Impact of Intimate Partner Violence on Children

INTRODUCTION

The World Health Organization defines intimate partner violence (IPV) as “behavior within an intimate relationship that causes physical, sexual or psychological harm”.¹ It is estimated that IPV affects 1 in 4 women in the United States (US), and that approximately 1 in 4 children will experience caregiver IPV during their lifetime (including witnessing, hearing, or otherwise being present).^2–4 Over 15 million US children are reported to be living in households with IPV in the past year, and children are reported present in 50% to 75% of IPV events reported to the police.^5–7 Exposure to and victimization from IPV are major public health concerns.

Individuals from structurally marginalized groups are disproportionately at higher risk of experiencing IPV, with social identity often intersecting with systems of oppression (e.g., racism, sexism, poverty, transphobia, and classism) to inform experiences of IPV, society’s responses to IPV, and victim’s help-seeking behaviors.^8,9 In a systematic review of help-seeking behaviors among African American women IPV survivors, authors found that survivors often defer engaging with the criminal justice system because they perceive they will neither be believed nor fully supported. When seeking help from the criminal justice system, survivors often receive delayed or inadequate assistance from law enforcement.^10–12 Ethnic minorities and immigrant women IPV survivors face barriers to seeking services such as immigration laws, fear of deportation, culture, religion, issues of cultural competence, and lack of diversity among frontline providers.^13,14 Poverty and IPV are tightly intertwined with compounding negative effects leading to increases in stress, powerlessness, and social isolation. These effects are magnified when other aspects of women’s identities are marginalized.¹⁵

DISCUSSION

Effects of Intimate Partner Violence Exposure In Utero and to the Mother–Infant Dyad

Pregnancy is a particularly high-risk period for IPV exposure. A meta-analysis of 92 studies from 23 countries examining IPV during pregnancy found percentages of emotional abuse of 28.4%, physical abuse of 13.8%, and sexual abuse of 8%.^16–18 In the US, it is estimated that between 3% and 9% of pregnant woman experience physical IPV.¹⁹

Potential harms to the pregnant person and growing fetus include physical trauma and dysregulation of the maternal hypothalamic–pituitary–adrenal (HPA) axis.²⁰ Studies have shown that HPA axis dysregulation throughout pregnancy may be harmful for both maternal mental health and fetal development.^21,22 More specifically, cortisol, which regulates the HPA axis, may be released, leading to alterations of the uterine environment.²³ This may lead to preterm birth and low birth weight, as well as overall poorer health and development of fetuses and infants.^23,24

Additionally, preconception and/or prenatal IPV may affect prenatal care utilization, with one study finding that women who experienced prenatal or preconception IPV were 30% more likely to have inadequate prenatal care.²⁵ IPV during pregnancy may also contribute to inadequate mother–infant bonding.²⁶ Mothers experiencing IPV often feel indifference, reduced affection, rejection, hostility, anger, or even impulses to harm the baby.^26,27 One theory states that victims of IPV may experience mental health conditions, including post-traumatic stress disorder, which impact parenting behaviors and subsequent maternal–infant bonding.²⁸ Similarly, IPV may lead to maternal stress, depression, low self-esteem, and anxiety, which can negatively impact parental capacity and attachment.²⁹ A recent scoping review of prenatal IPV exposure and child developmental outcomes demonstrated adverse effects on psychological, behavioral, physical health, and physiologic outcomes.³⁰ Further research is needed to understand the effects of prenatal IPV on social and cognitive outcomes.³⁰

Children’s Experiences with Intimate Partner Violence

The Violence: Impact on Children Evidence Synthesis (VOICES) study synthesized existing qualitative literature and provided a child-focused account of children’s lived experiences of IPV.³¹ In this systematic review, authors described children’s experiences with violence that ranged from shouting between parents, witnessing items being thrown, and acts of physical abuse toward a caregiver and themselves to witnessing a parent being killed by another parent. They also described the varied responses of children to the IPV, including shying away (eg, turning up the music or wearing headphones to mask the violence), interrupting (eg, intervening to protect the abused parent), watching, or being obstructed from participating. Older siblings often distracted the younger siblings from the violence or demonstrated protective behaviors toward siblings, caregivers, and animals.

Effects of Intimate Partner Violence Exposure on Child Well-being

It is not surprising that children’s experiences of IPV between caregivers are associated with long-term impacts on a child’s emotional and behavioral health. For example, children are more likely to have internalizing behaviors including anxiety, depression, withdrawal, and somatic complaints. Externalizing symptoms are also seen, including attention difficulty, aggressive behaviors, and rule-breaking or disruptive actions complaints.^4,32–34 IPV exposure is also associated with developmental delay, poor academic performance, and challenges with social functioning.^4,32–34

IPV exposure has also been linked to a variety of health and developmental concerns. Children who have experienced IPV are less likely to receive appropriate preventative care, placing them at risk for under immunization.³⁵ In their study, Gartland and colleagues found that one-third to one-half of the children with a language delay, mental health diagnosis, or physical health problem had experienced caregiver IPV. They noted that children who had earlier exposure to IPV had increased language problems at age 10 years. They also noted children exposed to IPV were more likely to have asthma, allergies, and obesity.³⁴ It is difficult to gain a full understanding of the effects of IPV exposure in infancy and childhood, as results of studies may be affected by the chronicity of the IPV, the type or severity of IPV, measurement parameters used, and confounding factors such as additional adverse childhood experiences (ACEs).

Co-occurrence of Intimate Partner Violence and Child Maltreatment

Children who witness IPV may be at increased risk for various forms of child maltreatment. A review article by Jouriles and colleagues noted that the rates of child physical abuse within 1 year of an IPV incident varied considerably from 18% to 97% depending on the physical abuse definition used.³⁶ Proposed explanations for perpetration of abuse toward the child included adult tendency toward aggressive behavior, stress, the spillover hypothesis (suggesting that one form of abuse leads to other forms of abuse) or acombination of the aforementioned.³⁶ Sayrs and colleagues examined risk factors for abusive head trauma and found that IPV increased the odds of abusive head trauma by 2 fold.³⁷ One study found higher rates of re-reporting to Child Protective Services (CPS) for lack of supervision among mothers who report IPV.³⁸ Mothers who reported IPV also were less likely to report routine well-child care and more likely to self-report medical neglect compared to mothers who did not report IPV.³⁹ Sexual abuse among children exposed to IPV has also been noted, with one study finding that 5% of child IPV witnesses disclosed sexual abuse.⁶

Identification and Detection of Injuries in Children with Intimate Partner Violence Exposure

Few studies have examined the frequency of injuries when children experiencing parental IPV present for a medical evaluation.^3,40–42 One study described inadvertent physical injuries in 139 IPV-exposed children ranging from 2 weeks to 17 years of age who presented to one pediatric emergency department (ED) over a 10 year period.⁴⁰ Children who did not sustain injuries were not included. In this study, children sustained a wide spectrum of physical injuries without any specifically identifiable patterns. The study could not provide data about the frequency of injuries in all IPV-exposed children seeking care, and the results of occult injury testing were not evaluated.

In another small study specifically examining the yield of occult testing in 61 IPV-exposed children less than 10 years of age for whom a child abuse pediatrician was consulted, authors found that 59% had injuries identified.⁴¹ Almost half of these injuries were occult and detected only by radiographs. Among the 15 children who had internal injuries including fractures, intracranial hemorrhage, or intra-abdominal injury, 14 children were less than 12 months old. However, given that a child abuse pediatrician had to be consulted to be included in this study, the cohort in the study was not representative of all IPV-exposed children receiving medical care.

Finally, in a third study, the authors examined the frequency of abusive injuries in children less than 3 years of age reported to CPS for IPV exposure whose caregivers agreed to a voluntary medical evaluation for the child.⁴² Of 90 children evaluated over 3 years, only 3 children (3.3%, 95% CI 0.7–9.4) were found to have cutaneous injuries, fractures, and/or intracranial findings. Each child was less than 6 months old, and only one child was found to have occult injuries. In this study, however, skeletal surveys were ordered with parental consent, and only 54% of the infants in the study had skeletal surveys performed.⁴²

The current literature provides incomplete guidance on the risk of abusive injury in the context of IPV, and while children less than 1 year old seem to be at highest risk, a more definitive study needs to be done to examine risk factors. A large multi-center study that examines both the frequency of abusive injuries in IPV-exposed children and the factors that enhance risk can help guide recommendations about evaluation for occult injury in this population.

Interventions

Home visiting

Home visiting (HV) is a multigenerational, curriculum-based, structured intervention to support parenting for pregnant women and/or families with young children (most commonly <3 years of age). Home visitors meet with families in their homes on a regular and frequent basis to develop relationships, provide support, and teach techniques and strategies to improve child health and family well-being.⁴³ Specifically, HV aims to improve maternal and child health, prevent abuse and neglect while promoting positive experiences, reduce crime and domestic violence, increase family education level and earning potential, promote children’s development and school readiness, and connect families to community resources and supports.^44,45 HV is both free and voluntary for families.

Since 2010, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program has provided federal funds to states, territories, and tribal entities with a focus on serving communities and families most at risk for poor outcomes.⁴⁴ Additionally, states typically provide significant additional funding for HV. Given the significant investment and reach of HV, there is great potential to address family and societal stressors, including violence and abuse. However, the success of programs is often dependent on home visitor training, strength of the curriculum, and reliability of delivery, among other factors.^45–48 As such, evidence of the effectiveness of HV is inconsistent.

Over the past few decades, HV programs have identified a unique opportunity to screen for and identify IPV. Multiple programs have created universal screening guidelines and interventions.^49–52 Table 1 provides a description of these programs.

Table 1.

Home visiting programs with intimate partner violence-based interventions

HV Program	Intervention	Outcome	References
Nurse Family Partnership	Training curriculum and coaching support for home visitors, manualized intervention for IPV, guidelines for reflective supervision, and site readiness checklist	Both groups had improvements in quality of life but no differences in secondary outcomes including IPV, posttraumatic stress, depression, substance use, and physical and mental health	Jack et al,49 2012 and Jack et al,55 2019
Domestic Violence Enhanced Home Visitation Program	Brochure-based intervention that included danger and level of readiness of IPV victims	There was a larger decrease in violence at 24 mo compared to HV alone	Sharps et al,50 2016
VoorZorg	Emphasis on stress reduction, financial independence, housing assistance, the Power and Control wheel, IPV consequences for children, and emotional support	There was a significant reduction in victimization and perpetration in the intervention group both during pregnancy and 24 mo after birth	Mejdoubi et al,51 2013
Hawaii Healthy Start Program	Connection to community services such as IPV shelters and groups, emotional support and problem solving at home visits	There was a reduction in maternal IPV victimization and perpetration for child’s first 3 y of life, but showed no significant difference in long-term follow up	Bair-Merritt et al,52 2010

Abbreviations: HV, home visiting; IPV, intimate partner violence.

A systematic review assessing HV IPV interventions showed 3 of the 6 programs had a statistically significant reduction of IPV in the short term. The programs that used IPV-specific interventions yielded significant improvements in contrast to the programs offering standard HV services.⁵³ Olds and colleagues looked at long-term outcomes on standard HV practices in Nurse–Family Partnership and found no impact on IPV reported by mothers in the program when their child was 9 to 12 years old.⁵⁴ Sharps and colleagues⁵⁰ found that those who received Domestic Violence Enhanced Home Visitation Program had a larger decrease in violence at 24 months when compared to those who experienced HV alone. However, other HV programs noted limitations in their implementation of the IPV interventions, which most likely contributed to mixed results.⁵⁵ Furthermore, although the evidence is mixed, HV has been shown to reduce child maltreatment in multiple studies.^56–58

HV is a promising program to improve early identification of those experiencing IPV and supporting victims. To reach its full potential in detecting and addressing IPV, HV may require more standardized interventions that demonstrate improvements in IPV over time, trainings that increase confidence of the home visitors in addressing IPV, and local/regional tools to support and provide resources to families experiencing IPV.⁵⁹

Confidentiality, universal education and empowerment and support

Current approaches including universal screening and disclosure-based provision of resources for IPV inadequately identify victims of IPV, thus preventing an opportunity for engagement and support.^5,60–62 Additionally, trials examining the impact of universal screening of women have not demonstrated differences in the reduction of IPV or improvement in quality of life in screened versus non-screened patients.⁶³ In fact, women who have experienced IPV often do not disclose IPV to health care providers for many reasons, including concerns about privacy, fear of judgment, mandated reporting, and language and cultural barriers.^64,65

The Confidentiality, Universal Education and Empowerment and Support (CUES) framework (Fig. 1) developed by Futures without Violence has been demonstrated to be acceptable and feasible.⁶⁶ CUES aims to promote survivor empowerment and autonomy by deprioritizing disclosure and providing resources about IPV to all women. CUES has also been associated with women being 60% more likely to end a relationship that felt unsafe and reductions in reproductive coercion.^67–69 Guidelines from the American Academy of Pediatrics now recommend a universal education and empowerment approach for IPV.⁴

Fig. 1.

Confidentiality, Universal Education and Empowerment and Support (CUES) framework.

Clinic-based services

The health care setting provides a unique venue for pediatric clinicians to provide integrated services for caregiver victims and their children. The Addressing Wellbeing through Advocacy, Knowledge, and Empowerment (AWAKE) is a children’s hospital-based, comprehensive program for caregiver victims that connects caregivers to IPV services during children’s visits.⁷⁰ Rahman and colleagues found that the AWAKE program continued receiving referrals even during the COVID pandemic, suggesting the importance of the pediatric health care setting as a potential source of IPV services for caregiver victims.⁷¹ Similarly, multidisciplinary, community-based approaches to IPV have a promising role. A particular example includes integrated medical-based and IPV-based services in a children’s advocacy center.^42,72

Special consideration: Child Protective Services reporting

While childhood experiences of caregiver IPV have numerous negative health impacts, and physical child abuse has been reported to co-occur in homes with IPV, there is little agreement on whether children should be reported to CPS after identified exposure to IPV alone. While identification of physical abuse or neglect of the child may lead to safety planning by CPS, non-abusive caregivers may be harmed through their own re-victimization, loss of custody, legal sanctions, or even escalation of IPV.^64,73 In a study of IPV survivors using the National Domestic Violence Hotline, half reported that mandatory reporting made their situation worse and one-third reported not disclosing IPV due to concerns about reporting.⁶⁴

Many state-based CPS policies recommend CPS investigators substantiate IPV-related reports based on a “harm or threat of harm threshold,” but no specific guidelines exist for clinicians when they care for children living with IPV.⁷⁴ In a study assessing IPV policy and standard practices of US children’s hospitals, authors found significant variability in the indications for CPS reporting, which were often subjective (eg, “if the child is deemed to be at risk”, or “if have significant concerns”).⁷⁵ In another study in which authors performed a Delphi review of experts in IPV and child abuse to determine best practices around reporting to CPS in the context of IPV, experts reached consensus on reporting when child abuse was clearly present but not for reporting based on children witnessing IPV, type of IPV, or impacts of child IPV exposure.⁷⁶ Lack of consensus or clarity on when to report to CPS in the context of IPV may introduce bias, as demonstrated in a study by Butala and colleagues that found increased odds of ED-based CPS reporting in the context of IPV among Hispanic patients even when adjusting for the nature of a child’s exposure to the IPV.⁷⁷

While pediatric clinicians may not be mandated to report to CPS for IPV alone, they may seek guidance from state laws and local policies.⁷⁸ Pediatric clinicians must assess whether there is harm or threat of harm to the child. An individualized assessment can occur through discussions with the caregiver and child (if verbal), medical record review and social work consultation if available. This may help clinicians determine whether the child has been injured during the violence, whether the abuser is preventing the caregiver from meeting a child’s needs, and whether the child has been negatively impacted by the IPV.

Best practices when making the CPS report are listed in Box 1. If the survivor caregiver is undocumented or the family has mixed immigration statuses, advocacy may be critical in exploring supports that the family can access immediately. When making the report, recommendations include assuring the child is not present and naming the abusive partner as the perpetrator of child abuse or neglect. Reporting to CPS may increase risk to the survivor caregiver and the child. Often an abusive partner will blame the caregiver survivor for causing CPS involvement, or may increase threats to tell CPS that the caregiver survivor is a bad parent. Among immigrants, abusers may increase threats about deportation and immigration, which may lead to concerns about seeking help in the future. Thus, it is important for clinicians to discuss concerns related to safety with caregiver survivors and encourage them to relay these to CPS so they can get the services they need to keep them and their children safe.

KEY POINTS.

• Maternal exposure to intimate partner violence (IPV) may adversely affect maternal–fetal bonding, fetal growth and development, and longitudinal childhood outcomes.

• IPV may co-occur with various forms of child maltreatment and lead to physical and emotional injury.

• Home visiting may provide a unique opportunity to assess and provide services for IPV.

• While IPV alone may not reach the threshold for reporting in some circumstances, pediatric clinicians may consider reporting to Child Protective Services when there is imminent harm or threat of harm to the child.

• A child’s visit can be leveraged to provide universal education about IPV and to start ongoing engagement with IPV-affected caregivers about safety and well-being.

Documentation

Discussions about IPV with the survivor caregiver must be thoughtfully and carefully documented in the medical record as discovery of a disclosure of IPV through health records may escalate violence in the home and lead to limitations in health care access for the survivor caregiver.^79,80 However, putting information about IPV in the health record may alert other providers working with the family for whom it might be important to know about this risk factor. Clinicians should understand who has access to the medical record as an abusive parent may have legal access to the child’s medical record if (s)he is a guardian. Documentation should be objective and brief. Any documentation about IPV should be shared with the IPV survivor caregiver. The 21st Century Cures Act, implemented in 2021, federally mandated the release of clinician notes to patients without charge or delay, raising concerns for victims of IPV whose abusers may have duplicitous or, in the case of children, legal access to the medical record.⁸¹ In a study performed in a pediatric and general ED examining note sharing behaviors for encounters related to IPV, authors found that electronic health record safety discussions were documented in only 28% of pediatric encounters and 84% of the notes were shared.⁸² The authors recommended discussions with survivor caregivers and shared decision-making around when to “unshare” notes through exceptions outlined by the Act, such as to prevent harm. If concerns around safety remain, clinicians may use code words or non-specific terms or consider documenting outside the medical record in a protected note type (eg, social work note). Best practice recommendations also assert that IPV should not be listed as a discharge diagnosis or billing code that is sent home and possibly viewed by the abuser.⁸⁰

Resiliency

Many children exposed to IPV do not experience any adverse symptoms or outcomes.⁸³ Therefore, identifying and promoting resiliency factors in the mother–child dyad has become an area of interest. Fogarty and colleagues⁸⁴ performed a systematic review and found that mother’s mental health may facilitate child resiliency. Furthermore, there are promising maternal–child dyad interventions that concurrently address maternal trauma, social support, and parenting strategies and childhood behavioral, emotional, and cognitive concerns.⁸⁵ Galano and colleagues⁸⁶ found that independent of these interventions, a child’s tendency toward anger, and maternal parenting and mental health affected childhood adjustment, and resiliency improved naturally over time. Further research should continue focusing on trauma-focused, comprehensive and dyadic approaches to caregiver victims and their children.

SUMMARY

IPV exposure and victimization are major public health concerns. Newer research into IPV exposure has shown potential adverse effects as early as the in utero period. There are also well-noted long-term effects on the mother–child relationship and a child’s physical, emotional, and mental health and well-being, including risk for subsequent child maltreatment. However, some children exposed to IPV may never experience these effects. Although trauma-focused universal education is the preferred intervention for caregiver victims, HV also provides promise. CPS reporting for childhood IPV exposure alone remains controversial given the potential negative implications to caregiver survivors and their children. Further research into childhood resiliency factors and development of primary preventive efforts may help to reduce these adverse effects.

Box 1.

Best practices when making a child protective services report

Inform survivor caregiver that a report will be made.

Discuss process of filing a CPS report.

Offer an opportunity for the survivor caregiver to participate or even initiate the report.

Offer to connect the survivor caregiver (using a warm-handoff) to an IPV advocate who can help with safety planning and resources.

Remain available to the survivor caregiver to address the family’s well-being.

Be thoughtful and carefully document discussions about IPV with the survivor caregiver in the medical record. Consider “unsharing” a note, using code-words or documenting in a protected note type to maintain safety.

Abbreviations: CPS, Child Protective Services; IPV, intimate partner violence.

Abbreviations

AWAKE

Addressing Wellbeing through Advocacy, Knowledge, and Empowerment

CPS

Child Protective Services

CUES

Confidentiality, Universal Education and Empowerment and Support

IPV

Intimate partner violence

HV

Home visiting