestic violence. Yet, as researchers have shown, separate service systems with unique histories and treatment philosophies have developed to address each form of violence. Child welfare agencies are empowered by state and federal laws to investigate reports of child abuse and neglect, offer services to families, make case recommendations to the juvenile court, and place children in foster and adoptive homes. Services provided to families keep children at home whenever it is safe to do so, and return children who have been removed, once the harmful circumstances have been addressed. If efforts to return the child home fail and the juvenile court terminates parental rights, child protective services (CPS) will find a permanent placement, such as an adoptive home, for the child. Ensuring the safety of the child is the principal mandate of CPS. In contrast, though many community-based domestic violence programs offer services to children, they focus mainly on providing support to battered women. And, while most CPS services are court-ordered, participation in community-based domestic violence programs is voluntary.

Despite these differences, growing recognition of the co-occurrence in many families of child maltreatment and domestic violence has resulted in greater willingness on the part of CPS staff and domestic violence service providers to work together. Collaborative efforts to date have identified beliefs common to both systems: (1) the presence of domestic violence in families is harmful to children, (2) the safety of the mother affects the safety of the child, and (3) perpetrators must be held accountable. Innovative pilot programs are successfully integrating child welfare and domestic violence services. Approaches include screening for domestic violence in all child maltreatment cases, having battered women's advocates on CPS staff to provide case consultation to workers and domestic violence services to families, and cross-field training for both CPS and domestic violence service providers.

Though these pilot programs show promise as models for collaboration, recent research reveals that cross-agency training remains limited and many professionals in each system believe the intervention goals of the other system conflict with their own. In addition, agency policies in both fields are unclear about how to intervene when both forms of violence are present in a family. In 1999, the National Council of Juvenile and Family Court Judges (NCJFCJ) published a set of guidelines for effective intervention in cases involving both child maltreatment and domestic violence. These guidelines, developed by a committee of key experts in both fields, provide a framework through which local communities can design comprehensive, community-based responses that include protections for adult and child victims, support services for the families, and effective and enforceable legal interventions.

RECOMMENDATION

• CPS and domestic violence service organizations must develop clear protocols for intervening with families in which both domestic violence and child maltreatment are present, offering services that provide safety and stability to the child, support to the battered woman, and treatment and sanctions for the batterer.

Legal-system interventions include responses by law enforcement personnel to calls of domestic violence, probation services for batterers, prosecution of criminal cases, and court decision-making. These systems have been slow to recognize and respond to the presence of domestic violence in their caseloads, but many states now have laws and protocols to improve responses. Several new law enforcement and court programs address the impact of domestic violence on children.

Between 1992 and 1996, only about half of female victims of domestic violence reported their victimization to law enforcement. In 88% of these cases, there was either a police response or the victim went to the police station for help. This figure marks a considerable improvement in law enforcement responses compared to two decades ago when it was standard policy not to intervene in what were viewed as private disputes. Although police are typically the first professionals on the scene after a domestic violence incident has occurred, they have limited services to offer families. Law enforcement departments in several locales throughout the country have initiated specific programs to improve interventions, including cooperative arrangements with mental health professionals who, upon notification by police, appear at the scene of the domestic violence incident to assist child and adult victims. Other strategies include police report documentation of a child's presence in the home, which automatically qualifies the child for state victims of crime funding for support services, and specialized training in child development for law enforcement personnel.

Domestic violence issues appear in all areas of the judicial system, including criminal court, juvenile court, family court, and other civil courts. Despite the recent use in several locales of innovative approaches to handle these cases, there is still widespread misunderstanding by judges and other court personnel about domestic violence and its potential impact on children. New programs (1) provide training on domestic violence issues to judges, child advocates, mental health professionals, and other court personnel; (2) offer coordinated, cross-agency responses to cases involving both domestic violence and child maltreatment; (3) utilize specialized domestic violence courts; or (4) have a one-family, one-judge approach in which one judge hears all civil and criminal cases involving a particular family. To be effective, innovative court approaches should include comprehensive training for all court personnel, access to a wide range of family services, and supportive court administrative practices. Judges can play an important leadership role in encouraging coordinated responses for children affected by domestic violence.

RECOMMENDATION

• Professionals who have regular contact with families and children, including teachers and child care workers, health and mental health care providers, law enforcement officers, child welfare workers, and court personnel, should receive ongoing training on domestic violence and its impact on children.

Laws and Public Policies Affecting Children Exposed to Domestic Violence

Federal and state policies in a wide range of areas affecting families may potentially have an impact on children exposed to domestic violence. These include, at the federal level, domestic violence laws as well as child protection and welfare reform legislation; and at the state level, criminal sanctions against batterers, civil protective orders, child protection laws, and child custody and visitation laws.

Very few of these federal and state laws directly address the needs of children exposed to domestic violence, and those that do have not been evaluated to understand their short- and long-term effects on the well-being of these children and their families.

Federal Legislation

Three federal laws enacted in the 1990s mandate policy changes that are likely to affect children exposed to domestic violence: (1) the Violence Against Women Act of 1994 (VAWA), (2) the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), and (3) the Adoption and Safe Families Act of 1997 (ASFA). VAWA directly addresses domestic violence, while PRWORA and ASFA have implications for the substantial number of families affected by domestic violence who are also involved with the welfare and/or child protection systems.

VAWA provides for increased services to battered women, improvements in prosecution of criminal cases involving domestic violence, and support for better law enforcement and other systems' responses to domestic violence. To the extent that these provisions improve battered women's safety and access to support services, they are likely to have a positive impact on these women's children as well. However, VAWA's direct emphasis on the needs of children exposed to domestic violence is quite limited. A new VAWA bill introduced in 1999 included provisions that directly and more comprehensively addressed children's needs, but was not enacted. A similar bill was introduced in 2000.

Between 20% and 30% of all families receiving cash assistance through welfare programs (now called Temporary Assistance to Needy Families) also experience domestic violence. PRWORA mandates that states impose time limitations, work requirements, and child support compliance on the receipt of cash assistance. The Wellstone/Murray Amendment to PRWORA, passed in 1997, addresses concerns regarding the ability of battered women to meet these new requirements. This amendment allows but does not require states to adopt exceptions to the time limits, work requirements, and child support compliance for domestic violence victims. These exceptions are important because they enable battered women who cannot meet the new requirements to access public assistance. Limited access to public assistance can severely affect a battered woman's ability to leave an abusive situation. Since September 1998, some 49 states have in place some type of domestic violence exception or special procedures for domestic violence victims, though not all are as comprehensive as the amendment's recommendations. Even if not all battered women need or choose to use them, it is important that the exceptions not just be on the books, but be fully implemented by welfare workers and available to all battered women seeking public assistance.

ASFA shortens the time lines within which CPS must develop permanent placements for children in the child welfare system, and creates fiscal incentives to place more foster children into adoptive homes once parental rights have been terminated. Though ASFA also renews requirements that CPS provide appropriate services to families whose children have been removed so that the children can possibly return home, it is unclear how these requirements are being interpreted by CPS and the courts. Some researchers raise concerns regarding the ability of battered women to regain custody of their children within the shortened time lines mandated by ASFA. Battered women leaving abusive situations may need more time than the law allows ensuring safety for them and their children, recovering from the trauma of being battered, find a new home and job, and enhance their parenting skills.

If improvements to the family's circumstances are not made within the time line, parental rights may be terminated, when it would be better for the children to stay in foster care a while longer before returning home. However, because appropriate services to battered women and their children are so limited, courts may decide that CPS has not provided the requisite services and grant exceptions to the time lines for these families. Though ASFA's goal of placing foster children in permanent homes more quickly is laudable, decisions regarding placement must include attention to the particular issues families face, and the appropriateness of services provided. Timely services that address the needs of families experiencing domestic violence are likely to result in better outcomes for children who have been both abused or neglected and exposed to domestic violence.

State Laws and Policies

State laws provide for protective orders and criminal sanctions against acts of domestic violence, which if properly enforced can help keep battered women and their children safe. Child custody and child welfare policies that do not consider the presence of domestic violence in a family may result in arrangements that are harmful to the children.

Criminal Sanctions

Criminal law in all states contains provisions that authorize the arrest and prosecution of those who commit acts of violence, such as battery, assault, kidnapping, and attempted murder. Until recently, these laws were rarely enforced in domestic violence cases. During the 1980s, however, some jurisdictions developed policies that require police to arrest perpetrators of domestic violence. Other recent legislation expands the range of criminal behaviors related to domestic violence to include intentional harassment of victims through stalking. These new trends in state legislation are important because they send a message to batterers and society that domestic violence will not be tolerated, and because they make imprisonment of the batterer a possible means of protection for abused women and their children. In addition, research suggests that mandatory arrest policies may be successful in deterring future violence by some batterers. Anti-stalking statutes hold promise of empowering women and law enforcement to interrupt an escalating cycle of violence before an assault occurs.

Civil Protective Orders

Civil courts can issue protective orders prohibiting a batterer from approaching the adult victim, the children, and various locations, such as the home, the victim's workplace, or the children's school. In some states, these orders can also include child custody and visitation arrangements. Battered women may contact law enforcement to intervene if a batterer violates the order. The consequences to a batterer of violating an order vary from state to state.

A recent study suggests that lack of enforcement by police and courts has limited the ability of protective orders to keep battered women and their children safe. Nonetheless, protective orders are commonly used by battered women to protect themselves and their children. Protective orders can be effective only if battered women know they are available and can obtain them, if the orders are tailored to address specific safety needs, and if penalties for violations have sufficient teeth to deter batterers from violating them. Research indicates that battered women are more likely to succeed in obtaining protective orders if they are represented by legal counsel.

RECOMMENDATION

• Courts must be empowered to design and enforce protective orders that comprehensively address the safety needs of battered women and their children. All battered women must have access to affordable legal counsel, so that they can utilize available legal means to protect themselves and their children.

Child Custom and Visitation Laws

Child custody and visitation laws guide family court decisions in divorce cases, regarding where the child will live and whether the child will have ongoing contact with a non-custodial parent. To reach these decisions, courts analyze the particular case circumstances to determine which arrangements will be best for the child. Courts are increasingly considering the presence of domestic violence in making these determinations.7Nonetheless, there are several trends in current state custody law that can lead to decisions in cases involving domestic violence that are not in the best interests of the children. These trends include: (1) a statutory preference for joint legal custody even when one or both parents object; (2) friendly parent provisions, which allow the court to prefer the parent who appears more cooperative and willing to share parenting; and (3) mandatory mediation. Joint-custody arrangements in family situations involving high levels of parental conflict are likely to have detrimental effects on the children. Policies that favor the "friendly parent" may lead to custody decisions against the battered mother, if she is unwilling to consider joint custody. Mandatory mediation in domestic violence cases denies the dynamics of power and control that exist in these cases, and that are contrary to mediation goals of cooperation and compromise.

Some state legislatures are recognizing that policies favoring joint legal custody, "friendly parents," and mandatory mediation may result in decisions and processes inconsistent with the children's best interests, and have adopted exceptions for domestic violence cases. In addition, several states have passed new laws that create a presumption against the batterer having custody, and require that the batterer overcome the presumption against him by showing that he is a fit parent. In some states, there is also a presumption against unsupervised visitation for non-custodial parents who have committed domestic violence.

RECOMMENDATION

• In child custody and visitation cases involving domestic violence, courts should consider in their analysis of the best interests of the child the potential impact on the child of ongoing exposure to parental conflict and violence.

Child Protection Policies
Though federal laws heavily influence state child protection laws and practice, states retain a great deal of freedom to define the parameters of state CPS work. Two types of state child protection legislation raise particular concern when applied to families experiencing domestic violence:

1. failure-to- protect laws that allow courts to make a finding of child maltreatment when a parent does not protect her child from harm, and
2. policies that make childhood exposure to domestic violence per se child maltreatment.

Failure-to-protect laws stem from the premise that omissions in a parent's behavior can cause child harm, and that parents have a duty to keep their children from harm. Filing failure-to-protect petitions against battered women blames the adult victim for the violence, assumes she can stop the violence, and denies the fact that many battered women make calculated decisions to stay with their abusers because they believe leaving could result in homelessness, lack of steady income, or even injury or death at the hands of the batterer. However, in child protection cases, the juvenile court has jurisdiction over the child only, and applies pressure to parents through the ability to terminate parental rights if child-rearing practices do not improve. This makes it difficult to hold batterers, who may not care about or have parental rights, accountable for the harm their violence causes the children.

Under current laws, failure-to-protect claims against a battered woman who wants to retain custody of her children may be the only way to provide CPS protection if the child is in danger. With assessment procedures and services in place to address domestic violence in the family, CPS can assist families in improving the circumstances for the child. Unfortunately, because most CPS agencies do not have specific domestic violence assessment procedures, training for caseworkers, or services, CPS intervention through failure-to-protect claims may result in decisions that are not best for the children.

In an effort to address the potential harm to children exposed to domestic violence, some policymakers are considering whether such exposure should be per se psychological abuse. Proponents argue that such policies would create a clear mandate for CPS intervention in cases in which children may be psychologically harmed, and would hold batterers more accountable for the effects of their violence by making them per se child abusers. Opponents argue that such policies may dissuade battered women from seeking help for fear of losing their children, and may further burden an already overloaded child welfare system. Before per se child abuse laws are passed, a thorough investigation of their potential impact is needed. Per se child abuse laws do not give courts and agencies the flexibility needed to assess the particular circumstances of each domestic violence case and determine appropriate interventions based on that case-by-case analysis.
In order to adequately address the wide range of circumstances existing within families with domestic violence, multiple, community-based response systems are needed that do not require court or CPS intervention.

RECOMMENDATION

• In designing new laws to address the effects of childhood exposure to domestic violence, policymakers should assess the potential unintended negative consequences of these laws and weigh them against the benefits.

Prevention strategies are critical to reducing the impact of domestic violence on children. Domestic violence prevention theories to date have borrowed heavily from public health models, which emphasize understanding the causes of the problem and identifying strategies to address the causes.

Researchers and advocates have identified as a critical barrier to prevention societal norms that condone domestic violence. Public beliefs that domestic violence is not wrong or harmful also undermine efforts to hold perpetrators accountable and make it difficult to garner support for tougher policies as well as funding for victims' services.

Campaigns to improve the public's understanding of the harms of domestic violence have been utilized extensively by community-based domestic violence organizations. An evaluation of a national public education campaign launched in 1992 by the Family Violence Prevention Fund shows success in improving the public's understanding of domestic violence and its impact, but shows mixed results with regard to increasing people's willingness to act in response to domestic violence.

School-based prevention programs are popular because they can reach so many children and youths, reduce misunderstandings regarding domestic violence, give safety information and planning, and offer positive alternatives for conflict resolution and relationship development. Some programs also train school personnel so they can intervene appropriately when children disclose the presence of domestic violence in their homes. Preliminary evaluations of school programs suggest that these strategies can be effective in changing the beliefs of students with regard to domestic violence and in possibly altering behavior as well. Other promising prevention approaches target families and couples directly through home visiting programs, for example, or behavioral-cognitive therapy for new couples at risk of violence.

Funding sources for domestic violence prevention efforts are extremely limited; even scarcer are resources for adequately evaluating prevention programs. Domestic violence prevention is difficult because it requires behavioral and societal changes, and it is difficult to measure these changes. Nonetheless, effective prevention approaches are pivotal to protecting children from the harms of exposure to domestic violence.

RECOMMENDATION

• Increased and ongoing public support is needed to develop effective prevention programs that address the underlying causes of domestic violence.

Research indicates that millions of children are exposed to domestic violence and that the potential effects from this exposure are substantial. This information alone creates an imperative for action, despite the fact that we do not yet have empirical evidence to show which interventions work best. Public and private service agencies must expand efforts to reach children exposed to domestic violence with the best interventions the current knowledge will allow. At the same time, new and better research is needed to improve our understanding of the number of children affected by domestic violence, the nature of that impact, other factors that influence outcomes for these children, and the effectiveness of intervention strategies. Excellent work is being done throughout the country to design and implement programs for children exposed to domestic violence. Solid efforts to date by researchers, advocates, policymakers, practitioners, and others in this young field have greatly improved our understanding of the potential harms to these children. Greater public and private financial support for these efforts is needed, so that future work can build on the good work that has already been done, to reach more children exposed to domestic violence, with more effective and comprehensive responses.

I. POLICY STATEMENT

All health care providers shall report acts of domestic violence pursuant to the laws of the state. All health care providers and support staff shall treat victims of domestic violence with respect and dignity, providing care, safety and referral information to victims in every health care setting.

II. GOALS AND OBJECTIVES

Health care providers caring for patients who may be victims of domestic violence shall:

• Recognize the widespread prevalence of domestic violence and its long-term effects on abused persons, their families, and the community.
  
• Recognize that domestic violence occurs not only against women, but that men and individuals in gay/lesbian relationships may also be victims.
  
• Develop awareness and sensitivity to the barriers that inhibit effective interaction between battered persons and health care providers (see appendices A & B).
  
• Identify the physical and behavioral signs and symptoms of domestic violence (see appendix C).
  
• Utilize appropriate interview and intervention techniques once abuse is suspected.
  
• Assess the patient’s level of risk for future violence.
  
• Treat victims of domestic violence with respect and dignity so they are not further victimized by the system from which they are seeking help.
  
• Promote patient autonomy, confidentiality and self-determination to the extent permitted by law.
  
• Understand and implement the legal duties and responsibilities of health care providers, including, but not limited to, reporting and documentation requirements (see appendices F, G, H).
  
• Utilize resources and referral options available to health care providers and their patients (see appendix H).
  
• Encourage countywide education and training for all health care providers in the identification, treatment, reporting, and support of patients who are victims of domestic violence.
  
• Make it known to the patient that the law mandates reporting situations of known or suspected violence.

III. SAMPLE DOMESTIC VIOLENCE PROTOCOL FOR HEALTH CARE PROVIDERS

• DEFINITIONS

1. A health care provider is any person who provides health care to any patient. This includes but is not limited to: physician, nurse, social worker, technician, nurse’s aide, nurse practitioner, mental health provider, dentist, podiatrist, chiropractor, medical assistant and physician’s assistant.
2. Domestic violence is abuse committed against an adult or fully emancipated minor who is or has been a spouse, cohabitant, or person with whom the perpetrator has had a child, or with whom the perpetrator has had a dating or engagement relationship.
3. Abuse is the intentional or reckless infliction, or attempted infliction, of bodily injury to another person.

A. EDUCATION AND TRAINING

All health care providers shall regularly participate in education and training programs on domestic violence.

B. STANDARDS OF CARE FOR HEALTH CARE PROVIDERS

1. HISTORY - Health care providers should routinely screen all patients for a history of domestic violence.
   
   
2. INTERVIEWING THE PATIENT - When domestic violence is suspected or reported (see appendix C), the health care provider should interview the patient alone in a private setting. The health care provider should interview the patient in a nonjudgmental manner and avoid blaming the patient for what has happened. This process should incorporate a discussion of the patient’s short-term options and plans including whether the patient can safely return home.
   
   
3. PHYSICAL EXAMINATION - When injuries are reported by a patient or observed by the provider, a physical examination and assessment for domestic violence must be done (see appendix E).
   
   
4. CHARTING - When domestic violence is suspected, doctors or their designees should make a complete legible record of any acute finding (see appendix F). Location of injuries should be drawn on a body map (see appendix G; This map may be photocopied if needed).
   The chart / record should include:
   § The patient’s own words, with the use of quotation marks, regarding the causes of the injuries or other important information.
   § A description of the patient’s injuries: type, extent, age, location.
   § Any opinion by the health care provider as to whether the explanation offered for the injury adequately explains the injury.
   § Photographs of the patient’s injuries if possible.
   § Past history of physical and sexual abuse.
   § Documentation regarding maintenance of physical evidence until it has been turned over to police.
   
   
5. IMPLEMENTATION OF A SAFETY PLAN - The health care provider’s interview process should incorporate a discussion of the patient’s short-term options and plans, including whether the patient can safely return home. Health care providers who admit a battered patient should ensure that patient’s confidentiality while in the hospital (i.e., remove the patient’s name from the switchboard computer, remove the patient’s name from outside the hospital room).
   § In all cases, the health care provider should refer the patient to local domestic violence agencies.
   § When the patient is willing, the health care provider should also assist the patient in calling a domestic violence crisis line.
   
   
6. REPORTING if the patient is suffering from an injury caused by domestic violence, the health care professional must report to a local law enforcement agency.
   Where there is current injury from domestic violence, a telephone report shall be made immediately or as soon as practically possible, and a written report must follow within two working days. The report form is shown below. This report form may be photocopied as needed. Phone reports should be made to the police department in the place where the incident occurred. Be sure to obtain case number. Upon receipt of a medical report or phone contact made by a medical professional where domestic violence is alleged, the agency of jurisdiction shall make a police report per the Penal Code Section. Written report must be sent within two working days to that police department.

APPENDIX A - BARRIERS FACING BATTERED PERSONS

This appendix contains a summary of the barriers to reporting domestic violence when battered persons meet with health care providers.
Battered persons usually do not initiate discussions concerning their abuse:

1. The patient may be fearful because of threats by the batterer.
   
   
2. The patient’s cultural ethnic and/or religious background may discourage revealing the fact of domestic violence to persons outside of the family.
   
   
3. The patient’s economic dependence upon the batterer may hinder revelation of the abuse.
   
   
4. The patient may believe that the children need two parents and that discussing the abuse will interfere with the abusive partner’s role in the family.
   
   
5. The patient may fear living alone.
   
   
6. The patient may feel a loyalty to the abuser.
   
   
7. The patient may pity the abuser and believe that the abusive behavior can change without assistance.
   
   
8. The patient may fear the batterer may commit suicide.
   
   
9. The patient may feel guilty about the violence.
   
   
10. The patient may love the batterer.
    
    
11. The patient may believe the batterer’s promises that the abuse will stop.
    
    
12. The patient may feel responsible for the battering.
    
    
13. The patient may deny that there has been abuse, or minimize the extent.
    
    
14. The patient may be embarrassed, humiliated and degraded about the abuse.
    
    
15. The patient may define abuse differently than the health care provider and therefore not recognize an abusive situation.
    
    
16. The patient may lack awareness or insight that physical symptoms are related to the stress of the abusive relationship.
    
    
17. The patient may believe the injuries are not serious enough to matter.
    
    
18. Gay men and lesbians may not wish to disclose their homosexuality.

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APPENDIX B – BARRIERS FACING HEALTH CARE PROVIDERS

This appendix outlines the barriers facing health care professionals as they attempt to detect domestic violence and provide an appropriate response to their patients who are victims of domestic violence. Health care providers are reluctant to as patients about possible domestic abuse they may have suffered for a number of reasons, including:

1. There is a difficulty identifying domestic violence within the patient population. The assumption is that patients from middle to upper class backgrounds are not at risk of abuse. Further, there is an assumption that if the patient does not bring up the subject, there has been no abuse.
   
   
2. There is a fear of offending the patient.
   
   
3. There is a sense that it is not the role of the health care provider to ask questions or intervene.
   
   
4. The health care provider may believe that it is the patient’s responsibility to raise the issue of abuse.
   
   
5. The health care provider may believe there is not enough time to ask about possible abuse.
   
   
6. The health care provider may fear becoming involved in a personal matter between intimates.
   
   
7. The health care provider may feel helpless given the complexity of the issue.
   
   
8. The health care provider may be completely unaware of, or uninformed about, the scope and dynamics of domestic violence.
   
   
9. The health care provider may ‘blame the patient’ and feel frustrated that the abused person does not leave the relationship.
   
   
10. The health care provider may disbelieve the patient because the alleged assailant is present and seems to be very concerned and pleasant.
    
    
11. Ignorance of, discomfort with, or insensitivity to the possibility of same sex domestic violence.
    
    
12. Ignorance of, discomfort with, or insensitivity to the possibility of violence of women vs. men.

APPENDIX C – CONSIDERATIONS FOR THE HEALTH CARE PROVIDER

During all patient contacts health care providers should be alert to the possibility that the patient has been the victim of domestic violence. The following factors and cues should be noted since they may indicate that the patient has been battered:

A. Behavioral Cues:

1. Nervous or inappropriate laughter or smiling
   
   
2. Crying
   
   
3. Sighing
   
   
4. Anxiety
   
   
5. Defensiveness, anger
   
   
6. Lack of eye contact, or fearful eye contact
   
   
7. Minimizes seriousness of injury
   
   
8. Overly attentive, aggressive or defensive partner
   

B. Verbal Cues:

1. Talks to a "friend" who has been abused
   
   
2. Refers to partner’s "anger" or "temper"
   
   
3. Responds affirmatively to any of the following questions:
   

• Have you been hit or harmed any time in the past year?
  
  
• Are you in a relationship with someone who hurts or threatens you?
  
  
• Has your partner ever destroyed things that you cared about?
  
  
• Has your partner ever forced you to have sex when you did not want to?
  
  
• Is your partner possessive about you? Does s/he have to know where you are at all times? Is s/he overly jealous.

C. Uses health care services repeatedly, especially for psychosomatic complaints or for injury to the same site.

D. Psychosomatic/emotional complaints including headaches, sleeping disorders, difficulty concentrating, anxiety, depression, fatigue, nightmares, suicide attempts or gestures, abdominal or gastrointestinal complaints, marital problems.

E. Reluctance to speak in the presence of the abuser.

F. Presence of child abuse within the family.

G. If a patient has been battered by a partner, the abuse is extremely likely to happen again. In almost all cases, there is nothing the patient can do within the relationship to stop the violence. In many cases, the batterer will apologize and swear to reform. Apologies, however, do not mean that the violence will stop,

APPENDIX D – SUGGESTED QUESTIONS FOR HEALTH CARE PROVIDERS

Health care providers should be prepared to ask their patients some or all of the following questions to determine if they are the victims of domestic violence:

1. Do you ever feel afraid of, or threatened by, your partner?
   
   
2. Are you in a relationship in which you have been physically hurt or threatened by your partner?
   
   
3. Are you in a relationship in which you are treated badly?
   
   
4. Have you been hit or battered in the last six months or since I last saw you?
   
   
5. Has your partner ever destroyed things that you cared about?
   
   
6. Has your partner ever threatened or abused your children?
   
   
7. Does your partner ever force you to engage in sex that makes you feel uncomfortable?
   
   
8. We all fight at home. What happens when you and your partner fight or disagree?
   
   
9. Has your partner ever prevented you from leaving the house, seeing friends, getting a job or continuing your education?
   
   
10. Does your partner watch your every move? Call home or work multiple times a day? Accuse you of having affairs with everyone?

It is important that any inquiry regarding a patient’s exposure to domestic violence be done as a part of the interview process.

Questions and attitudes not to ask or express:

1. What keeps you with a person like that?
   
   
2. Do you get something out of the violence?
   
   
3. What did you do at that moment that caused him/her to hit you?
   
   
4. What could you have done to avoid or defuse