Published online January 4, 2006
PEDIATRICS Vol. 117 No. 1 January 2006, pp. 99-109 (doi:10.1542/peds.2004-2542)
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Female Caregivers' Experiences With Intimate Partner Violence and Behavior Problems in Children Investigated as Victims of Maltreatment

Andrea L. Hazen, PhDa,b, Cynthia D. Connelly, PhDa,c, Kelly J. Kelleher, MD, MPHd, Richard P. Barth, PhDe and John A. Landsverk, PhDa,f

a Child and Adolescent Services Research Center, Children's Hospital and Health Center, San Diego, California
b Department of Psychology
f School of Social Work, San Diego State University, San Diego, California
c Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
d Office of Clinical Sciences, Columbus Children's Research Institute, Columbus, Ohio
e School of Social Work, University of North Carolina, Chapel Hill, North Carolina


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. We examined the relationship between women's experiences with intimate partner violence and their reports of child behavior problems.

METHODS. Data were from the National Survey of Child and Adolescent Well-Being, a national probability study of children who were the subjects of child abuse and neglect investigations. The sample consisted of 2020 female caregivers of children between the ages of 4 and 14 years who were interviewed about demographic characteristics, child behavior problems, female caregiver mental health, parenting behaviors, experiences with intimate partner violence, and community characteristics. Information on child abuse and neglect was obtained in interviews with child protective services workers. Multiple-regression analyses were used to investigate the association between caregiver victimization and child behavior problems while controlling for the effects of child, family, and environmental characteristics. The potential moderating effects of caregiver depression and parenting practices on the relation between intimate partner violence and child behavior problems were examined also.

RESULTS. Severe intimate partner violence was associated with both externalizing and internalizing behavior problems when other risk factors were controlled. Use of corporal punishment and psychological aggression were significant moderators, but maternal depression did not moderate the relation between intimate partner violence and behavior problems.

CONCLUSIONS. This study adds to the evidence that maternal caregivers' experiences with intimate partner violence are related to child functioning. The findings suggest that systematic efforts are needed to ensure that mental health needs are identified and addressed appropriately in children exposed to this violence.

Key Words: intimate partner violence • child behavior problems • child maltreatment • child protective services

Abbreviations: CPS—child protective services • NSCAW—National Survey of Child and Adolescent Well-Being • PSU—primary sampling unit • CBCL—Child Behavior Checklist • CIDI—Composite International Diagnostic Interview • CIDI-SF—Composite International Diagnostic Interview Short-Form • PC-CTS—Parent-Child Conflict Tactics Scales • CTS1—Conflict Tactics Scales

A body of empirical research conducted in the past 2 decades on the scope and consequences of children's exposure to intimate partner violence has directed increasing attention to this significant public health concern.1 This research has found that children are overrepresented in households that have experienced intimate partner violence,2 with estimates suggesting that between 11% and 20% of children in the United States are exposed to such violence while growing up.3

Numerous studies have also documented a relationship between exposure to intimate partner violence and a variety of adverse psychosocial outcomes in children and adolescents.3–7 Two recent meta-analyses of published studies8,9 concluded that children's exposure to intimate partner violence is associated with significant emotional and behavioral problems. Compared with children from nonviolent homes, children exposed to parental violence are more likely to exhibit internalizing problems10–13 such as anxiety and depression14,15 and externalizing problems11,13,16,17 such as aggression, oppositional behaviors, and conduct problems.10,15,18 In the studies conducted to date, the effect sizes for externalizing and internalizing problems have been of similar magnitude, which suggests comparable levels of risk for the development of these different problems.8,9

Although previous research has demonstrated that exposure to intimate partner violence is associated with emotional and behavioral difficulties, few studies have considered other risk factors for child psychopathology that are known to coexist in many families experiencing this violence.6,7,9,19 This oversight leaves open the possibility that other factors may account for the behavior problems. In their meta-analysis of 118 published studies, Kitzmann et al8 noted that only 32% controlled for mother's marital status, 18% controlled for socioeconomic status, 14% controlled for child physical abuse, <10% controlled for general stress, moving, or parental age, and none controlled for parental substance-use problems. Thus, the extent to which adverse behavioral and emotional outcomes observed in children who are exposed to intimate partner violence are associated with factors such as socioeconomic status, family structure, other maltreatment experiences, and community environment is not well understood.20 There is some evidence, however, that smaller effect sizes are obtained when such variables are taken into account.8

The existing research has also identified heterogeneity in children's responses to parental violence.21,22 The average effect size across studies reviewed by Kitzmann et al8 (ie, d = –0.34) indicated that 63% of children exposed to intimate partner violence were functioning more poorly than children not exposed to such violence and that ~37% of children from violent homes were functioning as well as comparison children. Researchers have pointed to the need to investigate potential moderators and mediators of the relation between exposure to intimate partner violence and adjustment to further our understanding of why some children experience poorer outcomes.6,19

One factor that may influence the effects of intimate partner violence on child functioning is maternal adjustment. Research has shown that women who are victims of partner violence are at risk for a range of psychological problems, including depression, posttraumatic stress disorder, and substance-use disorders,23 and that children are at greater risk for behavioral and emotional problems when their victimized mothers experience psychological difficulties. One investigation showed that maternal depression and posttraumatic stress symptoms moderated the relationship between intimate partner violence and adolescent mental health,24 and a longitudinal study found that maternal depression mediated the relationship between maternal victimization and child internalizing problems and partially mediated the relationship with externalizing problems.25

Similarly, characteristics of maternal parenting may affect the relationship between exposure to parental violence and child adjustment. Although findings are not entirely consistent, several studies have suggested that experiencing intimate partner violence can have a negative impact on the quality of maternal parenting. Specifically, studies have found that victimized women have reported more stress associated with parenting,10 display less warmth,15 and experience more conflict with their children10 relative to nonvictimized women. Other studies, however, have not shown adverse effects on parenting. For instance, Holden and Ritchie10 found no differences between victimized and nonvictimized women in either their use of negative parenting practices such as verbal and physical aggression or positive parenting behaviors such as reasoning and physical affection. In an investigation of women who were abused recently by an intimate partner, physical and psychological victimization were not directly associated with increased parenting stress or use of harsh discipline.26

Regardless of the extent to which intimate partner violence influences parenting, maternal parenting can influence the relationship between violence and child adjustment. Previous studies found that parenting stress12 and parenting behaviors27 were significant predictors of child behavior problems after controlling for the effects of violence. Maternal parenting behaviors have been found to moderate the relationship between intimate partner violence and adolescent trauma symptoms, with positive parenting associated with less trauma.24 Other investigations have shown that the effects of partner violence on child functioning were mediated through parenting practices.25,28

The current study investigated the relation between maternal caregiver experiences with intimate partner violence and child externalizing and internalizing behavior problems while accounting for other child, family, and environmental risk factors including socioeconomic status, maternal caregiver substance use, child maltreatment, and community environment. We also examined whether maternal caregiver depression and negative parenting practices moderated the effects of caregiver victimization on child behavior problems. This study involved a large, nationally representative sample of families reported to child protective services (CPS) because of suspected child abuse or neglect. Previous analyses have found high rates of intimate partner violence29 and other risk factors for behavior problems in these families (refs 30 and 31; R.P.B., J. Wildfire, MPH, and R. Green, MSW, "Poverty, Behavior Problems, and Child Welfare Services," unpublished manuscript available from R.P.B., 2004), which makes this an important population in which to explore the current research questions.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
Participants were drawn from the National Survey of Child and Adolescent Well-Being (NSCAW). The target population for the core NSCAW CPS sample consists of children in the United States who were subjects of child abuse and neglect investigations conducted by CPS agencies during the sampling period. The NSCAW study used a 2-stage stratified sampling procedure. In the first stage, the United States was divided into 9 sampling strata, with 8 of the strata corresponding to the 8 states with the largest child welfare caseloads and the ninth stratum consisting of the remaining states. A total of 92 primary sampling units (PSUs), representing a total of 36 states, were selected randomly from this national sampling frame, with probability of PSU selection proportional to the size of the PSU's service population. The second stage involved the selection of children from lists of closed investigations from the sampled CPS agencies within the PSUs. All children sampled were involved in investigations closed between October 1, 1999, and December 31, 2000. Children aged 0 to 14 years were sampled randomly on a monthly basis from lists of cases for which an investigation was completed in the preceding month regardless of whether the investigation was founded or substantiated. When multiple children in a family were involved in an investigation, 1 child was selected randomly to participate. Children who were investigated as perpetrators of abuse (as opposed to victims) were ineligible for the study, as were children who were members of the same family of a previously selected child. (For additional detail on the NSCAW study design and sampling procedures, see ref 32).

The NSCAW CPS sample consists of 5501 children. The analyses presented here were limited to children between 4 and 14 years of age (n = 3114). Because information on intimate partner violence was not obtained from nonpermanent caregivers of children placed in out-of-home care, only the portion of the sample that included children who were not in out-of-home placement at the time of the baseline interview were eligible. This represents ~90% of all CPS cases. Among these 2491 cases, 2020 (81%) had baseline interviews with a female caregiver in which data on intimate partner violence and child behavior problems were obtained. (The remaining 471 cases could not be included in the analyses because data on intimate partner violence and/or child behavior problems were missing or interviews were conducted with a male caregiver.)

Procedure
Current caregivers of children selected for the NSCAW study were interviewed about demographic characteristics, community environment, child functioning, caregiver mental health, substance use, parenting practices, criminal involvement, and experiences with intimate partner violence. Interviews with caregivers were conducted in English (96%) or Spanish depending on the respondent's primary language. Average interview administration time ranged from 70 to 150 minutes. Before data collection, detailed information about the study was presented, and written informed consent was obtained from participants. Caregivers received an honorarium of $25 or $50 for their participation. Interviews were conducted in the caregivers' homes by using computer-assisted interviewing. For the portions of the interview inquiring about intimate partner violence, substance use, criminal involvement, and parenting practices, participants answered questions confidentially by entering responses directly into a laptop computer after audio prompts heard on earphones.

Interviewers had prior experience conducting research interviews with children and high-risk families or had training and experience in counseling, social work, teaching, or a related profession. All field-work staff completed a 12-day training program that included didactic and practice activities and were required to pass a certification test on interviewing procedures.

All study methods, including protocols for recruiting participants and obtaining informed consent, were reviewed and approved by an institutional review board at Research Triangle Institute (the contracted organization for the NSCAW field work) and the Office of Management and Budget. Relevant state and local agency institutional review boards also reviewed and approved the study protocols.

Measures
Child Behavior Problems
Children's behavior problems were assessed with the Child Behavior Checklist (CBCL),33 which contains 118 problem items that are rated on a 3-point scale (0: not true; 1: somewhat or sometimes true; 2: very true or often true). The CBCL includes broadband scales that measure internalizing problems such as anxiety and depression and externalizing problems such as aggressive and delinquent behavior. Acceptable 1-week test-retest reliability has been reported for the externalizing (r = 0.93) and internalizing (r = 0.89) scales.33 Significant associations between CBCL scores and analogous scales on other instruments such as the Quay Peterson Revised Behavior Problem Checklist support the construct validity of the CBCL.33

Child Health
Caregivers were asked to provide an overall rating of child health (ie, excellent, very good, good, fair, or poor) by using a question from the Child Health Questionnaire.34 For the current analyses, child health was coded as a dichotomous variable (ie, good = excellent, very good, or good; poor = fair or poor).

Child Maltreatment
Interview modules developed for the NSCAW study were used to gather information from CPS workers on the types of child abuse and neglect involved in the index report made to the participating CPS agency. Physical and sexual abuse were coded as present or absent based on information provided by CPS workers after review of the agency case files. (The identity of the perpetrator of the child maltreatment was not coded for these variables.) Information was also obtained on previous maltreatment reports made to CPS.

Community Environment
Community environment was measured by using the abridged community-environment scale that was developed for use in the Philadelphia Family Management Study.35 The scale consists of 9 items that inquire about perceived neighborhood safety and quality of life. The first 5 questions ask the caregiver to rate the extent to which the following are present in her neighborhood: assaults and muggings; delinquent gangs or drug gangs; open drug use or drug dealing; unsupervised children; and adolescents "hanging out" in public places. The last 4 items obtain perceptions of neighborhood safety; support provided by neighbors; parental involvement with children; and overall satisfaction with the neighborhood. The community-environment scale was scored by summing the responses on the 9 items and dividing by the number of items that each individual answered. Scores ranged from 1 to 3, with higher scores indicating poorer perceived neighborhood safety and quality of life. Reliability in the NSCAW study is good ({alpha} = .86).

Demographic Information
Information was gathered from caregivers on demographic characteristics including caregiver age, gender, race/ethnicity, marital status, education, income, number of household members, and relationship to the child participant as well as child age, gender, and race/ethnicity. Poverty status was determined relative to the 2000 federal poverty threshold, which is based on family income and number of household members. Urbanicity of residence was defined by whether the residence was located in a metropolitan statistical area.

Female Caregiver History of Arrest
Project-developed questions were used to gather information on the female caregiver's lifetime history of being arrested. History of arrest was coded as present if the caregiver reported at least 1 arrest and absent if no arrests were reported.

Female Caregiver Depression and Substance Dependence
Female caregiver major depression and substance dependence (ie, alcohol and/or drug dependence) were assessed with screening scales from the World Health Organization Composite International Diagnostic Interview Short-Form (CIDI-SF).36 The version of the CIDI-SF used in the present study provided substance-dependence diagnoses based on Diagnostic and Statistical Manual of Mental Disorders: DSM-IIIR37 criteria, and major depression diagnoses were based on Diagnostic and Statistical Manual of Mental Disorders: DSM-IV criteria.38

The items in the CIDI-SF scales were derived empirically from the World Health Organization CIDI39 by using data from the National Comorbidity Survey.40 Analyses suggest excellent concordance between diagnoses derived with the CIDI-SF and CIDI.36 The psychometric properties of the CIDI have been investigated extensively.41 Interrater reliability has ranged from 0.67 to 1.0.42,43 Test-retest evaluation has yielded {kappa} values of .62 to .78 for the disorders included in this study.41 Concordance with clinical diagnoses has ranged from 0.76 to 0.84,44 and comparisons with the Schedules for Clinical Assessment in Neuropsychiatry ranged from 0.66 for lifetime to 0.69 for current diagnoses.42

Female Caregiver Parenting Practices
The psychological-aggression and corporal-punishment scales of the Parent-Child Conflict Tactics Scales (PC-CTS)45 were used to assess caregivers' parenting practices in the previous year. Items on the PC-CTS are rated on an 8-point scale that reflects the frequency of occurrence of each behavior (1, 2, 3–5, 6–10, 11–20, and >20 times, not in the past 12 months but previously, and never). Items on the psychological-aggression scale include swearing at the referent child, calling the child names, and threatening to send the child away from the home. The corporal-punishment scale inquires about spanking with a bare hand or hard object, slapping on various parts of the body, pinching, and shaking the child. The psychological-aggression and corporal-punishment subscales were scored by adding the midpoints of the response categories of each item on the relevant subscale (the midpoints are as follows: 0 for none; 1 for 1 time; 2 for 2 times; 4 for 3–5 times; 8 for 6–10 times; 15 for 11–20 times; and 25 for >20 times).

Research on the psychometrics properties of the PC-CTS has found marginal internal consistency, with Chronbach's {alpha} = .55 for overall physical assault (which includes the corporal-punishment subscale) and Chronbach's {alpha} = .60 for psychological aggression.45 Construct validity has been moderate, with correlations of –0.34 between corporal punishment and child's age and –0.34 between corporal punishment and parent's age.

Intimate Partner Violence
The Conflict Tactics Scales (CTS1)46 physical-violence scale was used to assess caregivers' experiences with intimate partner violence. The CTS1 consists of "minor" and "severe" subscales, reflecting the severity of the violent acts contained in each subscale. The minor items include being pushed, grabbed, shoved, and slapped, whereas the severe items inquire about experiences such as being choked, beaten up, and threatened with a knife or gun. Response categories range from 0 (never) to 6 (>20 times), indicating the frequency of occurrence in the preceding 12 months. For events that did not occur in the preceding 12 months, the respondent is asked whether they ever happened. Dichotomous prevalence scores can be derived for the overall physical-assault scale as well as for the minor and severe subscales, with a score of 1 assigned if ≥1 of the acts in the scale occurred and a score of 0 assigned if none of the acts occurred. For the present analyses, 3 mutually exclusive categories were created to characterize the caregiver's experiences with intimate partner violence in the preceding year: minor physical violence only, severe physical violence, and no violence. Psychometric testing has supported the reliability and validity of the CTS1.46 In the current study, {alpha} coefficients ranged from .74 to .85.

Statistical Analysis
All analyses were conducted with weighted data by using the SUDAAN (Research Triangle Institute, Research Triangle Park, NC) statistical package. Analysis weights were constructed in stages corresponding to the stages of the NSCAW sample design. Selection of a child was the product of 2 probabilities: the probability of selection of the PSU (county) of residence for the child and the probability of selection of the child, given that the child's county of residence was sampled. Weights based on these probabilities were adjusted further to account for small deviations from the original sampling plan and for nonresponse.

Multiple linear regression was used to examine the association of caregiver victimization with child externalizing and internalizing problems while controlling for other risk factors. The moderating effects of caregiver depression and parenting practices on the relation between intimate partner violence and child externalizing and internalizing problems were then investigated with multiple regression. In these analyses, the potential moderator was entered into a model that included the predictors used in the preceding regression analyses for internalizing and externalizing problems along with the interaction terms for intimate partner violence and the moderator. Separate analyses were conducted for each potential moderator. Standard diagnostic procedures were conducted for all regression models to ensure there were no problems with multicollinearity.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Sample Characteristics
Sociodemographic characteristics of the sample are shown in Table 1. The mean age of the children was 8.64 years, and 50.5% were male. With regard to racial/ethnic background, 46.6% were non-Hispanic white, 27.8% were black, 18.2% were Hispanic, and 7.4% were of other racial/ethnic backgrounds. The majority (94.5%) of the maternal caregivers were the biological mothers of the index children. Their mean age was 33.85 years, and 50.7% were non-Hispanic white, 25.6% were black, 17.8% were Hispanic, and 5.9% were of other racial/ethnic backgrounds. With regard to marital status, 31.4% were married, 43.7% were separated, divorced, or widowed, and 24.9% had never been married. Almost one third (30.1%) had less than a high school education, 41.8% had a high school diploma or equivalent, and 28.1% had at least some post–secondary education or training. Approximately half (52.9%) of the families were living at or below the federal poverty threshold. The past-year prevalence of intimate partner violence among the female caregivers was 28.7%, with 15.9% reporting at least 1 incident of severe physical violence and 12.8% reporting experiences with minor violence but not with any severe violence.


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  		TABLE 1 Sample Characteristics

 
Multiple-Regression Analyses Predicting Externalizing and Internalizing Problems
The weighted means and standard errors (SEs) for the CBCL externalizing and internalizing scales' raw scores were 14.83 (SE: 0.56) and 8.82 (SE: 0.39), respectively. The following variables were entered simultaneously in each multiple linear-regression model predicting externalizing (Table 2) and internalizing (Table 3) behavior problems: child age, child gender, child race/ethnicity, caregiver education, poverty level of household, family size, urbanicity of county of residence, caregiver history of arrest, caregiver substance dependence, child physical maltreatment, child sexual maltreatment, history of prior reports of child maltreatment, child health status, community environment, and caregiver intimate partner violence victimization.


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  		TABLE 2 Multiple-Regression Analysis of Externalizing Problems

 

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  		TABLE 3 Multiple-Regression Analysis of Internalizing Problems

 
Externalizing Problems
Of the demographic variables, older age was a significant predictor of externalizing behavior problems (B = 0.34; P < .01), as was male gender (B = 3.09; P < .001). Hispanic children were more likely to have lower externalizing scores compared with non-Hispanic white children (B = –2.67; P < .05). Poor child health (B = 5.43; P < .01), caregiver history of arrest (B = 2.36; P < .01), caregiver substance dependence (B = 4.58; P < .05), and prior reports of maltreatment (B = 2.32; P < .01) were significant predictors of greater externalizing behavior. Caregiver victimization by severe intimate partner violence (B = 2.17; P < .05) was also positively associated with externalizing problems. Victimization by minor violence, however, was not a significant predictor (B = 1.44; P > .05).

Internalizing Problems
Older age (B = 0.60; P < .001) and poor child health (B = 8.26; P < .001) were significant predictors of internalizing problems. Caregiver victimization by severe intimate partner violence was also associated with greater internalizing problems (B = 2.37; P < .01), but victimization by minor violence was not (B = 1.27; P > .05). No other predictors in the model were significantly associated with internalizing behaviors.

Moderating Effects of Caregiver Depression and Negative Parenting Practices
Multiple linear-regression analyses were conducted to investigate the moderating effects of caregiver depression and negative parenting practices (ie, caregiver use of psychological aggression and corporal punishment) on the relation between intimate partner violence and child externalizing and internalizing problems. Separate analyses were conducted for each potential moderator. In each model, the child, family, and community-environment predictors used in the preceding analyses were entered along with the moderator of interest and interaction terms for intimate partner violence and the moderator. Moderation is indicated if an interaction term is significant.

Moderating Effects: Externalizing Problems
Caregiver depression was not a significant moderator of the relation between intimate partner violence and child externalizing problems. The interaction term for severe intimate partner violence and depression was not significant (B = –1.31; P > .05), nor was the interaction term for minor violence and depression (B = –0.25; P > .05).

Caregivers' psychological aggression directed toward their children was found to be a moderator of the relation between severe intimate partner violence and externalizing problems, as indicated by a significant interaction term (B = –0.10; P < .05). Specifically, the association between severe violence and externalizing problems diminished as use of psychological aggression increased. The interaction term for minor violence and psychological aggression was not significant (B = –0.10; P > .05).

Caregivers' use of corporal punishment was a significant moderator of the relation between intimate partner violence and externalizing problems. The interaction term for severe violence and use of corporal punishment was significant (B = –0.21; P < .05), as was the interaction term for minor violence and corporal punishment (B = –0.22; P < .05). The association of intimate partner violence and externalizing behaviors decreased as corporal punishment increased.

Moderating Effects: Internalizing Problems
For internalizing problems, the interaction between intimate partner violence and caregiver depression was not significant for severe (B = –3.14; P > .05) or minor (B = –1.45; P > .05) violence, which is consistent with the finding for externalizing behavior.

The interaction for minor violence and caregiver use of psychological aggression was significant (B = –0.09; P < .05), but for severe violence and psychological aggression, it was not significant (B = –0.04; P > .05).

The interaction term for severe violence and corporal punishment (B = –0.16; P < .05), as well as for minor violence and corporal punishment, was significant (B = –0.16; P < .05). Similar to the findings for externalizing problems, as use of corporal punishment increased, the relation between intimate partner violence and internalizing problems diminished.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This study demonstrated, in a nationally representative sample of families referred to CPS, that women's victimization by severe forms of intimate partner violence was associated with children's externalizing and internalizing behavior problems. As one of the first studies to document this relationship in a CPS sample, it extends previous research in this area, which has been conducted primarily with samples recruited from battered-women's shelters and community settings.9 Although this sample is far from representative of all women victimized by intimate partner violence, it can be generalized back to a known population of considerable public interest. The current findings also extend the literature by demonstrating this relationship when other potent risk factors related to socioeconomic status, caregiver antisocial behavior, child maltreatment, and community environment were taken into account. Few prior studies have examined models that included a range of risk factors for child psychopathology that tend to be prevalent in families experiencing intimate partner violence.8

The severity of violence experienced by caregivers was an influential factor in predicting child behavior, in that victimization by severe forms of physical violence, such as being kicked, bitten, beat up, choked, and threatened with a weapon, was associated with internalizing and externalizing problems, but no relation was found for victimization by less severe forms such as being pushed, grabbed, shoved, or slapped. Other investigations have found that severity of violence was related to child outcomes,47,48 but overall, very few studies have distinguished milder forms of intimate partner violence from more severe forms,8 as was done in this study. In light of the present findings, attention to this distinction in future research seems warranted and may contribute to improved prediction of children's risk for adverse consequences.

In addition to intimate partner violence, other predictors of externalizing problems were female caregiver substance use and arrest. These results are consistent with previous work that has found a relation between parental antisocial problems and oppositional, aggressive, and other externalizing problems in their children.30,49 Prior reports of maltreatment were also associated with externalizing problems, which corroborates recent findings that have shown that a greater number of re-referrals to CPS were associated with elevation in child behavior problems50 and suggest that children living in homes with chronic family violence are at significant risk for behavior disorders.

Although severe intimate partner violence was found to be associated with child functioning, female caregivers' use of corporal punishment and psychological aggression were moderators of this relationship. Specifically, psychological aggression was found to moderate the effects of severe intimate partner violence on externalizing problems in that the relationship was strongest at lower levels of psychological aggression and diminished as psychological aggression increased. Meanwhile, corporal punishment moderated the relation between severe intimate partner violence and both externalizing and internalizing problems, with the association of intimate partner violence and child adjustment diminishing as female caregivers' use of corporal punishment increased. Existing research has documented the negative impact of psychological maltreatment27,51–53 and corporal punishment54–56 on children. The present findings support the importance that harsh parenting practices may have on child functioning. Poor parenting undoubtedly can shape a range of behavioral and emotional difficulties, but mothers may also have difficulty dealing with children who display such problems and may react by using coercive parenting strategies.26,57 There is a clear need for longitudinal research to shed additional light on these complex relationships.

This study has several limitations. First, we did not directly assess children's exposure to intimate partner violence but rather relied on caregiver reports of their victimization as a proxy measure for exposure. Although it would have been desirable to have these specific data, a recent meta-analysis of studies on intimate partner violence and child functioning found that effect sizes did not differ in the studies that directly assessed exposure compared with those that used reports of the presence of intimate partner violence in the home.8 It seems reasonable to assume that the observed associations were not affected significantly by our use of a measure of caregiver experiences. Future research, however, would benefit from more complex assessment of children's exposure to and involvement with intimate partner violence occurring in their homes. Holden58 recently proposed a taxonomy of exposure that consists of categories ranging from actively being involved to ostensibly being unaware of the violence and reflects the type of fine-grained assessment that is needed to better understand children's experiences with parental violence. Second, the cross-sectional nature of the data limits conclusions about the direction of the observed associations. However, because NSCAW is a longitudinal study, we will be able to examine these relationships prospectively in future analyses. Third, no information was obtained in this study on the characteristics of the perpetrator of the intimate partner violence or his relations with the children studied. Prior research has found that perpetrators of intimate partner violence are also likely to be abusive toward children in the home,59,60 making it difficult to disentangle the effects of intimate partner violence and child maltreatment on adjustment. Other characteristics of the abuser's relationship and interactions with the child, such as being the biological parent, have also been shown to have an effect on adjustment.10,61 It is notable that the current study lacks information on variables such as the abusive partner's access to the child, parenting practices, and child maltreatment that may be important contributors to child outcomes. To extend our understanding of the relation between intimate partner violence and child adjustment, it will be important for future studies to go beyond the assessment of maternal and child attributes and pay much greater attention to variables associated with the perpetrator of the violence.

This study adds to the evidence that maternal caregivers' experiences with intimate partner violence are related to child functioning. The findings suggest that systematic efforts are needed in CPS, intimate partner violence programs, and social service agencies to ensure that mental health needs are identified and addressed appropriately in children exposed to this violence. Likewise, those dealing with child behavior problems in pediatric health care and other settings should consider intimate partner violence when assessing family-related issues. Prior research has reported prevalence rates for recent intimate partner violence of ~3% to 17% in pediatric settings,62–64 and the American Academy of Pediatrics65 has recommended that pediatricians should routinely screen for intimate partner violence. To provide optimal care for the overall physical and emotional well-being of children, providers in these settings must have a comprehensive understanding of children's home lives.

Although there are currently a variety of interventions provided by intimate partner violence and social service agencies for children who have been exposed to parental violence, few have undergone systematic evaluation, and none have been tested with families in the CPS system.66,67 There are some promising findings associated with programs that have offered psychoeducational interventions for children along with complementary interventions for mothers that have provided assistance with parenting and advocacy to help obtain needed resources and services such as housing, transportation, and financial assistance.57,68,69 The importance of parenting education in addressing the needs of these families is supported by the current findings on the moderating effects of caregivers' use of psychological aggression and corporal punishment on child outcomes. A profitable direction for future research would be to extend the evaluation of these interventions to families involved with CPS.


   ACKNOWLEDGMENTS
 
Support for this work comes from National Institute of Mental Health grant MH59672 (to Dr Landsverk), National Institute of Justice grant 2002-WG-BX-0014 (to Dr Kelleher), National Institute on Drug Abuse Research Scientist Development Award K01-DA15145 (to Dr Connelly), and the Administration for Children and Families, US Department of Health and Human Services (to Dr Barth). The National Survey of Child and Adolescent Well-Being was funded under a contract from the Administration for Children and Families, US Department of Health and Human Services.

We thank Donald Slymen, PhD, for statistical consultation; Jinjin Zhang, MSc, and Patsy Wood, MA, for data management and analysis; and Cynthia Fuller, BA, for assistance with manuscript preparation.


   FOOTNOTES
 
Accepted Mar 30, 2005.

Address correspondence to Andrea L. Hazen, PhD, Child and Adolescent Services Research Center, 3020 Children's Way, MC 5033, San Diego, CA 92123–4282. E-mail: ahazen{at}casrc.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

Our conclusions do not necessarily represent those of the Administration for Children and Families, National Institute of Mental Health, National Institute of Justice, or National Institute on Drug Abuse.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
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