Tertiary Child Maltreatment Prevention Strategies: Not Only Last but Also Least Effective of the Three Traditional Approaches – Carly Foster

Introduction
Child maltreatment has been recognized in numerous publications as a global public health problem that needs immediate attention and intervention. Currently, the U.S. Child Abuse Prevention and Treatment Act recognizes four major types of child maltreatment: physical abuse, neglect, sexual abuse, and emotional abuse. In 2006, U.S. state and local Child Protective Services (CPS) cited that more than 900,000 children were victims of abuse in an investigated 3.6 million reports of children being abused or neglected (1). Agencies such as the World Health Organization and the U.S. Centers for Disease Control and Prevention argue that children who have experienced abuse and neglect are at an increased risk of negative health outcomes such as higher rates of alcoholism, drug abuse, depression, smoking, multiple sexual partners, suicide, and chronic disease (2, 3). Organizations agree that these health outcomes are in addition to the immediate physical and emotional effects of maltreatment. Public health prevention programs are absolutely essential to eradicating this global crisis. Unfortunately, many of the current public health prevention programs have originated from treatment programs. Considered to be prevention, the treatment programs are designed to alter the behavior of the abuser and protect the child from future abuse (4).
There are three types of child maltreatment programs currently recognized: primary, secondary, and tertiary prevention. Primary prevention strategies promote dissemination of information regarding positive parenting techniques, child development, risk factors for child maltreatment, and resources across communities and society. Secondary prevention strategies target individuals who are determined to be at “high-risk” for child maltreatment. Those at “high risk” for abuse may have predictive factors for child maltreatment such as history of abuse, drug or alcohol use, young age, and low levels of education. Tertiary prevention, closely related to treatment programs, strive to end further abuse and target the individual abuser. Minimal evidence exists to demonstrate effectiveness of this strategy and most professionals involved with families of abuse stress the importance of primary and secondary strategies if child maltreatment is ever to be eradicated (4).
Prevention of Abuse “After the Fact” May be too Late
Due to the complicated nature of predicting and identifying root causes of abuse, tertiary prevention programs may not address the many factors that may contribute to abuse. Many researchers agree that the perpetration of abuse results from complex interactions among characteristics of parents, children, cultures, and environmental influences (5). In a Developmental Psychology argument, Belsky attributes child maltreatment to three contexts – the developmental, immediate interactional, and environmental contexts of maltreatment. The “developmental context” examines the roles of parent and child characteristics in child maltreatment. When focusing on parent-child interaction and its processes associated with abuse, the “immediate interactional context” is analyzed. Lastly, the “broader context" discusses effects of the community, cultural, and evolutionary processes on child maltreatment (6). The volume of factors contributing to abuse limit prevention programs that target individual perpetrators of abuse. When developing a prevention program for groups of people who have committed child maltreatment, it is extremely difficult to reach the individual level and address specific needs. Next steps would include developing methods to identify the root causes of abuse for each individual perpetrator of child maltreatment in order to effectively prevent the behavior.
In addition to the multiple factors contributing to child maltreatment, tertiary prevention strategies tend to be punitive in nature and do not address social, economic, or psychological factors affecting the perpetrator of abuse. Response to child abuse and neglect involves identification of maltreatment and referral of victims and perpetrators for associated health care, social, and legal services; treatment of medical and psychological effects; and the reporting of abuse and neglect to the appropriate investigatory authorities in order ensure appropriate protection for the child. In addition to the child receiving protective services, the perpetrator may have to undergo such activities as parent support groups, parent education, home visitations, mental health, and other social support and therapeutic services (7). Despite efforts to affect behavior changes and prevent future abuse, studies show that one-third or more of the parents receiving intense support maltreated their children while in treatment. Many researchers suspect that over one-half of the families served are likely to mistreat their children following tertiary prevention strategies (8).
Some argue that the stress of treatment and prevention programs in addition to the existing array of factors may contribute to continued maltreatment of children. In addition, it may be difficult for parents and caregivers to focus on the treatment and prevention program when the root causes of child maltreatment have not been addressed (8). Other researchers argue that parental risk factors for child maltreatment, such as mental health problems and substance abuse may exacerbate the difficulty of establishing a trusting and open dialogue with parents (9).
Tertiary child prevention strategies have been shown to be most effective when the programs were more intense and prolonged, rather than short-term regimes. Generally a program that lasts longer than 4-6 weeks may be considered a ‘longer’ program (10). This data suggests that the success of the intervention, however, may depend on its ability to engage and retain parents for the entire program. The National Center for Injury Prevention and Control reported thirty to eighty percent of families most at risk for child maltreatment actually complete prevention programs. Even though families may attend programs, studies have shown they do not always adopt changes or maintain their skills. Despite the effectiveness of tertiary prevention programs, they have limited impact if they are unable to reach, engage, and retain prospective participants (11).
The last and perhaps most significant reason why prevention programs after the fact may be too late is demonstrated by Geeraert et al. This meta-analysis of 40 child maltreatment prevention programs suggests abusive parenting may become a fixed pattern of parent-child interaction without intervention (12). The reality is child maltreatment may exist for a long period of time before the authorities and child protective services become involved. This study provides important insight into the complex nature of parent-child relationships. Merrill also suggests that there are certain traits according to Personality Theory that predispose individuals for abuse. He suggests that parents may be categorized into four groups based upon psychological traits – chronically aggressive; rigid and compulsive, lacking warmth and reason; those who demonstrate a high degree of passivity and dependence; and extremely frustrated individuals (13). Not only is the treatment and prevention of further abuse more difficult at the tertiary level, but also may be ineffective if child maltreatment patterns are ingrained behaviors or personality traits of the perpetrator.
Control Theory
Control Theory, as defined by Glasser in 1986 states that all behavior is an attempt to satisfy powerful forces within ourselves. He argues that regardless of our circumstances, all people do, think, and feel is always the best attempt at the time to satisfy the forces within them. This behavior may be ineffective or even destructive to oneself or those around them. Individuals have choices, and he notes that people are typically unaware that they choose much of their misery (14). Expanding on this idea, Flowers explains that family violence may be an attempt to maintain power and control over another or others. He also argues that the use of force is always a choice. He even mentions that abusers would not necessarily become “out of control” when dealing with a police officer or member of society, but may become out of control when dealing with family or children (15). Utilizing Control Theory to explain child maltreatment challenges previous arguments that the causation of abuse is due to psychological, social, or environmental factors. This adds an additional layer to the problem and an additional reason why tertiary prevention programs may not be effective in stopping abuse.
If a parent or caregiver is using child maltreatment as a form of control, intervention and treatment may be extremely difficult. Family violence occurs in the absence of social controls that would normally result in positive behavior and punish acts of violence. Unless the abuser regains control in other aspects of their life such as social, economic, and emotional factors, treatment and prevention efforts may not decrease the incidence of child maltreatment. There are also researchers who argue whether social control is designed to keep violence from occurring or to maintain a certain level of family violence. There are still conflicting norms as to whether the use of violence in families is acceptable; many still feel that a certain amount of violence in families is accepted and even mandated.
What about the Child? The Ecological Model and Tertiary Prevention
Arguably, parental involvement is the most influential factor in determining child outcome. Attentive, stimulating, affectionate, and responsive child rearing may lead to optimal child development. Of the many influences associated with abuse, characteristics of parents are considered to be most important because they mitigate the external influences such as the environment. Thus, parents are often the target of interventions designed to prevent the occurrence of child abuse (17).
Though parental traits and behaviors may be an important aspect of child maltreatment, the Ecological Model considers the entire context of the abuse in order to understand and prevent child maltreatment. The four factors affecting child maltreatment include the parent, the family (including the child), the community, and the culture or society. Each of these levels may affect the child differently. Previous arguments have discussed the parent, the community, and the societal factors of abuse, but the purpose of this argument emphasizes the importance of the child. Tertiary prevention factors focused on the parent may not address the special needs or temperament of the child, nor prevention strategies targeted towards the child.
Many studies suggest that characteristics of the child do not increase the likelihood of child maltreatment. On the other hand, studies have shown that children who have special needs such as physical or mental disabilities, difficult temperaments, and mental health problems are more likely neglected. Regardless of whether child characteristics increase the likelihood of child maltreatment, the Ecological Model highlights the interaction between parents and children as considerations for abuse. A parent with high levels of stress interacting with a child with a difficult temperament may increase the probability of child maltreatment. Additionally, child characteristics may indirectly affect the parenting strategies used and the child-parent relationship. If a tertiary prevention strategy does not incorporate child characteristics, the program may be ineffective in preventing child maltreatment (18).
Following reported cases of abuse, parents are often referred to Child Protective Services (CPS) in order to undergo varying levels of therapy and treatment. Children often undergo therapy to address any feelings associated with the abuse and prevent them from being an abuser in a future family setting. What about the child’s role in preventing the abuse? Tertiary prevention programs do not empower children to prevent the abuse and obtain help when they are subjected to abuse. Without consideration for the child, tertiary prevention programs may not be successful in ending future abuse.
Conclusion
Minimal evidence exists to demonstrate effectiveness of tertiary prevention of child maltreatment and future research needs to focus on primary and secondary prevention efforts. Arguments against the tertiary prevention strategies include: the target population has already perpetrated the abuse, the Control Theory suggests an additional factor to address, and the child is left out of most tertiary prevention strategies. In order to fully understand and prevent child maltreatment, multi-faceted and multi-agency approaches need to be researched and validated. It is important for public health professionals to develop strategies based on the most current research.
Prevent Child Maltreatment Before it Starts:
Implement Parent Training Programs for all New Parents

There are three types of child maltreatment programs currently recognized: primary, secondary, and tertiary prevention. Primary prevention strategies promote dissemination of information regarding positive parenting techniques, child development, risk factors for child maltreatment, and resources across communities and society. Secondary prevention strategies target individuals who are determined to be at “high-risk” for child maltreatment. Those at “high risk” for abuse may have predictive factors for child maltreatment such as history of abuse, drug or alcohol use, young age, and low levels of education. Tertiary prevention techniques, closely related to treatment programs, strive to end further abuse and target the individual abuser. Primary prevention of maltreatment in the form of parent training should be implemented for all new parents, regardless of risk factors (4). This achievement would require an overhaul of the pre and post-natal care system, but may benefit children in the long term.
The Approach
Similar to Project 12-ways of the Behavior Analysis & Therapy Program of the Rehabilitation Institute at Southern Illinois University, this intervention would offer a range of services to families. The primary focus of Project 12-ways is to teach children and their parents the skills necessary to get along without abuse and neglect. This initiative emphasizes that family problems may be eased by teaching parents effective child-rearing skills. By incorporating the principles of Project 12-ways into the proposed national public health intervention, all new parents would receive parent training as a part of their pre and post-natal care. If finances were not a barrier to this intervention, home visitation may also be an important aspect of the parent training experience. By sending clinicians, social workers, or case managers to the families’ homes, the program would be able to identify risk factors for child maltreatment and assess the progress the families have made in accordance with the parent training.
Prevent Child Maltreatment Before it Begins
In a meta-analysis of 23 parent training programs, Lundahl et. al reported moderate but significant positive gains in all outcome constructs, such as attitudes linked to abuse and emotional adjustment. This study argues parent training is effective in reducing the risk of physical abuse, emotional abuse, and neglect. Following parent training, parents were more likely to develop child-friendly beliefs and attitudes and understand children’s developmental capabilities, emotions, and intentions. Parent training programs challenged the notion that corporal punishment is an effective long-term discipline strategy. Parent training also served to enhance the emotional well-being and stability of the parent, a major risk factor attributed to child maltreatment. When parents interacted with children following parent training, they were more likely to use warmth and democratic reasoning rather than coercion or force (5).
By conducting parent training for all expecting parents, the program trainers may be able to identify risk factors present in the parents. For instance, they may be able to assess the stress and anxiety levels of the parents, their employment status, and emotional attitudes towards child abuse. Early identification of these indicators is an important reason why primary prevention may be most effective. In tertiary prevention, or treatment, the root causes of child maltreatment have not been addressed, whereas primary prevention would enable parents to address risk factors for child maltreatment prior to the child’s birth or early in the child’s development (8). Similarly, the parental training programs may identify mental health problems and substance abuse, which are thought to contribute to child maltreatment and prevent open dialogue with healthcare providers (9).
In a meta-analysis by Geeraert et al, of 40 child maltreatment prevention programs, he suggests abusive parenting may become a fixed pattern of parent-child interaction without intervention (12). If parental training was practiced, parents and children may be more likely to develop positive interactions and relationships, rather than abusive patterns. Parent education programs improve parenting competence, effectively address risk factors for child maltreatment, and may result in fewer incidents of child maltreatment. Moreover, family visits may be an important factor to ensure that child maltreatment does not become a fixed interaction between parents and children (9). Primary prevention strategies encourage fixed patterns of positive parent-child interaction and may be more effective than tertiary prevention strategies.
Control Theory and Primary Prevention Strategies
If a parent or caregiver is using child maltreatment as a form of control, intervention and treatment may be extremely difficult. Primary prevention strategies may enhance social controls, resulting in positive behavior and reducing acts of violence. Parent training programs may assist parents to gain control in other aspects of their life such as social, economic, and emotional factors. Early identification of risk factors for child maltreatment may intensify the parent training, incorporating anger management and classes on self-control. Primary prevention strategies may also address the concern that many parents still believe that the use of violence in families is acceptable or mandated. Primary prevention and parent education may provide alternate strategies for parenting and an opportunity for parents to learn the long-term effects of child maltreatment (15).
The parent education classes would also require a component of child development and behaviors. This segment may reinforce the argument that, by understanding child development, the parents may have a better sense of what actions constitute “normal” childhood behaviors. This strategy may enable parents to relinquish their need for power if they are aware of the aspects of child development over which they do not have control.
The Ecological Model: When Primary Prevention Strategies Acknowledge the Child
Arguably, parental involvement is the most influential factor in determining child outcome. Primary prevention strategies promote attentive, stimulating, affectionate, and responsive child rearing, which may lead to optimal child development. Of the many influences associated with abuse, characteristics of parents are considered to be most important because they mitigate the external influences such as the environment. Thus, parents are often the target of interventions designed to prevent the occurrence of child abuse (17).
Primary prevention strategies address the special needs or temperament of the child. Studies have shown that children who have special needs such as physical or mental disabilities, difficult temperaments, and mental health problems are more likely neglected (18). The proposed parent training program would incorporate principles from the Triple P – Positive Parenting Program in Australia. The Triple P-Positive Parenting Program is comprised of five levels of intervention, which customizes the program with increasing intensity based on the necessities of the families. Level 1 aims to increase community awareness of available parenting resources and to increase parents' receptivity to participating in the Triple-P Positive Parenting. Levels 2-5 incorporate specific concerns of the child into the education. Level 2 of the program offers targeted interventions for specific concerns such as a child's developmental or behavioral difficulties. Level 3 of the Triple P-Parenting Program targets families with a child who possesses mild to moderate behavioral difficulties. The fourth level of the program offers intensive training in positive parenting skills to parents with children who possess more severe behavioral difficulties. Level 5 of the program is geared towards families with children who exhibit persistent behavioral problems and experience additional external risk factors such as parental depression or martial difficulties. This intensive program is specific to meet the families’ needs and the training includes: parenting skills training; mood and stress management training; and, partner support training (9).
Primary prevention strategies may also empower children to prevent the abuse and obtain help when they are subjected to abuse. Without consideration for the child, prevention programs may not be successful in stopping abuse before it starts. The Self Esteem and Assertiveness and Stress Reduction components in Project 12-ways are a great model for empowering the children. These programs aim to educate children about asserting their feelings and reducing stress, each important life skills.
Conclusion
Although labor intensive and a tremendous financial commitment, primary prevention strategies, such as parent training and home visitation may be the most effective methods to eliminate child maltreatment. Secondary prevention strategies target individuals who are at “high-risk” for child maltreatment, but studies have shown that there may be many false positives and false negatives for individuals at risk for committing child maltreatment. Tertiary prevention strategies are implemented following the abuse and may not be effective in reducing child maltreatment. Thus, a strategy of ending child maltreatment may be to stop it before it starts.
References

1. U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2006 [Washington, DC: U.S. Government Printing Office, 2008] available at: http://www.childwelfare.gov.
2. Prevention of child maltreatment. World Health Organization.
3. Preventing Childhood Maltreatment. Program Activities Guide. U.S. Centers for Disease Control and Prevention.
4. Knudsen D. Child Maltreatment: Emerging Perspectives. Rowman Altamira, 1992
5. Brad W. Lundahl, Janelle Nimer and Bruce Parsons. Preventing Child Abuse: A Meta-Analysis of Parent Training Programs. Research on Social Work Practice 2006; 16; 251
6. Belsky, Jay. Psychological Bulletin. Vol 114(3), Nov 1993, 413-434.
7. Chalk R, King PA, Violence in Families: Assessing Prevention and Treatment Programs. Committee on the Assessment of Family Violence Interventions Board on Children, Youth, and Families. Commission on Behavioral and Social Sciences and Education. National Research Council and Institute of Medicine National Academy Press, Washington, D.C., 1998
8. Cohn AH, Daro D. Is Treatment Too Late: What Ten Years of Evaluative Research Tell Us. Child Abuse Neglect. 1987: 11(3): 433-42.
9. Holzer PJ, Higgins JR, Bromfeld LM, Higgins DJ. The effectiveness of parent education and home visiting child maltreatment prevention programs. Child Abuse Prevention Issues. no.24 Autumn 2006.
10. Kelly, RF (2000). Family preservation and reunification programs in child protection cases: Effectiveness, best practices, and implications for legal representation, judicial practice, and public policy. Family Law Quarterly, 34(3), 359-391.
11. National Center for Injury Prevention and Control. Using Evidence-Based Parenting Programs to Advance CDC Efforts in Child Maltreatment Prevention Research Activities. Atlanta (GA): Centers for Disease Control and Prevention; 2004.
12. Geeraert L, Van den Noortgate W, Grietens H, Onghena P. The Effects of Early Prevention Programs for Families with Young Children at Risk for Physical Child Abuse and Neglect: A Meta-Analysis. Child Maltreatment, Vol. 9, No. 3, 277-291:2004.
13. Merrill EJ. Physical Abuse of Children: An Agency Study, in V De Francis, ed., Protecting the Battered Child (Denver: American Human Association, 1962).
14. Glasser W. (1986). Control Theory -- A New Explanation of How We Control Our Lives. Harper and Row, New York
15. Flowers RB. Domestic Crimes, Family Violence and Child Abuse: A Study of Contemporary American Society. McFarland, 2000.
16. Finkelhor D, Gelles RJ. The Dark Side of Families: Current Family Violence Research. SAGE, 1983.
17. Belsky, J. 1984. "The Determinants of Parenting: A Process Model." Child Development. 55: 83-96.
18. Harrington D, Dubowitz H, Chapter 5 in, Family Violence: Prevention and Treatment. Hampton RL. SAGE, 1999.
19. Project 12-Ways: Behavior Analysis & Therapy Program of the Rehabilitation Institute at Southern Illinois University. http://www.p12ways.siu.edu/

Improving Interventions for Domestic Violence: A Community-Based Ethnographic Approach – Rachel Stein

Current Interventions for Domestic Violence

Nearly one third of American women become victims of domestic violence at some point during their lifetimes (1). The true prevalence of domestic violence is likely higher than the percentage reported, as many women are reluctant to admit to being victimized and abused (2). Their reluctance demands an explanation. What is it about how domestic violence is screened that prevents women from disclosing their experiences? Current approaches to screening have multiple limitations, and their weaknesses are evident in three key areas: the setting of the screening, the questions asked, and the recommended interventions for a positive screen. These approaches to domestic violence are deeply rooted in the individualistic notions of western biomedicine, and it is this paradigm that renders these approaches inadequate to address this pervasive public health problem.

Setting

Most screening for domestic violence occurs in a clinical setting, usually between a physician and a patient. Doctors are trained to ask questions about domestic violence as part of taking a patient’s social history. As the average time allotted for primary care appointments is fifteen minutes, this screening must elicit the necessary information in the shortest amount of time possible. Moreover, the social history tends to be the last element of a patient’s history that is taken, and many physicians, pressured by their chronically overbooked schedules, are not able to find time to ask these questions. Consequently, only one to fifteen percent of all women are asked about domestic violence by their primary care doctors (3).

When a physician is able to make the time to screen for domestic violence, women may not feel comfortable sharing this intimate aspect of their lives. It has been reported that over 90 percent of women screened for domestic violence feel comfortable answering the questions that clinicians ask them (4). Public health practitioners subscribing to the western biomedical paradigm would find this screening intervention an enormous success. These practitioners, however, may not take into account that most of the women in the sample studied were low-income African American women who were employed and unmarried, as the biomedical paradigm neglects the social factors that contribute to an individual’s health behavior. Given this sociocultural context, it may not be accurate to assume that 90 percent of all women feel comfortable answering screening questions about domestic violence.

Domestic violence transcends race, ethnicity, class, and other sociocultural factors, and women that belong to different subtypes of these categories have different conceptions of and levels of comfort with disclosing information about their intimate relationships. For example, although African American women may confide in their physicians readily, as in the example given above, Orthodox Jewish women may not. Orthodox Jewish culture discourages speaking about private issues and life experiences, including marriage and intimacy, outside of one’s immediate family. In this culture, it is also shameful to admit to having marital problems. An Orthodox Jewish woman is therefore less likely to report domestic violence and to seek help (5).

In addition to considering cultural differentials in privacy, it is important to be aware of how a woman would feel answering questions about domestic violence when her children are with her, which is often the case in a clinical setting. Overall, women are more comfortable answering questions about domestic violence when they are alone than when they are with their children, particularly when the questions refer to feeling unsafe. Latina women tend to be less comfortable disclosing incidences of domestic violence when their children are present than White and Black women. Their higher level of discomfort may be explained the desire to adhere to the “machismo” culture, to be loyal to their families, and to maintain their privacy in front of their children (6).

These findings suggest that the clinical setting may not be the most appropriate place to screen for domestic violence for all women. Practitioners who subscribe to the biomedical approach may not come to this realization, and many women and children may wrongfully be assumed to be safe in their home environments.

Questions

Domestic violence screening based on the western biomedical paradigm not only occurs in an inopportune setting but also may ask inappropriate questions. Two screening tools that are recommended in the clinical setting, likely because of their brevity, are the HITS (Hurt-Insult-Threaten-Scream) and the WAST (Woman Abuse Screening Tool). The HITS asks women about the frequency of physical violence, insults, threats, and screaming or cursing in their relationships. The WAST inquires about the amount of tension in a relationship, degree of difficulty in resolving arguments, feelings of self worth, fear, and physical, emotional, and sexual abuse (7). These questions are problematic on multiple levels: the various ways that they can be interpreted, their potential to be considered disrespectful in certain cultures, and their disregard for context.

People of different backgrounds have different understandings of what domestic violence entails and have different expectations for what they will be asked to disclose to a stranger, including to a physician. Latina women, who report greater discomfort than White and Black women when answering questions about domestic violence in the presence of their children, have different conceptions of domestic violence than White and Black women. They perceive it as physical and emotional abuse more than sexual and financial abuse, all of which health care providers define as domestic violence. Latina women also recognize men’s expectations of women to shoulder a greater burden of household work as a form of abuse, while most providers do not (8). The questions asked in the HITS and WAST may therefore be confusing and disconcerting for Latina women because they ask about experiences that these women may not consider domestic violence. The screening questions may imply that certain experiences that Latina women consider normal are pathological and may suggest that certain experiences that these women find problematic are of no concern.

Latina women may also interpret the precise words used in the questions differently from their physicians. For example, the HITS asks how often a woman’s partner curses at her. This use of the word “curse” refers to swearing or using insulting language. In Latino culture, however, “curse” refers to the invocation of evil spirits against another person (9). This question would likely not elicit the information about which a health care provider had intended to inquire.

In addition to understanding cultural differences in conceptions of domestic violence and in interpretations of the screening questions, the structure of and manner of asking these questions is also important and may present a barrier to screening. Modes of communication are highly culturally specific, and disregarding these differences may pose severe problems in addressing domestic violence. This inadequacy is clearly delineated in the experience of American Indian women. The prevalence of domestic violence is higher among American Indian/Alaska Native women than among White, Black, and Asian/Pacific Islander women (10). Screening American Indian women for domestic violence, however, may be more harmful than helpful to them. According to Mescalero Apache culture, it is impolite to ask direct questions because they force an individual to give a forthright and potentially embarrassing answer (11). The HITS and WAST, which are designed to be concise and direct to accommodate the short amount of time allotted for primary care appointments, would be inappropriate and disrespectful to ask to a Mescalero Apache woman and may prevent her from seeking medical care in the future.

The questions asked in the HITS and WAST reflect the western biomedical paradigm in their disregard for cultural differences and decontextualization of domestic violence. It is important for clinicians to be aware that the questions they ask and the manner in which they ask those questions may be interpreted differently by women from various backgrounds. Additionally, the questions do not enable clinicians and patients to understand what the other means by “domestic violence.” These discrepancies limit the ability of domestic violence screening to accurately assess the prevalence of domestic violence and prevent clinicians from helping and empowering women to escape abuse and victimization.

Interventions

The lack of cultural competency in screening for domestic violence, both in the setting of the screening and in the questions asked, deters women from disclosing their true life experiences. Even if these limitations are overcome and a woman admits to being victimized, a clinician may not be equipped with appropriate resources to help her. Many clinicians do not screen for domestic violence because they would not know what to do if the screen was positive. Furthermore, the interventions that are recommended are directed towards individual women in isolated circumstances, failing to address the context of domestic violence and to approach this issue at the group or societal level.

The United States Preventive Task Force has identified certain criteria to evaluate the effectiveness of a screening tool. A test is required to have a certain degree of accuracy, measured by sensitivity and specificity, and the screening as well as the subsequent action taken must lead to improved outcomes. Regarding the second criteria for follow-up care, unlike a positive screening for cervical cancer, which is followed by a standard protocol consisting of repeat pap smears and possibly a colposcopy, the follow-up for a positive screening for domestic violence is an intimidating enigma for many physicians (12). In response to this uncertainty, a group of clinicians in California developed the AVDR – Asking, Validation, Documentation, and Referring – model for physicians to follow when confronted with a case of domestic violence. In the first step, physicians are encouraged to ask women about safety in general and specifically in their relationships. If they disclose that they are not safe, the model then suggests that the physician state clearly that abuse is not acceptable, express concern for the patient, and explain to her that she is not to blame. In the third step, a clinician is to document signs and symptoms of abuse and record the patient’s story. Finally, the model provides physicians with a list of resources where they may refer a patient, including local agencies, hotlines, and shelters, and suggests that they create a plan to follow up with her (13).

Although the AVDR model demonstrates compassion and encourages a doctor-patient relationship based on support and trust, it fails to contextualize domestic violence. Women do not exist in a vacuum, and without taking into account sociocultural determinants of behavior, physicians cannot fully understand why a woman would not disclose being victimized or would not leave an abusive relationship. The model does not suggest that providers inquire about cultural worldviews or social policies that may unintentionally permit domestic violence, such as the emphasis of gender role separation in Orthodox Jewish culture (14). The AVDR model also holds individual women responsible for taking action, while in many cultures, change at a group or societal level would be more beneficial. The biomedical approach to societal problems views society as “individuals en masse” rather than as a whole being, and this conception is not effective “when the target [domestic violence] is a social entity with its own laws and dynamics” (15).

The current approach to screening for domestic violence is inadequate in its setting, in the content and manner of the questions asked, and in the recommended interventions for a positive screen, as is evident by the reluctance of many women to disclose this information even when their own and their children’s well-being are at risk. The limitations of this screening are rooted in its foundation in the western biomedical paradigm, which neglects the sociocultural determinants of behavior and which approaches behavior change at the individual level rather than at the group or societal level. Only by considering these crucial factors and by confronting domestic violence at these multiple levels can effective screening tools and interventions be designed to empower women to ensure the safety of themselves and their children.

An Alternative Intervention for Domestic Violence

Given the limitations of current approaches to domestic violence based on the western biomedical paradigm, alternative screening interventions founded upon theories of the social sciences may be more effective. These interventions would directly address the context of domestic violence and would approach this issue at the individual and group levels. In doing so, they would construct comfortable settings for screening, develop appropriate screening questions, and recommend proper interventions.

Setting

Screening for domestic violence in a medical setting is often not conducive to eliciting disclosures of domestic violence. To locate more appropriate settings for screening women, it may be helpful for public health practitioners to conduct field work in the targeted communities, as recommended by the Cultural Theory. This theory emphasizes the influence of society and culture on human behavior, and fieldwork is one method of data collection that enables investigators to discover the social and cultural nuances of specific communities.

By immersing themselves in the community, observing people and events, and interviewing community members, public health practitioners may find that rather than screening women in primary care clinics and health centers, screening women in settings where they spend time on a regular basis and where they feel most comfortable may be more effective. Screening could take place in schools, community centers, and religious institutions. In Early Intervention programs, which seek to help children at risk for developmental, emotional, social, behavioral, and school problems, ongoing service coordinators meet regularly with the children’s caretakers in their homes and at the children’s day care centers to ensure that they are receiving the services that they need (16,17). Head Start programs, which help prepare low-income pre-school children for school and provide social services to their families, have a similar design. Each family is assigned a family case manager, who supports families with issues of employment, housing, immigration, health care, education, finances, and family communication and relations. Family case managers meet with the children’s caretakers regularly at the Head Start sites (18). Screening for domestic violence in Early Intervention sites, Head Start preschools, and other locations where women regularly spend time would not place a great burden on them in terms of travel, and these locations are familiar places where women may feel more at ease.

Screening interventions for domestic violence may also benefit from modeling the Early Intervention and Head Start programs’ employment of community members as ongoing service coordinators and family case managers. One third of Head Start staff members were initially involved as parents of children in Head Start programs (19), which places them in a unique position to help other parents in their communities. Women may feel more comfortable sharing personal information with their peers than with their doctors. There are also cultural differences in notions of privacy that impose barriers to the disclosure of domestic violence. While African American women may feel more comfortable sharing intimate aspects of their lives with their physicians (20), Orthodox Jewish women may not. The pressure that the Orthodox Jewish community places on avoiding a shanda, a shame that brings disgrace to all Jews by revealing the imperfections of the community, discourages women from disclosing incidences of domestic violence to their health care providers. Providing these women with peer counselors and advocates may empower them to speak freely about the more intimate aspects of their lives without causing a shanda (21). Domestic violence screening conducted in settings such as Early Intervention and Head Start sites and implemented by service coordinators and case managers who are members of the target community would thus likely improve the accuracy of the screening and ensure that women who are victims of domestic violence are receiving the services that they need.

Questions

The ethnographic focus of the Cultural Theory could also be used to design more culturally appropriate and respectful domestic violence screening questions. Conducting fieldwork among the Mescalero Apache has taught anthropologists that members of this community find direct inquiries disrespectful and discourteous because they force the individuals being questioned to reveal personal information that they may not feel comfortable sharing (22). Asking less direct and more open-ended questions may not only help women feel more at ease but also elicit more complete and helpful responses. These types of questions are those for which physicians strive yet often fail to ask due to time constraints, but they are questions that anthropologists are experts in asking. They directly address social context and past experiences, and they enable domestic violence screening to unravel a woman’s true story.

Pediatricians, child psychiatrists, and early childhood experts have suggested taking a similar ethnographic approach to parenting. They encourage parents to reflect back on their own childhoods, as unresolved fears and experiences from the past may compromise their relationships with their children (23). The questions they recommend that parents ask themselves and that pediatricians address inquire about their most vivid memories, their relationships with their parents, how they felt when they were separated from their parents, how they were disciplined, their experiences of trauma and loss, their meaningful relationships with people other than their parents, and how they see their own childhoods influencing how they interact with their children (24).

Applying this model to domestic violence, screening questions could be designed to provide greater context of women’s past and current situations. These questions would be asked in a sequence from least to most intrusive, allowing women to feel more comfortable with and to begin to trust their peers, service coordinators, or case managers implementing the screening. First, women may be asked whether they feel safe in their current relationships, and, as the Cultural Theory would recommend, what they mean by “safe.” Subsequent questions may ask women whether they experienced domestic violence as a child, whether they know others who are or were in abusive relationships (although perhaps using a more mild term), how they feel that their relationships with their partners affect their children, and other open-ended questions. Such questions would promote a strong relationship between women and their peers conducting the screening, and the stories that these questions elicit will enable their peers to connect them to appropriate and effective resources.

Interventions

Many physicians do not screen for domestic violence because they would not know what to do if confronted with a positive result. Additionally, the resources that they are able to offer women are often limited. Problem Solving Education (PSE) is an alternative intervention, currently used to treat depression, that addresses many of the inadequacies of current interventions. PSE draws from both the Cultural Theory and Maslow’s Hierarchy of Needs and can be effectively implemented by peer counselors in informal settings.

PSE consists of seven steps that an individual and counselor work through together to help that individual overcome the daily challenges contributing to his or her depressed mood. These steps include defining the problem, setting realistic and tangible goals for problem resolution, brainstorming multiple solutions to achieve those goals, creating guidelines for decision-making, using those guidelines to evaluate potential solutions, enacting the solution chosen, and evaluating the outcome. PSE is conducted over four to six 30-minute sessions, and individuals and their counselors focus on a different problem or challenge during each session. Reflecting principles of Maslow’s Hierarchy of Needs, these problems must be simple, specific, and describable in objective terms, such that lower order needs are met before higher order needs are addressed (25). PSE has been shown to be successful in treating depression in the primary care setting (26) and is currently being evaluated as an intervention for depression among mothers with infants in neonatal intensive care units (I acquired most of the information about PSE discussed in this paper through my experience working with the pediatrician conducting this clinical trial). Applying this model to interventions for domestic violence, women and their peer counselors, or problem solving educators, could take small steps to ultimately work towards the goal of leaving an abusive relationship.

As suggested by the Cultural Theory, culture is a crucial factor motivating behavior change, and in designing PSE as an intervention for domestic violence, it is important to take culture into account. Problem solving educators would ideally be members of their clients’ communities. They may be familiar with the challenges that these women face, be well-informed about available resources, and be able to help these women devise creative and culturally acceptable solutions to their problems. Problem solving educators from the women’s communities would also be able to meet them in accessible and familiar places. Furthermore, because PSE requires only a few hours to complete, service coordinators and case managers from Early Intervention, Head Start, and similar programs could serve as problem solving educators and, after having screened women for domestic violence, could integrate PSE into their existing counseling sessions.

To improve upon the inadequacies of current domestic violence screening and interventions, which are rooted in the individualistic principles of western biomedical theory, public health practitioners may employ social science theories to design more culturally acceptable and effective interventions. These alternative interventions would be implemented in appropriate and comfortable settings for women, would ask culturally sensitive and open-ended questions based on ethnographic techniques, and would promote a community-based team approach to overcoming the daily challenges that women face. These interventions would address the larger context underlying cases of domestic violence and would approach the issue at both the individual and group levels. In doing so, these alternative interventions would be able to more accurately screen women for domestic violence and more successfully meet the needs of women who screen positively.

References

1. Family Violence Prevention Fund Get the Facts. Domestic Violence Is a Serious, Widespread Social Problem in America: The Facts. San Francisco, CA: Family Violence Prevention Fund, 2008. http://endabuse.org/resources/facts/.
2. Felson R, Pare, P-P. The Reporting of Domestic Violence and Sexual Assault by Nonstrangers to the Police. University Park, PA: Pennsylvania State University, 2005.
3. Chen P et al. Randomized Comparison of Three Methods to Screen for Domestic Violence in Family Practice. Annals of Family Medicine 2007; 5:430.

4. Chen 433.

5. Horsburgh B. Lifting the Veil of Secrecy: Domestic Violence in the Jewish Community (pp. 207, 220). In: Sokoloff NJ, ed. Domestic Violence at the Margins: Readings on Race, Class, Gender, and Culture. Piscataway, NJ: Rutgers University Press, 2005.

6. Zink T et al. Mothers’ Comfort with Screening Questions about Sensitive Issues, Including Domestic Violence. Journal of the American Board of Family Medicine 2006; 19:363-364.

7. Chen appendix.

8. Lewis MJ et al. Perceptions of Service Providers and Community Members on Intimate Partner Violence within a Latino Community. Health Education and Behavior 2005; 32:75.

9. Curse (p.661). In: Langenscheidt Editorial Staff, ed. Langenscheidt Compact Spanish Dictionary. New York, NY: Langenscheidt, 2004.

10. Grossman SF, Lundy M. Domestic Violence across Race and Ethnicity: Implications for Social Work Practice and Policy. Violence against Women 2007; 13:1032.

11. Farrer CR. Play and Inter-Ethnic Communication: A Practical Ethnography of the Mescalero Apache. New York: Garland Publishing, 1990.

12. Cole TB. Is Domestic Violence Screening Helpful? Journal of the American Medical Association 2000; 284: 552.
13. Gerbert B et al. Simplifying Physicians' Response to Domestic Violence. Western Journal of Medicine 2000; 172:329-330.

14. Horsburgh 207.

15. Susser M, Susser E. Choosing a Future for Epidemiology: I. Eras and Paradigms. American Journal of Public Health 1996; 86: 671.

16. Feldman MA. Introduction: What is Early Intervention? (pp. 1-2). In: Feldman MA, ed. Early Intervention: The Essential Readings. United Kingdom: Blackwell Publishing, 2004.

17. New York State Department of Health. The Early Intervention Program: A Parent's Guide for Children with Special Needs - Birth to Age Three. Albany, NY: New York State Department of Health. http://www.health.state.ny.us/community/infants_children/early_intervention/parents_guide/step4.htm.

18. Boston Head Start and Children’s Services. Head Start. Boston, MA: Action for Boston Community Development, Inc. http://www.bostonheadstart.org/our-services/head-start/.

19. Boston Head Start and Children’s Services. Head Start Families. Boston, MA: Action for Boston Community Development, Inc. http://www.bostonheadstart.org/families/.

20. Chen P 433.

21. Horsburgh 207.

22. Farrer C.

23. Zuckerman B, Zuckerman P, Siegel D. Promoting Self-Understanding in Parents - for the Great Good of Your Patients. Contemporary Pediatrics 2005; 22: 78.

24. Contemporary Pediatrics Guide for Parents. Ask Yourself About Your Childhood - and Make Yourself a Stronger Parent. Woodcliff Lake, NJ: Contemporary Pediatrics. http://contemporarypediatrics.modernmedicine.com/contpeds/data/articlestandard//contpeds/162005/156681/article.pdf.

25. Hegel MT et al. Training Residents in Problem-Solving Treatment of Depression: A Pilot Feasibility and Impact Study. Family Medicine 2004; 36: 204-208.
26. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR. Randomised Controlled Trial Comparing Problem Solving Treatment with Amitriptyline and Placebo for Major Depression in Primary Care. BMJ 1995; 310: 441-445.