PEDIATRICS Vol. 121 No. 3 March 2008, pp. e473-e480 (doi:10.1542/peds.2007-1671)
ARTICLE |
Impact of Intimate Partner Violence on Children's Well-Child Care and Medical Home
a Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
b Alaska State Department of Health and Social Services, Anchorage, Alaska
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. Intimate partner violence has been linked to poor child health. A continuous relationship with a primary care pediatric provider can help to detect intimate partner violence and connect families with needed services. The objectives of this study were to determine the relationship between intimate partner violence and (1) maternal report of a regular site for well-child care, (2) maternal report of a primary pediatric provider, (3) well-child visits in the first year of life, (4) up-to-date immunizations at 2 years of age, (5) maternal report of medical neglect, and (6) maternal report of the pediatric provider–caregiver relationship.
METHODS. This retrospective cohort study evaluated data from 209 at-risk families participating in the evaluation of the Healthy Families Alaska program. Research staff interviewed mothers near the time of an index child's birth and again at the child's second birthday. Medical charts were abstracted for information on well-child visits and immunizations.
RESULTS. Mothers who disclosed intimate partner violence at the initial interview (n = 62) were significantly less likely to report a regular site for well-child care or a primary pediatric provider. In multivariable models, children of mothers who disclosed intimate partner violence tended to be less likely to have the recommended 5 well-child visits within the first year of life and were significantly less likely to be fully immunized at 2 years of age. Differences in medical neglect were not statistically significant. Of mothers who reported a specific primary pediatric provider, those with intimate partner violence histories trusted this provider less and tended to rate less favorably pediatric provider–caregiver communication and the overall quality of the pediatric provider–caregiver relationship.
CONCLUSIONS. Future research should explore effective ways to link intimate partner violence–exposed children with a medical home and a primary pediatric provider and to improve relationships between pediatric providers and caregivers who face violence at home.
Key Words: intimate partner violence • medical home • health service use • immunizations • pediatric provider-caregiver relationship
Abbreviations: AAP—American Academy of Pediatrics • IPV—intimate partner violence • HFAK—Healthy Families Alaska • OCS—Office of Children's Services • CTS2—Conflict Tactics Scale 2
The Maternal and Child Health Bureau1 and the American Academy of Pediatrics (AAP)2 emphasize the importance of family context to child health and underscore family-centeredness as an essential element of a pediatric medical home. Indeed, families often depend on their pediatrician as a source of support and information for their psychosocial needs, as demonstrated by the AAP's statement, "When a family's distress finds its voice in a child's symptoms, pediatricians are often parents’ first source for help."2 To provide optimal family-centered care, however, a trusting pediatric provider–caregiver partnership must develop through regular attendance at child health maintenance visits.2
Establishment of the pediatric provider–caregiver relationship is particularly important for families who deal with complex, multifaceted psychosocial problems. Intimate partner violence (IPV) is a common problem in which families frequently face concurrent challenges including poverty, unemployment, and substance use.3–5 Because IPV has been linked with myriad poor child health outcomes6,7 and because abused women may not seek routine preventive health care for themselves, the pediatric medical home may be an important site for IPV screening and intervention for families.8
We have a poor understanding, however, of the well-child care of children whose mothers have IPV histories.9 Similarly, limited work has been done to explore the pediatric provider–caregiver relationship in families with IPV. One cross-sectional study, based on maternal self-report, suggested that abused women regularly brought their infants for well-child visits.8 A second cohort study found that abused women did bring their children to preventive visits in the child's first year of life but that these visits did not occur at recommended time intervals.10 This study was limited because fewer than 60% of families provided data in the second 6 months of the index child's life. In a sample of at-risk families, Nelson et al11 determined that whereas abused and nonabused women were equally likely to believe that their child's clinician provided compassionate, family-centered care, abused women tended to trust their child's provider less.
Additional research to examine the impact of IPV on children's well-child care, including the pediatrician–caregiver relationship, is needed. We conducted a retrospective cohort study using data collected to evaluate the Healthy Families Alaska (HFAK) program; women were enrolled during pregnancy, and families were followed through the child's second birthday. Our objectives were to determine the relationship between IPV and (1) maternal report of a regular site for well-child care, (2) maternal report of a primary pediatric provider, (3) well-child visits in the first year of life, (4) up-to-date immunizations at 2 years of age, (5) maternal report of medical neglect, and (6) maternal report of the pediatric provider–caregiver relationship.
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METHODS |
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Participants
The parent study and these analyses were approved by the authors’ institutional review board. The parent study also was approved by the hospitals where families were recruited. Women who enrolled in the initial HFAK program evaluation provided written informed consent to participate.
Study Design, Setting, and Sample
This retrospective cohort study examined data that were collected from the HFAK program evaluation. The protocols for the HFAK program and evaluation of the program have been described in detail elsewhere.12,13 Briefly, the HFAK program evaluation sought to determine, through a randomized trial, the effectiveness of home visitation in preventing child maltreatment and promoting child health and development and healthy family function. The program was not found to have any significant impact on reducing child maltreatment or other modifiable parental risk factors.13
From January 2000 to July 2001, HFAK staff identified 404 at-risk pregnant women.12,13 Women were recruited primarily through hospital obstetric units at the time of birth or were referred from their prenatal care clinics. A minority of referrals came from other community service providers. The study included families from 5 areas in Alaska: Anchorage, Juneau, Fairbanks, Mat Su Valley, and Kenai. To be eligible for participation, women had to have been considered "at risk," as defined by a score of 
25 on the Kempe Family Stress Checklist, a validated measure that assesses for child maltreatment risk factors such as parental substance use, caregiver history of abuse as a child, and unrealistic expectations of children.14,15 There were no age-related eligibility criteria for interested women.
Of the 404 identified pregnant women, 16 (4%) were not eligible for the study, 12 because they had been previously enrolled in HFAK and 4 because the mother did not speak English well enough to complete study activities. Of the remaining 388 families, 22 (6%) declined study participation; 364 (94%) gave informed consent for the study and were randomly assigned. Group assignments (HFAK: n = 179; control: n = 185) were predetermined using a table of random numbers, equal allocation, and randomization within site in blocks of 10. Research staff completed the baseline maternal interview within 1 month of study enrollment. Overall, 325 (90%) of those randomly assigned were interviewed at baseline; the others declined the interview (n = 12) or could not be located (n = 27). Thus, 84% of the 388 eligible families completed baseline interviews and became full study participants. Follow-up interviews (at the child's second birthday) were obtained for 85% of the HFAK group and 86% of the control group.12,13
For this study, families were included when the mother retained custody of the index child for the full 24 months (birth to 24 months). We applied this inclusion criterion to minimize missing medical chart information, because this information was often lost when children transitioned to out-of-home care. Families also were excluded when the child remained in the mother's care but had missing medical chart information. Most often families were excluded by this criterion when they had moved out of state at some point before the child's second birthday and medical charts were not easily obtained.
Data Collection and Measurement
Trained research staff collected baseline data during an interview with enrolled pregnant women. Families were contacted (although not interviewed) when children were 8 and 16 months to reduce study attrition. Follow-up data were collected from 4 sources when the children were 2 years of age: (1) Alaska Office of Children's Services (OCS) computer files of child protective services reports, (2) pediatric medical charts, (3) interviews with the child's birth mother, and (4) observation of the home environment and of primary caregiver/child interaction. Research staff who were responsible for collecting data were blinded to family group assignment. They were carefully trained in study procedures and monitored to prevent measurement bias and drift. One investigator (Ms Caldera) collected medical chart data while blinded to family group and IPV status.
Independent Variable: IPV
IPV was assessed using the revised Conflict Tactics Scale (CTS2), which asks about physically violent behaviors that were used by intimate partners in response to conflict in the past 12 months.16–18 Specifically, the measure asks about acts of aggression ranging from pushing or shoving to using a knife or a gun. Response options are categorical, ranging from never to >20 times. The CTS has been used as a measure of family violence in hundreds of published articles. 
reliability coefficients for the husband-to-wife physical aggression scale range from .79 to .91, and wife to husband reliability coefficient equals .82.17 Good construct validity also has been demonstrated.17
The CTS2 was introduced to participants by telling them, "No matter how well a couple gets along, there are times when they disagree, get annoyed with the other person, want different things from each other, or just have spats or fights because they are in a bad mood, are tired, or for some other reason. Couples also have many different ways of trying to settle their differences. This is a list of things that might happen when you have differences." When women had an existing or recent (past 12 months) relationship with the infant's father, they were instructed to answer the questions about this relationship. Ninety-eight percent of women answered CTS2 questions specifically about the father of the infant. Ten women stated that they had no relationship with the father of the infant or with any other partner in the past 12 months. These women were categorized as negative for IPV. IPV was defined as positive when the woman responded during the baseline interview that either she or her partner had used a total of 3 acts of physical violence in the past 12 months.
Dependent Variables
Regular Site for Well-Child Care and Primary Pediatric Provider
In the follow-up interview, mothers were asked the following questions:
- Is there a place you usually take the infant for well-child care, such as shots and routine examinations?
- Is a particular person your infant's doctor?
Well-Child Visits and Immunizations
During the baseline and follow-up interviews, staff members asked the mother to name all of the location(s) and provider(s) they intended to use or did use for medical services for their child. One investigator (Ms Caldera) contacted each provider to obtain medical chart data. She followed any and all leads in these medical charts for the additional providers, obtaining and abstracting the appropriate records, until all were exhausted. For immunizations, records were obtained from the birth hospital, outpatient medical charts, and public health registries.
We defined the outcomes of well-child visits and immunization status on the basis of the AAP's recommendations for preventive pediatric health care.19 Both were binary variables, with well-child visits reflecting receipt of the recommended 5 postbirth well-child visits in the first year of life (by 1 month, 2 months, 4 months, 6 months, and 9 months) and immunization status indicating receipt of all recommended vaccinations at the 2-year mark. Because of the likely use of PRP-OMP (a specific brand of Haemophilus influenzae vaccine for which 3 rather than 4 doses are considered adequate) in some practices, 3 Haemophilus influenzae type B vaccines were considered full immunization.
Medical Neglect
Medical neglect was defined as a positive response during the follow-up interview to the following question on the parent–child version of the CTS17: "Please tell me how many times in the last year this has happened to you in trying to care for your child. How many times were you not able to make sure infant got to the doctor or hospital when he/she needed it?" Response choices ranged from never to >20 times.
Pediatric Provider–Caregiver Relationship
Only mothers who identified a primary care pediatric provider in the follow-up interview responded to the pediatric provider–caregiver relationship questions (n = 164). Information regarding the specific type of pediatric provider (pediatrician, physician's assistant, nurse practitioner) was not collected. Attributes of this relationship were assessed using a version of Safran's Primary Care Assessment Survey,20,21 which has been modified for use in pediatrics. Previously conducted factor analysis using the modified version of the Primary Care Assessment Survey within the HFAK sample22 demonstrated 4 subscales with excellent reliability. The subscales were interpersonal treatment (3 items; Cronbach's = .90), contextual knowledge of the patient (3 items; Cronbach's = .87), trust (4 items; Cronbach's = .76), and communication (4 items; Cronbach's = .92). Items included in each subscale are detailed in Table 1. An overall measure of the quality of the pediatric provider–caregiver relationship was established by combining the 4 subscales (Cronbach's = .94).21,23 Initial responses were on Likert scales; the total score from each subscale was standardized to range from 0 to 100, with higher scores indicating more favorable responses.
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Covariates
All covariates were based on baseline data, with the exception of child insurance status, home environment, and substantiated child abuse, which were not available at the initial interview (generally occurring before the child's birth).
Demographics
Data on mother's age, race, income, education, and marital status were collected at the baseline interview; child's insurance status was measured at the follow-up interview.
Intervention Status
Within the parent study, mothers were randomly assigned to the intervention group, in which they received intensive paraprofessional home visitation (described elsewhere)12,13 or to a control group.
Maternal Depression
Women's depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale, with depression defined as a score of >15.24,25 The Center for Epidemiologic Studies Depression Scale, developed at the National Institute of Mental Health as a self-report questionnaire of depressive symptoms in the past week, has been widely used to assess depression in both urban and rural populations, with Cronbach's ranging between .85 and .9.
Maternal Substance Use
Maternal substance use was defined in 2 ways: any illicit drug use in the past year and problem alcohol use. Problem alcohol use was defined as self-report of alcohol use in the past year along with a history of alcohol problems, as measured by 2 positive responses to the 4 CAGE questions.26,27 The CAGE questionnaire, a widely used screening tool, has been validated in primary care settings.26
Home Environment
The 55-item infant-toddler version of the Home Observation for Measurement of the Environment measured the quality of the home environment.28–30 Higher scores are more favorable, with low scores representing an impoverished environment. Interrater reliability and Cronbach's have both been reported to be .92.31
Child Abuse
All health care providers in Alaska, including those who treat Alaskan Native children, are mandated reporters of child abuse and neglect. The Alaska OCS maintains a computerized system to track child protective service reports. Subject-identifying data were provided to the OCS for computer matching. The OCS returned a list of matches with data on report date, type, and whether the report was substantiated. Child abuse was defined as a substantiated Child Protective Services report filed for child maltreatment directed against the index child.
Data Analyses
All analyses were conducted using Stata 9.1 (Stata Corp, College Station, TX). Characteristics of families with and without IPV were compared using Pearson's 
2 tests or Fisher's exact test (maternal race only). Using Pearson's 2 statistics, we assessed the bivariable relationships between IPV and (1) maternal report of a regular site for well-child care, (2) maternal report of a primary pediatric provider, (3) well-child visits in the first year of life, and (4) up-to-date immunizations at 2 years of age. Fisher's exact test determined the association between IPV and medical neglect. We used unpaired Student's t tests to compare families with versus those without IPV on maternal ratings of the pediatrician–caregiver relationship.
We then used multivariable logistic regression, in 2 separate models, to determine the association of IPV with the binary outcomes of receipt of recommended well-child visits and up-to-date immunizations. Multivariable linear regression models were used to estimate the association between IPV and each continuous subscale of the pediatric provider–caregiver relationship. Multivariable regression was not performed with some outcomes (maternal report of a regular site for well-child care, maternal report of a primary pediatric provider, and maternal report of medical neglect) because of limited sample size. Choice of model covariates reflected either evidence of confounding in bivariable analyses or documented associations in previous studies.32–34 The regression models contained the following covariates: maternal factors (age, education, depression, and substance use), intervention group status, and substantiated child abuse. P < .05 was considered statistically significant; P values between .05 and .10 were considered a tendency or a trend.
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RESULTS |
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A total of 210 women met inclusion criteria for this study. Reasons for exclusion were (1) mother lost custody at some point during 2 years (n = 53), (2) child died prenatally or postnatally (n = 3), (3) study attrition (n = 36), and (4) extensive missing medical chart data (n = 23). One additional woman was missing baseline IPV data and thus was excluded from analysis, resulting in a final study sample of 209.
In the baseline interview, 62 (30%) of the 209 women disclosed being in a violent relationship (defined as 3 acts of violence by them or by their partner) within the past 12 months. Of these 62 women with IPV, 22 (36%) stated that the violence was perpetrated only by them and 6 (10%) stated that the violence was perpetrated only by their partner. For the remaining 34 (54%), the IPV was bidirectional. Of the 22 women who disclosed female-perpetrated violence only, 14 (64%) either lived with or were married to their partners. Of the 6 families with reported male-only violence, 2 (33%) either lived with or were married to their partners. Finally, of the 34 families with bidirectional IPV, 18 (53%) were either living with or married to their partners.
Characteristics of families with and without IPV are detailed in Table 2. Women who did not experience IPV were significantly more likely to be 25 years of age (P = .01) and to have graduated high school (P = .001). Women who disclosed IPV were more likely to have problem substance use (P = .04) and to have a substantiated CPS report filed (P = .05). Most children in both groups were insured, with no between-group differences (P = .44)
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Table 3 presents data from bivariable analyses. Mothers who reported IPV were less likely than those who did not report IPV to specify a regular site for their children's primary care (P = .04) and to identify a primary pediatric provider (P = .05). Similarly, children of women who reported IPV were less likely to have had 5 well-child visits in the first year of life (P = .04) and to have been fully immunized by 2 years of age (P = .04). Rates of self-reported medical neglect were higher in mothers who reported IPV (7%) than in mothers who did not report IPV (3%), although this difference was not statistically significant (P = .45). Of women who named a primary pediatric provider for their child, mean scores for trust were significantly lower in women who disclosed IPV (P = .01). Ratings of pediatric provider–caregiver communication (P = .09) and overall pediatric provider–caregiver relationship quality (P = .06) tended to be lower for mothers who reported IPV.
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The impact of IPV on well-child visits was attenuated in multivariable analyses controlling for potential confounders (Table 4), although children of mothers with IPV histories still tended to be less likely to have had 5 recommended well-child visits in the first year of life (P = .08). As in bivariable analyses, children of mothers with IPV histories were significantly less likely to be up-to-date on immunizations at 24 months (P = .04). Mean scores for trust in the child's pediatric provider were lower for women who disclosed IPV (P = .04); ratings of communication (P = .09) and of the overall quality of the pediatric provider–caregiver relationship tended to be less favorable (P = .07).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In this retrospective cohort study that followed children from birth to 2 years of age, women who disclosed IPV were significantly less likely to report having a regular site for their child's well-child care or a primary pediatric provider. Children of mothers who reported IPV tended to be less likely to have the recommended 5 well-child visits within the first year of life and were significantly less likely than peers to be fully immunized by 2 years of age. In addition, of mothers who reported a specific primary pediatric provider, those with IPV histories trusted this provider less and tended to rate less favorably communication with this provider and the overall quality of the pediatric provider–caregiver relationship.
To obtain well-child care at a single site and with a primary provider, caregivers must identify the need for care, choose an accessible primary health care site and provider, make an appointment, transport themselves and their child to that site, and then pay for the care. Women currently or recently in violent relationships may not establish such a "medical home" for their children for multiple reasons, ranging from comorbid depression or substance use33 to a lack of consistent transportation. Abused women also may avoid contact with a pediatric provider or even a particular pediatric medical care site because of previous negative experiences with physicians35 or for fear that the provider will involve Child Protective Services if current IPV is discovered.33,36 A more complete understanding of these or other potential barriers will facilitate the establishment of a medical home for IPV-exposed children.
Our findings regarding the tendency toward having fewer well-child visits differ from the study by Martin et al8 of women who participated in the North Carolina Pregnancy Risk Assessment Monitoring System, which concluded that abused women did bring their infants to the pediatrician for well-child care and that the mean number of visits did not differ by abuse status. One potential reason for the discrepancy is that the North Carolina study depended on maternal report as opposed to medical charts. Other literature supports our finding of immunization delay among IPV-exposed children.37 Attala and McSweeney,37 for example, compared immunization rates in a community-based sample of children of abused versus nonabused women. She concluded that children of abused women were more likely to be underimmunized than children of nonabused women.
Our study results demonstrated that mothers who had IPV histories and identified a primary pediatric provider tended to rate lower the overall quality of the relationship with this person, driven primarily by lower ratings of trust and communication with this provider. These findings are cause for concern given that previous research documented that ratings of the clinician–patient relationship were positively associated with adherence to physician recommendations and favorable behavior change.20,38 Because pediatric providers have frequent contact with women and children, they may be in a unique position to offer support and resources for IPV39; lack of a strong partnership between caregivers and providers, however, may compromise pediatric providers’ ability to help families who face violence.
Some study results have found female-perpetrated IPV to be as or more prevalent than male-perpetrated IPV.17,40,41 In this study, of relationships with IPV, 36% of women stated that they were the sole perpetrators of violence, 10% reported male violence only, and 54% had bidirectional violence. Some researchers suggest that the reports of significant female-on-male violence are biased and fail to recognize that most female-on-male violence is in self-defense.42 Still others argue that we must distinguish between "common couple violence" and "intimate terrorism," with "common couple violence" involving infrequent, low severity, bidirectional violence that couples use to resolve disagreements and "intimate terrorism" involving more severe violence intended to control and subjugate women.43 The differential impact of these forms of violence on children is not well understood, and both have the potential to have a negative impact on children's health and development. In this study, the sizes of each subgroup (female-on-male only, male-on-female only, and bidirectional) were too small to allow sound statistical inferences with regard to child outcomes in families with varying types of violence, but this is an area that warrants additional study.
Our study results should be interpreted in light of several limitations. Because our sample consists of high-risk mothers in Alaska, selected on the basis of child abuse potential (with the sample further narrowed by this study's eligibility criteria), our results are not generalizable to the greater population. This particular sample also was unique, in that the mothers self-disclosed multiple risks to the HFAK program staff and were followed via the evaluation interviews. As such, they might not be representative of at-risk families overall, particularly those who are less likely to disclose sensitive information. Our sample therefore may differ from others in how they approached their children's well-child care and their child's primary pediatric provider, further limiting generalizability. Similarly, because all members of this cohort were exposed to psychosocial risks such as poverty, chaotic home environments, and other factors that may influence our dependent variables, the differences between groups may have been attenuated. Even in this high-risk sample (with the groups with and without IPV similar with regard to multiple risk factors), however, we found negative consequences of IPV on children's well-child care. Additional studies should investigate the IPV–well-child care relationship in a more diverse and representative sample. Also, the relatively small sample size potentially limited our power to find significant results. Finally, although we attempted to conduct a thorough search of all medical charts, it is possible that there are some visits for which we did not account. Because the medical charts abstractor (Ms Caldera) was blinded to IPV status, however, we believe that this is a nondifferential source of bias.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our findings of suboptimal well-child care for children with mothers who reported IPV are concerning given that a continuous relationship with a primary care pediatric provider can help to detect risks to child health, such as IPV, and to connect families with needed services. Because IPV is common and has an impact on children's health, pediatric primary providers must be prepared, within the context of the existing medical home, to screen for IPV and to provide assistance to families who experience violence. Future research should explore effective methods for incorporating routine IPV screening into outpatient pediatric settings, ways to link IPV-exposed children with a medical home, and approaches to improve relationships between pediatric providers and caregivers who face violence at home.
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ACKNOWLEDGMENTS |
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Healthy Families Alaska program evaluation was supported by Alaska Mental Health Trust Authority and Alaska State Department of Health and Social Services.
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FOOTNOTES |
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Accepted Jul 21, 2007.
Address correspondence to Megan H. Bair-Merritt, MD, MSCE, 200 N Wolfe St, Room 2021, Baltimore, MD 21287. E-mail:mbairme1{at}jhmi.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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