Behavioral problems among children whose mothers are abused by an intimate partner

Child Abuse & Neglect 27 (2003) 1231–1246

Behavioral problems among children whose mothers are abused by an intimate partner Mary A. Kernic a,∗ , Marsha E. Wolf a , Victoria L. Holt a , Barbara McKnight b , Colleen E. Huebner c , Frederick P. Rivara a,d a

Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA b Department of Biostatistics, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA c Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA d Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA Received 13 November 2002; received in revised form 3 December 2002; accepted 14 December 2002

Abstract Objectives: To determine the association between children’s exposure to maternal intimate partner violence (IPV) and behavior problems as measured by the parent report version of the Child Behavior Checklist (CBCL). Methods: The study population was comprised of 167 2- to 17-year-old children of Seattle women with police-reported or court-reported intimate partner abuse. The CBCL normative population served as the comparison group. Risk of behavior problems was calculated among the exposed children, in the presence and absence of a history of reported child maltreatment, relative to the normative population. Multiple logistic regression served as the primary method of analysis. Results: Children exposed to maternal IPV were more likely to have borderline to clinical level scores on externalizing (i.e., aggressive, delinquent) behavior (RR = 1.6, 95% CI: 1.2, 2.1) and total behavioral problems (RR = 1.4, 95% CI: 1.1, 1.9) compared to the CBCL normative sample after adjusting for age and sex. Children who were exposed to maternal IPV and were victims of child maltreatment were more likely to receive borderline to clinical level scores on internalizing (i.e., anxious, depressed) behaviors (RR = 2.6, 95% CI: 1.5, 3.6), externalizing (i.e., aggressive, delinquent) behaviors (RR = 3.0, 95% CI: 1.9, 4.0) and total behavioral problems (RR = 2.1, 95% CI: 1.2, 3.2) compared to the CBCL normative sample after adjusting for age and sex.

∗

Corresponding author address: Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth Avenue, Seattle, WA 98104-2499, USA. 0145-2134/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.chiabu.2002.12.001

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Conclusions: Exposure to maternal IPV is significantly associated with child behavioral problems both in the presence and absence of co-occurring child maltreatment. Appropriate attention to the mental health of children living in households with IPV is needed. © 2003 Elsevier Ltd. All rights reserved. Keywords: Intimate partner violence; Child witness; Domestic violence; Child behavior; Child abuse; Child maltreatment

Introduction At least 1.5 million children are exposed to their mothers’ abuse by an intimate partner in the United States each year (Greenfeld et al., 1998; Tjaden & Thoennes, 1998; US Census Bureau, 2000). Prior research suggests that children living in households in which their mothers are abused are at increased risk of behavioral problems, but many of these studies are weakened by several methodologic problems. Descriptive studies of children exposed to maternal intimate partner violence (IPV) were the first to indicate a high degree of behavioral distress (e.g., depression, anxiety, aggressive behaviors, and post-traumatic stress) among this group, but the lack of comparison groups made these observations inconclusive (Kilpatrick & Williams, 1998; Levine, 1975; Moore, 1975; O’Keefe, 1994; Penfold, 1982; Smith, Berthelsen, & O’Connor, 1997; Stagg, Wills, & Howell, 1989; Wildin, Williamson, & Wilson, 1991). Analytic studies that have examined this association are also inconclusive. A common approach has been to use Achenbach’s Child Behavior Checklist (CBCL) to compare levels of internalizing behaviors (depressive, withdrawn, or anxious behaviors), externalizing behaviors (aggressive, delinquent behaviors), and social competence (competence in school, social situations, and involvement in activities) among children in households experiencing IPV relative to children from non-violent households (Fantuzzo et al., 1991; Jaffe, Wolfe, Wilson, & Zak, 1986a; Jaffe, Wolfe, Wilson, & Zak, 1986b; O’Keefe, 1994). Although many studies found a significant association between children’s exposure to maternal IPV and internalizing and externalizing behaviors (Fantuzzo et al., 1991; Jaffe et al., 1986a, 1986b; O’Keefe, 1994), other studies have found no such association (Jaffe, Wolfe, Wilson, & Zak, 1985; Wolfe, Jaffe, Wilson, & Zak, 1985; Wolfe, Zak, Wilson, & Jaffe, 1986), an association only with externalizing behaviors (Sternberg et al., 1993), or an association only with internalizing behaviors (Christopoulos et al., 1987; Cummings, Pepler, & Moore, 1999; Holden & Ritchie, 1991). Studies that have evaluated the association between exposure to maternal IPV and total behavioral problems (includes internalizing, externalizing behaviors as well as social, thought and attentional problems) have consistently shown a positive association (Christopoulos et al., 1987; Cummings et al., 1999; Davis & Carlson, 1987; Holden & Ritchie, 1991; Hughes, Parkinson, & Vargo, 1989; Kolbo, 1996; Moore & Pepler, 1998; Wolfe et al., 1985). Findings with regard to social competence have been more mixed with roughly half the studies showing deficits in social competence among children exposed to their mothers’ abuse by an intimate partner (Davis & Carlson, 1987; Fantuzzo et al., 1991; Jaffe et al., 1986b), one showing an effect but only among current shelter residents (Wolfe et al., 1986) and the remainder finding no such effect (Christopoulos et al., 1987; Hughes et al., 1989; Jaffe et al., 1986a; Wolfe et al., 1985).

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Despite the agreement of most studies that children exposed to their mother’s abuse are at increased risk of at least some type of behavioral disturbance, the validity of much of the previous work in this field is compromised by the inability to account for the co-occurrence of child abuse (Christopoulos et al., 1987; Cummings et al., 1999; Gleason, 1995; Hinchey & Gavelek, 1982; Holden & Ritchie, 1991; Jaffe et al., 1985, 1986a, 1986b; Jouriles, Murphy, & O’Leary, 1989; Kilpatrick & Williams, 1998; Kolbo, 1996; O’Keefe, 1994; Rosenbaum & O’Leary, 1981; Westra & Martin, 1981; Wolfe et al., 1985). Additionally, most studies have typically sampled from battered women’s shelters, affecting both generalizability to the broader population of children exposed to maternal IPV and challenging validity on the grounds that behavioral disturbance among this population may be at least in part attributable to the disruption associated with relocation to a shelter (Christopoulos et al., 1987; Davis & Carlson, 1987; Holden & Ritchie, 1991; Hughes et al., 1989; Jaffe et al., 1985, 1986b; Mathias, Mertin, & Murray, 1995; McCloskey, Figueredo, & Koss, 1995; O’Keefe, 1995; Rossman & Rosenberg, 1992; Wolfe et al., 1985, 1986). This study was designed to explore the relationship between exposure to maternal IPV and child behavior problems and to address the limitations of previous studies in several ways. First, child maltreatment data were collected on the IPV-exposed group, allowing us to calculate estimates of the risk of behavioral problems associated with exposure to maternal IPV both in the presence and in the absence of child maltreatment. Second, city-wide police-reported data on IPV incidents were used to allow for greater external validity. Finally, we collected data on the duration of exposure to maternal IPV, allowing us to confirm that IPV exposure occurred in advance of the outcome period of interest.

Methods Subjects The IPV-exposed group consisted of dependent children whose mothers were victims of police-reported or court-reported intimate partner violence in Seattle, Washington, and who participated in the Women’s Wellness Study (WWS) described in detail elsewhere (Wolf, Holt, Kernic, & Rivara, 2000). Briefly, the WWS study population consisted of 448 Seattle women 18 years and older who were victims of abuse by a male intimate partner that resulted in a police-reported incident or a filing of a protection order between 10/15/97 and 12/31/98. Sampling of Women’s Wellness participants was through stratified random sampling based on history of police involvement and protection order status. Eligible children were aged 2–17 years upon their mother’s entry into the WWS and lived with their mother at least part-time during the 12 months prior to her enrollment. Upon entry to the WWS, 186 of the women (41.5%) had children between 2 and 17 years of age who had lived with them during the prior 12 months or more. In families with several eligible children, one child was randomly chosen as the index child using an assignment scheme based on the ranking of computer-generated random numbers. Of the 186 eligible children, 14 (7.5%) were excluded because CBCL outcome data were provided on a child other than the assigned index child, or it was unclear if the CBCL was provided for the

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correct child. Additionally, 5 (2.7%) mothers refused to fill out a CBCL. Thus, the final sample size was 167 IPV-exposed children, which was 89.3% of those known to be eligible. Data on child maltreatment were collected on the IPV-exposed group from reports of physical abuse, sexual abuse, or severe neglect to the Seattle Police Department (primarily through Child Protective Services). A child was considered positive for child maltreatment if any report of abuse was found to warrant investigation, regardless of the outcome of that investigation. This broader definition was used in order to provide a more sensitive measure of child maltreatment given the difficulty in prosecuting cases of alleged abuse. Using this definition, 24 of the 167 IPV-exposed children (14.4%) were also found to be victims of child maltreatment. The standardized normative samples for the Achenbach’s CBCLs for ages 2–3 years and ages 4–18 years served as the comparison group (Achenbach, 1991a, 1991b). The CBCL normative samples (n = 2736) were used in the development and standardization of the CBCL by its authors and were sampled to be representative of the US population in terms of socioeconomic status (SES), ethnicity, region, and urban-suburban-rural residence. The study protocol was approved by the University of Washington’s Human Subjects Committee. Child behavior outcomes The Child Behavior Checklist was completed by mothers of the participating IPV-exposed children upon entry to the Women’s Wellness Study. Eighty-six percent of the interviews were completed via telephone by trained interviewers, and the remainder were self-administered and returned by mail. The CBCL is a well-standardized, extensively used psychometric instrument with high reliability and validity. We used the established age- and sex-specific cutoff scores for each of the CBCL scales as reported by Achenbach (1991a, 1991b). These authors established the cutoff scores as those that best distinguished the non-referred children of the normative sample from the clinically referred children. Scores above the cutoff, therefore, provide an indication that the exhibited behavioral problems are sufficiently atypical to be of clinical concern, and have been shown to correlate well with clinical diagnoses of behavioral problems and external risk factors associated with behavioral dysfunction (Jensen & Watanabe, 1999; Kasius, Ferdinand, van den Berg, & Verhulst, 1997). The proportion of children scoring in the borderline or clinical range on each CBCL scale (internalizing behaviors, externalizing behaviors, social competence, and total behavioral problems) served as the primary outcomes of interest. Within the normative population, scores in the clinical range represented the upper 10th percentile for behavioral subscales and the lower 2nd percentile for the social competence subscale. An additional 8 and 3% of each age-sex group within the normative population fell within the borderline clinical range on the behavioral subscales and social competence subscales, respectively. Although internalizing, externalizing, and total behavioral scales were designed for assessment with children ranging in age from 2 to 18 years of age, the social competence scale was designed to be used among children aged 6–18 years. We, therefore, limited our analysis of social competence to children within this age group (n = 70 for children exposed to maternal IPV only and n = 13 for children exposed to maternal IPV and child maltreatment).

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Maternal intimate partner violence Conflict Tactics Scale—revised. To assess the type and severity of maternal intimate partner violence, we used the revised version of the Conflict Tactics Scale (CTS2). The Conflict Tactics Scale is a 27-item instrument designed to capture information on the occurrence and frequency of specific acts of reasoning, negotiation, psychological, physical, and sexual abuse used within the context of an intimate relationship. Using the CTS2, we were able to categorize presence or absence of physical abuse, psychological aggression, and sexual coercion during the 1 year prior to the index episode of abuse that led to the mother’s enrollment in the parent study (Straus, Hamby, Boney McCoy, & Sugarman, 1996). Although we used all items of the CTS2 for physical abuse (12 items) and psychological abuse scales (8 items), we shortened the sexual abuse scale to include one minor and one severe item out of the potential 3 minor and 4 severe items from this scale. We chose to shorten this scale to lessen the emotional burden to subjects caused by answering questions that would unnecessarily capture explicit details about sexual abuse events. The two items we used captured the two major themes captured by this scale simply without added detail. These themes include use of sexual abusive acts not involving the use of physical force and sexual abusive acts involving physical force. To describe further the abuse history, we added individual items to the questionnaire to elicit information on the duration of physical abuse (0, ≤6, 7–12, 13–24, 25–60, >60 months) and duration of emotional abuse (0, ≤6, 7–12, 13–24, 25–60, >60 months). Covariates Additional data collected by maternal report on the IPV-exposed group included the child’s age and sex, household income, parental occupation, number of parents in the household, mother’s symptoms of depression, maternal alcohol abuse, and severity and duration of maternal IPV. Maternal depression. We used the 20-item Center for Epidemiologic Studies of Depression Scale (CES-D) to assess maternal depressive symptoms (Radloff, 1977). Participants were asked to report responses to CES-D items for the 1-week period prior to the interview. Responses were based on a 4-point Likert scale ranging from “rarely or none of the time” to “most or all of the time.” Depression was categorized as a dichotomous yes/no variable using a CES-D total cutoff score of 16 or greater. The CES-D has been reported to have high internal consistency and to discriminate well between inpatient and general population samples (Radloff, 1977; Schulberg et al., 1985). NET alcohol screen. The 3-item NET (Normal-Eyeopener-Tolerance) scale was used to measure problem drinking among mothers in the year prior to the index incident of intimate partner abuse (Bottoms, Martier, & Sokol, 1989). The scale comprises two dichotomous (yes/no) questions to measure self-opinion on whether each mother felt she was a “normal” drinker and whether she ever drank in the morning to steady her nerves or in response to a hangover. The purpose of the third question was to arrive at a measure of alcohol tolerance by questioning the number of drinks required to feel intoxicated. Problem drinking was defined as having an

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affirmative response to either of the first two questions or a tolerance level at or above three drinks. This measurement scheme for the NET has been found to compare favorably with other brief screening measures. Russell et al. (1994) report sensitivity of 71% and specificity of 86% for this measure relative to a gold standard measure of risk drinking based on the Bowman, Stein, and Newton (1975) interpretation of the timeline follow-back procedure (Russell et al., 1994). Socioeconomic status. Family socioeconomic status was defined using the Hollingshead 9-step scale for parental occupation (Hollingshead, 1975). To be comparable to the SES data available for the CBCL normative sample, we used the higher of the two parental occupation scores if both parents were employed, and grouped SES data into lower (occupation score of 1–3.5), middle (4–6.5), and upper (7–9) SES levels.

Analysis Multiple logistic regression was used to compute the relative risk estimates of behavior problems associated with a child’s exposure to maternal abuse by an intimate partner, in the presence and the absence of child maltreatment, relative to the CBCL normative sample. Because child maltreatment data were not available on the CBCL normative sample, we treated child maltreatment (coded as a dichotomous yes/no variable) as a second level of exposure among children exposed to maternal IPV, and considered all normative children to be unexposed to child maltreatment. Separate risk estimates were calculated for children exposed to maternal IPV who were not victims of child maltreatment and those who were exposed to both maternal IPV and child maltreatment. Because most of our outcomes were not rare occurrences, we used the odds ratio correction methods described by Zhang to provide a more reliable measure of the relative risk (Zhang & Yu, 1998). We tested for significant differences in the effect of IPV by age and sex and found that odds ratios did not vary significantly by either factor; therefore, we calculated summary odds ratios for each level of exposure after adjusting for age and sex. Likelihood ratio statistics were used to determine the statistical significance of the exposure–outcome relationship. We categorized the child’s age, race, and socioeconomic status to be comparable to the categories used to describe the CBCL normative sample (Achenbach, 1991a, 1991b). To examine the contribution of type, severity, and duration of maternal IPV to each outcome of interest, we added the following categorical variables to a model that contained age, sex, child maltreatment, and a dichotomous maternal IPV exposure variable: severity of maternal IPV-related physical abuse (none, minor, severe) and emotional abuse (none, minor, severe) in the year prior to WWS enrollment, and duration of maternal IPV-related physical abuse and psychological aggression. Duration of maternal IPV (<6, 7–12, 13–24, 25–60, >60 months) was reported by the subjects’ mothers. We did not assess the contribution of these factors to the rarer outcome of poor social competence due to insufficient sample size. To evaluate whether confounding by socioeconomic status among the IPV-exposed children could explain the associations between IPV and behavior problems, we performed a subanaly-

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sis that assessed the prevalence of behavior problems within subgroup of IPV-exposed children living in higher income households (annual incomes ≥$35,000; n = 36) relative to all children in the comparison group.

Results Study population IPV-exposed and CBCL comparison children differed in terms of sociodemographics (Table 1). The IPV group was more likely to be of non-White race, and of lower socioeconomic status than the CBCL normative population. Additional data available on the IPV-exposed group indicated that 78.5% of their mothers experienced physical abuse in the past year, with the majority of those having experienced severe acts of physical violence (Table 2). Almost all mothers of IPV-exposed children reported having experienced some form of psychological aggression in the past year, and 80.8% experienced severe psychological aggression. Additionally, more than three quarters of the study mothers reported a history of either physical and/or emotional abuse of at least 1 year’s duration, with more than half of those having experienced this abuse for 5 years or more. Concurrent problems of depression and alcohol abuse were identified among many of the women. Almost 60% showed symptoms of severe depression Table 1 Demographic characteristics of IPV-exposed and CBCL comparison children IPV-exposed (n = 167)

CBCL comparison (n = 2736)

n (%)

n (%)

Age (years) 2–3 4–11 12–18

33 (19.8) 97 (58.1) 37 (22.2)

368 (13.5) 1200 (43.9) 1168 (42.7)

Sex Female Male

79 (52.7) 88 (47.3)

1407 (51.4) 1329 (48.6)

Race/ethnicitya White Black Hispanic Other

48 (30.4) 52 (32.9) 22 (13.9) 36 (22.8)

2018 (73.8) 444 (16.2) 180 (6.6) 94 (3.4)

Hollingshead parental occupational statusa Upper 33 (19.8) Middle 84 (50.3) Lower 50 (29.9)

953 (34.8) 1193 (43.6) 590 (21.6)

Characteristic

a

Sample sizes for the CBCL comparison group were estimated from published data that were rounded to the nearest whole percent.

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Table 2 Additional characteristics of IPV-exposed children (n = 167) Characteristic

n (%)

Mother’s education Less than high school High school graduate Some college/post-high school College graduate/advanced degree

20 (12.0) 48 (28.7) 73 (43.7) 26 (15.6)

Single parent household

88 (47.3)

Severity of maternal IPV-related physical aggression None Minor Severe

36 (21.6) 29 (17.4) 102 (61.1)

Severity of maternal IPV-related psychological aggression None Minor Severe

3 (1.8) 29 (17.4) 135 (80.8)

Duration of maternal IPV-related physical abuse (years) <1 1 to <5 ≥5

51 (32.9) 54 (34.8) 50 (32.3)

Duration of maternal IPV-related emotional abuse (years) <1 1 to <5 ≥5

44 (27.0) 56 (34.4) 63 (38.7)

Maternal depressive symptoms None (CES-D score <16) Minor (CES-D score ≥16 and <27) Severe (CES-D score ≥27)

27 (16.2) 40 (24.0) 100 (59.9)

Maternal alcohol problems (NET score ≥1)

42 (25.8)

Reported child maltreatment

24 (14.4)

(CES-D cutoff of 27 or greater), and over 25% were positive for at least one indicator of alcohol abuse on the NET. Internalizing behavior The relative risk of borderline to clinical levels of internalizing behavior problems associated with exposure to maternal IPV without concomitant child maltreatment was slightly but nonsignificantly elevated (RR = 1.3, 95% CI: .9–1.7) (Table 3). Children exposed to both IPV and child maltreatment were more than twice as likely to have a borderline to clinical level score on the internalizing behavior scale compared to CBCL comparison children (RR = 2.6, 95% CI: 1.5–3.6).

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Table 3 Relative risk of borderline to clinical level CBCL scores among IPV-exposed children by child maltreatment history relative to CBCL comparison children CBCL scale

Internalizing behaviors Externalizing behaviors Poor social competenceb Total behavioral problems

Exposed to maternal IPV only (n = 143)

Exposed to maternal IPV and child maltreatment (n = 24)

n (%)

RRa

95% CI

n (%)

Rra

95% CI

33 (23.1) 42 (29.4) 5 (7.1) 37 (25.9)

1.3 1.6 1.2 1.4

.9–1.7 1.2–2.1 .5–2.9 1.1–1.9

11 (45.8) 13 (54.2) 0 9 (37.5)

2.6 3.0 0 2.1

1.5–3.6 1.9–4.0 – 1.2–3.2

a

Relative to normative children after adjusting for age and sex. Social competence measured only among subjects aged 6–18 years (n = 70 for those exposed to maternal IPV only, n = 13 for those exposed to maternal IPV and child maltreatment, and n = 2116 for normative group). b

Externalizing behavior In contrast to the findings regarding internalizing behavior problems, children in both IPV-exposed groups were significantly more likely to score in the borderline to clinical level range on the externalizing behavior scale. We found children exposed to IPV only to be 1.6 times as likely (95% CI: 1.2–2.1) and children exposed to both IPV and child maltreatment to be 3.0 times as likely (95% CI: 1.9–4.0) to score in the borderline to clinical level range on externalizing behaviors relative to CBCL comparison children. Poor social competence We found no evidence of a significant association between poor social competence and exposure to maternal IPV (RR = 1.2, 95% CI: .5–2.9). None of the children exposed to both maternal IPV and child maltreatment received social competence scores in the borderline to clinical range. Total behavioral problems Children exposed to maternal IPV, without concomitant child maltreatment, were 40% more likely to have a total behavioral problem score within the borderline to clinical range than CBCL normative children (RR = 1.4, 95% CI: 1.1–1.9). Children who experienced both IPV and child maltreatment even more likely to receive scores indicating a high level of total behavioral problems (RR = 2.1, 95% CI: 1.2–3.2). Analysis of the contribution of type, severity, and duration of maternal abuse In evaluating the contribution of type, severity, and duration of IPV on children’s behaviors, we found only duration of physical abuse added to the effect of IPV exposure. Children exposed to long-term maternal physical IPV were significantly more likely than those with shorter term exposure to exhibit borderline to clinical levels of total behavioral problems (Table 4).

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Table 4 Relative risk of borderline clinical to clinical level score for total behavioral problems among IPV-exposed children relative to CBCL normative children by duration of physical abuse and child maltreatment history Duration of maternal IPV <6 months 6 months to ≤1 year >1 to <5 years 5 years or more

Exposed to maternal IPV only (n = 132)a

Exposed to maternal IPV and child maltreatment (n = 23)a

n (%) with outcome

RRb

95% CI

n (%) with outcome

RRb

95% CI

7 (21.2) 1 (7.1) 11 (26.8) 17 (38.6)

1.1 1.1 1.5 2.9

.5–2.3 .3–4.1 .7–2.9 1.6–5.2

2 (25.0) 2 (66.7) 1 (16.7) 3 (50.0)

1.7 1.8 2.3 4.5

.6–4.8 .4–7.7 .8–6.7 1.6–12.6

Excludes those subjects missing data for duration of maternal IPV (n = 11 for those exposed to maternal IPV only; n = 1 for those exposed to maternal IPV and child maltreatment). b Relative to normative children after adjusting for age and sex; test for trend p = .03; model estimates are based on dummy variable version of duration of maternal physical IPV; using Zhang correction for RR approximation by an OR with a common outcome. a

Furthermore, relative risk estimates were greater for exposed children with a history of child maltreatment than for children exposed to maternal IPV only at each level of maternal IPV duration. Contribution of socioeconomic status In a subanalysis that limited our IPV-exposed group to children from households with incomes of at least $35,000, the proportion of children with scores in the borderline to clinical level range on all four CBCL scales was as high or higher than that for the sample as a whole. We found that after removing children at risk of behavioral difficulties due to socioeconomic disadvantage from our analysis (IPV-exposed children from households with <$35,000 annual income), high problem scores were still common within the remaining, relatively socioeconomically advantaged group. Specifically, within this subset, 25.0, 27.5, 14.3, and 30.0% of non-abused IPV-exposed children scored in the borderline to clinical range on the internalizing, externalizing, social competence, and total behavioral scales, respectively.

Discussion Using the CBCL normative sample as a reference group, we found significant positive associations between children’s exposure to maternal IPV and borderline to clinical level scores on the CBCL scales that measure externalizing behaviors and total behavioral problems. These findings confirm those of prior work, but importantly, do so in the context of a more representative sample from which we were able to provide risk estimates separately for IPV children with or without concomitant child maltreatment relative to the normative population (Fantuzzo et al., 1991; Jaffe et al., 1986a, 1986b; O’Keefe, 1994; Rossman & Rosenberg, 1992). Among children who were also victims of child maltreatment, relative risk estimates were of greater magnitude and were significantly elevated for internalizing behaviors as well.

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The association that we found between children’s exposure to maternal IPV and internalizing behaviors was consistent with prior studies in that the relative risk estimate was elevated, but it did not achieve statistical significance in the absence of a joint exposure to child maltreatment (Christopoulos et al., 1987; Cummings et al., 1999; Fantuzzo et al., 1991; Holden & Ritchie, 1991; Jaffe et al., 1986a, 1986b; O’Keefe, 1994). We did not find a significantly greater proportion of exposed children to have poor social competence. In agreement with the studies that have reported on total behavioral problems associated with children’s exposure to maternal IPV, we found a significantly greater proportion of children to score within the borderline to clinical range on the total behavioral problems scale of the CBCL (Christopoulos et al., 1987; Davis & Carlson, 1987; Holden & Ritchie, 1991; Hughes et al., 1989; Jaffe et al., 1986b; Kolbo, 1996). Our calculations of crude relative risks for clinical level behavioral problems based on previously published studies indicate our estimates of association are more conservative than those reported previously (Christopoulos et al., 1987; Davis & Carlson, 1987; O’Keefe, 1994; Sternberg et al., 1993; Wolfe et al., 1985). We were able to calculate estimates of the crude relative risks for clinical level internalizing behaviors and clinical level externalizing behaviors associated with IPV exposure from three prior studies. We found the estimates from these prior studies to be 1.3, 3.3, and 5.7 for internalizing behaviors and 1.9, 2.1, and 4.5 for externalizing behaviors (Christopoulos et al., 1987; O’Keefe, 1994; Sternberg et al., 1993). The crude relative risk we obtained from the present study when we limited our outcome to clinical level internalizing behavior scores was 1.3, identical to that of Sternberg et al. Our estimate increased slightly to 1.4 with the inclusion of children who were also victims of child maltreatment. The relative risk for clinical level externalizing behaviors obtained in our study was 1.5 for children exposed to IPV only and 1.8 for the group as a whole (with and without child maltreatment). Because two of the three earlier studies did not provide data allowing for the calculation of separate relative risk estimates by child maltreatment status, we would expect these estimates to be elevated compared to relative risk estimates obtained from our analysis of non-abused IPV-exposed children. However, our relative risk estimates were still lower than those of prior studies that did not account for child maltreatment, even after combining non-abused and abused IPV-exposed children in our calculations. Because the shelter populations represented by earlier studies tended also to have much higher prevalence of child maltreatment among IPV-exposed children compared with the general population used in our study, the estimates from prior studies would be expected to remain elevated by comparison because they are more heavily weighted with child maltreatment victims than our sample. For example, estimates of the prevalence of child maltreatment among the IPV-exposed populations utilized in these studies have ranged between 26 and 97%, compared to 14% found in the current study (Christopoulos et al., 1987; Davis & Carlson, 1987; Hughes, 1988; Hughes et al., 1989; Kolbo, 1996). There are two likely explanations for the lower child maltreatment estimates found in our study. First, our estimates of child maltreatment are likely conservative compared to those that would have been obtained by maternal report. Second, many of the characteristic differences in shelter populations relative to general populations of IPV families also place shelter populations at much greater risk of co-occurring child maltreatment. The results from studies using shelter populations are likely not generalizable to the majority of IPV-exposed children for other reasons as well (Edleson, 1999). Several factors related to

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living at a battered women’s shelter may negatively affect children’s behavior and therefore result in upwardly elevated estimates of risk of children’s behavioral problems relative to the general population of IPV-exposed children. These include being in an actively abusive phase of the relationship, being exposed to more severe violence, having fewer financial and social resources, and experiencing acute distress due to relocation (Wolfe et al., 1986). We were also able to calculate crude relative risk estimates for clinical level total behavioral problems from two additional prior studies of children from battered women’s shelters (Davis & Carlson, 1987; Wolfe et al., 1985). From the data provided from these earlier studies, we calculated crude relative risk estimates of 2.5 and 7.0 for non-abused IPV-exposed and abused IPV-exposed children combined. This compares to crude estimates from our study of 1.8 when limiting to non-abused IPV-exposed children and 1.9 when including both abused and non-abused IPV-exposed children. Over 50% of the IPV-exposed children in the study with the relative risk of 7.0 were also victims of child maltreatment. Additionally, selection bias may have been a problem for this study in that mothers chose which of their children served as the study subject in families with more than one child. Lending credence to this concern, some women from our study volunteered to study interviewers that they wished to report on the behavior of one of their other children rather than the randomly assigned child we sampled because they believed that child was more affected by the abuse. We avoided this bias by maintaining the random sampling scheme. There has been an ongoing discussion in the literature about the possibility of maternal depression contributing to bias in reports of child behavior. However, no consistent pattern has arisen to substantiate these concerns. In support of the validity of our maternally reported findings, we found, in a related study of school-aged children of WWS participants, significantly more externalizing problem behaviors based on school records of academic suspension and frequent absenteeism among IPV-exposed children relative to comparison children (Kernic et al., 2002). Although our sample was more broadly representative of children of abused women than samples drawn from battered women’s shelters, it was nonetheless limited to children of women whose abuse was reported to the police or court system. It is conceivable that the effects of intimate partner abuse on children differ by whether that abuse is reported, which would necessarily affect the generalizability of our results. Results from the National Crime Victimization Survey (NCVS) suggest that reporting an incident to the police is more likely among IPV victims whose abuse results in injury (55% of injured victims reported to the police vs. 46% of non-injured) (Bachman & Saltzman, 1995). If reported IPV is more severe than unreported IPV, and severe IPV negatively impacts children’s behavior more than less severe IPV, our estimates of child behavior problems may be greater than those that would be observed had families of unreported IPV also been included in our sample. A related limitation of this study is the possibility of misclassification of exposure. Neither maternal IPV nor history of child maltreatment was available on the CBCL normative sample. In the analyses reported here, we assumed no exposure to either of these factors in the normative sample, when, in truth, some of these children are likely to have had one or both exposures. This type of misclassification would result in a slight underestimate of the risk of adverse behavioral outcomes associated with children’s exposure to their mother’s abuse by an intimate partner. For example, we calculated, using an observed estimate of police-reported IPV in Seattle (i.e.,

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33.5 per 1000 women-years) and the NCVS estimate that 50% of IPV is reported to police, that our risk estimate for externalizing behaviors was underestimated by approximately 5% due to this type of misclassification. In this study, we used the CBCL normative sample rather than a local comparison group for which socioeconomic status could be directly assessed. Because no published data are available for the frequency of clinical level scores among the CBCL normative sample by socioeconomic status, we were limited in our ability to adjust for socioeconomic status in our analyses. As a result, our estimates were potentially elevated since the IPV-exposed sample was of lower SES than the CBCL normative sample, and lower SES has been associated with poorer performance on the CBCL (Raadal, Milgrom, Cauce, & Mancl, 1994). However, confounding by SES is an unlikely explanation of our significant results since we found comparable or higher proportions of IPV-exposed children to score in the borderline to clinical level ranges on each CBCL scale when we limited our analysis to IPV-exposed children from households with annual incomes of $35,000 or more. Additionally, lower SES may be a consequence of IPV (for instance, victimized mothers have separated from their abusers), therefore, controlling for SES would be inappropriate. We chose explicitly not to adjust for factors, such as maternal depression or alcohol abuse, which might have been a consequence of abuse. This choice was made because it was our intention to measure the entire effect of maternal IPV on child behavior rather than its effect above and beyond mediating factors such as these. These findings provide significant evidence of the association between children’s exposure to maternal IPV, with or without a history of reported child maltreatment, and the occurrence of behavioral problems. An important direction for future research will be to focus on the identification of factors that serve to mediate the relationship between IPV exposure and behavioral problems, thereby directing research on the development of effective interventions with these children. Our results indicate that appropriate attention to the mental health needs of children exposed to IPV, with or without the presence of child maltreatment, is strongly warranted.

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Résumé Objectifs: Examiner s’il y a une relation entre le fait pour des enfants d’avoir été exposés à la violence entre leur mère et un partenaire intime (IPV) et la présence de troubles de comportement mesurés par le témoignage parental au Child Behavior Checklist (CBCL).

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Méthode: La population étudiée était constitutiée de 167 enfants de 2 à 17 ans dont les mères résidant à Seattle avaient signalé des abus à la Police ou au Tribunal. La population normale du CBCL a servi de groupe de comparaison. Le risque de problèmes de comportement a été calculé auprès des enfants exposés, selon la présence ou l’absence de signalements pour mauvais traitements par rapport à la population normale. La méthode principale d’analyse a été la régression multiple. Résultats: Les enfants exposés à la violence subie par leur mère (IPV) ont semblé plus susceptibles de présenter des scores de niveau limite à cliniquement évidents pour le comportement extériorisé (I.E. agressif ou délinquant) (RR = 1.6, 95% CI: 1.2, 2.1) ainsi que des comportements globalement à problèmes (RR = 1.4, 95% CI: 1.1, 1.9) par comparaison avec l’échantillon normal au CBCL après correction pour l’ˆage et le sexe. Les enfants exposés et qui ont été victimes de mauvais traitements ont semblé plus susceptibles de présenter des scores de niveau limite à cliniquement évidents pour les comportements internalisés (anxiété, dépression) (RR = 2.6, 95% CI: 1.5, 3.6), extériorisés (agressif, délinquant) (RR = 3.0, 95% CI: 1.9, 4.0) et les problèmes généraux de comportement (RR = 2.1, 95% CI:1.2, 3.2) par comparaison avec l’échantillon normal après correction pour l’ˆage et le sexe. Conclusion: Etre exposé à la violence subie par leur mère de la part d’un partenaire intime est associé de façon significative à des problèmes de comportement qu’il y ait eu ou non en mˆeme temps chez ces enfants des mauvais traitements. Il faut donc accorder de l’attention à la santé mentale des enfants vivant dans les foyers où il y a IPV.

Resumen Objetivo: Determinar la asociación entre la exposición de los niños a episodios de violencia doméstica (VD) y los problemas de conducta medidos con la versión para padres del CBCL. Método: La muestra del estudio se compuso de 167 madres de niños/as de entre 2 y 17 a9 A os que viv´ıan en Seattle y que hab´ıan notificado a la polic´ıa o a la justicia un episodio de violencia doméstica. Las puntuaciones normativas del CBCL sirvieron como grupo de comparación. Se calculó el riesgo de presentar problemas de conducta entre los niños expuestos en relación a la puntuación de la población normativa y teniendo en cuenta la presencia o ausencia de una historia de notificaciones de maltrato infantil. El principal método de análisis fue la regresión log´ıstica múltiple. Resultados: Los niños expuestos a VD ten´ıan más tendencia a presentar puntuaciones l´ımite o cl´ınicas en conducta (e.j., delincuencia y agresiones) externalizada (RR = 1.6; 95% CI: 1.2, 2.1) y en el total de problemas de conducta (RR = 1.4, 95% CI: 1.1, 1.9) comparados con las puntuaciones de la muestra normativa en el CBCL después de haber ajustado el género y la edad. Los niños que fueron expuestos a VD y fueron v´ıctimas de maltrato infantil ten´ıan más tendencia a presentar puntuaciones l´ımite o cl´ınicas en conducta (e.j., ansiedad y depresión) internalizada (RR = 2.6; 95% CI: 1.5, 3.6), conductas externalizadas (RR = 3.0; 95% CI: 1.9, 4.0) y en el total de problemas de conducta (RR = 2.1, 95% CI: 1.2, 3.2) comparados con las puntuaciones de la muestra normativa en el CBCL después de haber ajustado el género y la edad. Conclusiones: La exposición a la violencia doméstica está significativamente asociada con problemas de conducta en la infancia tanto en presencia como en ausencia de maltrato infantil. Se necesita una atención adecuada a los problemas de salud mental de los niños que viven en hogares donde se produce exposición a situaciones de violencia doméstica.