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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Service needs of children exposed to domestic violence: Qualitative findings from a statewide survey of domestic violence agencies☆

Kristen A. Berg1, Anna E. Bender, Kylie E. Evans, Megan R. Holmes⁎, Alexis P. Davis2, Alyssa L. Scaggs, Jennifer A. King Center on Trauma and Adversity at the Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, United States

A R T I C L E I N F O

Keywords: Intimate partner violence Child maltreatment Family violence Intervention Trauma-informed care

A B S T R A C T

Objective: Each year, more than 6% of all U.S. children are exposed to domestic violence and require inter- vention services from agencies that serve affected families. Previous research has examined detrimental biop- sychosocial consequences of domestic violence exposure during childhood and the importance of effective prevention and intervention services for this population. However, less research has explored diverse inter- vention professionals’ own perspectives on the needs of the domestic violence-exposed children they serve. Method: This study employed an inductive approach to thematic analysis to investigate intervention profes- sionals’ reflections and advice regarding the service, policy, and research needs as well as overall strategies to better protect children exposed to domestic violence. Results: Respondents articulated four primary themes of (a) building general education and awareness of the effects of domestic violence exposure on children; (b) the need for trauma-informed care; (c) the salience of cultural humility in serving affected families; and (d) essential collaboration across service domains. Respondents discussed these themes in the context of four key systems of care: the clinical or therapy, family, school, and judicial systems. Conclusions: Future research should integrate the voices of affected children and families as well as examine models for effectively implementing these recommendations into practice settings.

1. Introduction

More than a quarter of children are projected to witness domestic violence (also known as intimate partner violence) in the United States by the time they reach age 18, with an estimated 6.4% of all children exposed each year (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009). Domestic violence exposure induces substantial economic burden nationwide, incurring over $55 billion in aggregate lifetime costs, including increased healthcare spending, increased crime, and reduced labor market productivity (Holmes, Richter, Votruba, Berg, & Bender, 2018). Children who have been exposed to domestic violence are at higher risk for a range of behavioral and mental health problems

compared with non-exposed children (e.g., Fong, Hawes, & Allen, 2019; Kitzmann, Gaylord, Holt, & Kenny, 2003; Vu, Jouriles, McDonald, & Rosenfield, 2016; Wood & Sommers, 2011).

A variety of social service agencies, domestic violence service pro- viders, and other systems of care provide essential services to families impacted by domestic violence. While a growing body of literature has examined service gaps and practitioner perspectives from domestic violence service agencies specifically, less research has examined do- mestic violence-specific agencies in tandem with those that frequently collaborate with domestic violence agencies to address systemic service gaps and/or provide other necessary treatment for trauma. Our study contributes to building this knowledge by surveying such agencies

https://doi.org/10.1016/j.childyouth.2020.105414 Received 13 April 2020; Received in revised form 24 August 2020; Accepted 24 August 2020

☆ Funded through The HealthPath Foundation of Ohio. The contents of this publication do not necessarily reflect the views or policies of the funders. This information is in the public domain. Readers are encouraged to copy and share it, but please credit the authors. Funded through The HealthPath Foundation of Ohio. The contents of this publication do not necessarily reflect the views or policies of the funders. This information is in the public domain. Readers are encouraged to copy and share it, but please credit the authors.

⁎ Corresponding author at: Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-7164, United States.

E-mail address: mholmes@case.edu (M.R. Holmes). 1 Present affiliation: Center for Health Care Research and Policy, The MetroHealth System, 2500 MetroHealth Dr., Cleveland, OH 44109, United States. 2 Present affiliation: Florida Policy Institute, 1001 N Orange Ave., Orlando, FL 32801, United States.

Children and Youth Services Review 118 (2020) 105414

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across the state of Ohio to generate an assessment, from providers’ own perspectives, regarding gaps in service provision and policies crucial to promoting resilience among families and children exposed to domestic violence.

1.1. Prevalence

Domestic violence (DV) refers to physical violence, sexual violence, stalking, and/or psychological aggression perpetrated by a current or former intimate partner (Centers for Disease Control and Prevention, 2016). The CDC’s National Intimate Partner and Sexual Violence Survey (NISVS) estimates that more than 10 million adults each year in the United States are physically assaulted by current or former intimate partners, with more than 1 in 4 women (27.3%) and more than 1 in 10 men (11.5%) victimized by DV at least once in their lives (Breiding et al., 2014). Research suggests that DV is more prevalent among couples with children, placing children at risk for both direct and in- direct witnessing of violence (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006). Children who witness DV may see or hear the violence, attempt to intervene in or stop the violence, or perceive the aftermath of violence such as notice bruising or tension within the household (Cross, Mathews, Tonmyr, Scott, & Ouimet, 2012). In the state of Ohio, the current study’s site, an estimated 163,000 children are exposed to DV annually and 657,000 before the age of 18 (U.S. Census Bureau, 2015).

1.2. Negative effects of childhood domestic violence exposure

Children’s exposure to DV has been linked to a number of deleter- ious outcomes across a range of developmental domains. DV exposure has predicted more internalizing (e.g., anxiety and depressive symp- toms) and externalizing (e.g., hyperactivity and aggression) behaviors in youth, social and emotional impairments, poorer cognitive outcomes, and impaired physiological functioning due to hyper-activated stress responses (Koolick et al., 2016; Perkins & Graham-Bermann, 2012; Saltzman, Holden, Holahan, 2005; Vu, Jouriles et al., 2016). Affected youth also demonstrate higher rates of bullying and dating violence as both perpetrators and victims (Choi & Temple, 2016; Jouriles, Mueller, Rosenfield, McDonald, & Dodson, 2012; Moretti, Obsuth, Odgers, & Reebye, 2006; Voisin & Hong, 2012). These negative sequelae have been observed across developmental stages from infancy to adoles- cence, with DV-exposed youth exhibiting poorer outcomes compared with their nonexposed counterparts (Howell, Barnes, Miller, & Graham- Bermann, 2016).

The detrimental effects of children’s witnessing DV have been lar- gely conceptualized by developmental traumatology and emotional security models. Witnessing the assault of a caregiver at the hands of another caregiver is particularly threatening to children’s sense of safety and well-being. DV signals caregivers’ distress and unhappiness, the possibility of family dissolution, and/or the possibility of a care- giver’s serious harm or death (Davies et al., 2002). Witnessing threat to the integrity or life of a caregiver destabilizes a child’s foundational sense of stability integral to emotional well-being, dysregulates chil- dren’s stress response systems over time, and increases risk of post- traumatic stress symptomatology (Davies & Martin, 2013; De Bellis & Zisk, 2014). Such trauma can impair children’s developing brains and physiologies, increasing vulnerability to adverse behavioral, physical, cognitive, and socioemotional functioning (De Bellis, 2001; De Bellis & Zisk, 2014).

1.3. Co-occurrence of child maltreatment and domestic violence

Children who witness DV are also at increased risk of poly- victimization (i.e., experiencing multiple forms of victimization such as DV exposure with child abuse and/or neglect; Finkelhor, Turner, Hamby, & Ormrod, 2011). A national survey found that 33.9% of youth

who witnessed DV during the past year were also maltreated during the same time period, compared with 8.6% of youth who reported only child maltreatment (Hamby, Finkelhor, Turner, & Ormrod, 2010). In the state of Ohio, approximately 4 in 10 DV-exposed children also ex- perience maltreatment. The Ohio Department of Job and Family Services (2016) reported that 39,401 cases in State Fiscal Year 2014—or 43% of all child maltreatment cases—had a notation of “Concern of Domestic Violence.”

Considering the high rate of co-occurrence, child welfare workers, DV service providers, and law enforcement personnel are all critical in identifying and serving children. However, studies of these providers’ perceived knowledge and competence at addressing co-occurring mal- treatment and DV have found discrepancies. For example, research has found that DV service providers and child welfare personnel were more likely to identify and address DV exposure and child maltreatment, respectively, with limited skills and training around identifying their co-occurrence (Coulter & Mercado-Crespo, 2015; Hazen et al., 2007; Kohl, Barth, Hazen, & Landsverk, 2005). Such evidence suggests com- partmentalized provider training focused on intervention services for families who are, statistically, likely to be dually affected.

1.4. Complex needs of families who experience domestic violence

Families affected by DV, and often co-occurring child maltreatment, experience complex needs consequent of multiple interrelated family traumas. Adults and children exposed to DV are likely to present with symptoms of complex trauma or impairments across regulatory and interpersonal domains (Cook et al., 2017; Pill, Day, & Mildred, 2017). Symptoms of complex trauma, spanning from emotional dysregulation to cognitive and physical difficulties, manifest in unique presentations not necessarily aligned clearly with diagnostic criteria and require more individualized treatment (Cook et al., 2017; Pill et al., 2017; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). DV-affected fa- milies tend to also experience substance use (Afifi, Henriksen, Asmundson, & Sareen, 2012; Macy, Giattina, Parish, & Crosby, 2010), homelessness (Pavao, Alvarez, Baumrind, Induni, & Kimerling, 2007), and interruptions in children’s education (Kiesel, Piescher, & Edleson, 2016). Each of these concerns reflects another domain of service pro- vision in a complex web of presenting needs; however, the ability of agencies to offer such multigenerational and comprehensive services requires additional staffing, training, and logistical considerations.

1.5. Service systems that interface with families affected by domestic violence

Such complex needs demand collaborative, interactive, and co- ordinated systems of care. Historically, DV agencies were established to provide advocacy and wraparound services (e.g., crisis care, safe shelter, legal interventions, counseling) for affected families (Macy et al., 2010a; Panzer, Philip, & Hayward, 2000; Zweig & Burt, 2007). However, in the aftermath of a DV incident, families may also interface with law enforcement, child welfare, school, or medical systems. Re- cognizing the need for a cross-system collaborative response, the seminal Greenbook practice guidelines were published in 1999 by the National Council of Juvenile and Family Court Judges (NCJFCJ), urging the field to reduce service fragmentation and coordinate system re- sponses to children dually exposed to DV and maltreatment (Schechter & Edleson, 1999). Several cooperative response models have since been implemented, including the Safe Start Initiative (Kracke & Cohen, 2008), Handle with Care programs (Bushinski, 2018), coordinated community response teams (Banks, Dutch, & Wang, 2008), and Family Justice Centers (Murray, Wyche, & Johnson, 2020). Despite the colla- borative progress of these initiatives, research documents a history of divergent philosophies and service approaches across agencies involved (Gordon, 1988; Humphreys & Absler, 2011; McKay, 1994). For ex- ample, child welfare approaches often identify the child as the victim

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and the non-offending caregiver as implicitly culpable. In contrast, DV agencies primarily focus on the non-offending caregiver as the victim. The paradigm differences reflected in these two systems, as well as other networks of care, complicate collaborative efforts that would best promote family safety and healing from trauma (Appel & Kim-Appel, 2006; Holmes, Bender, Crampton, Voith, & Prince, 2019).

1.5.1. Challenges faced by service providers In addition to challenges to creating and enacting a collaborative

model of care, providers face multiple other barriers to effectively identifying and serving families affected by DV. Providers report in- adequate training and skills around inclusively serving subpopulations (based on race/ethnicity, sexual orientation, urbanicity, disability status, immigrant status, etc.), rendering those affected families under- served (Helfrich & Simpson, 2006; Lehrner & Allen, 2009; Messing, Ward-Lasher, Thaller, & Bagwell-Gray, 2015). Families have also re- ported barriers to engagement such as fear and distrust of the child welfare, legal, and justice systems (Alaggia, Regehr, & Jenney, 2012; Baker, Cook, & Norris, 2003; Lichenstein & Johnson, 2009). When fa- milies do engage with services, providers articulate limitations around enacting trauma-informed practices—those grounded in recognizing and responding to the cognitive, psychological, socioemotional, and physical consequences of trauma (Leitch, 2017)—to most effectively mitigate the effects of DV exposure (Laing, Irwin, & Toivonen, 2012; Trevillion et al., 2012). Furthermore, providers report challenges around funding to continually meet the needs of families and offer ongoing training and education for staff (Stover & Lent, 2014).

1.6. Current study

While there is research that examines collaborative approaches to serving families affected by DV, to the authors’ knowledge, no study has synthesized open-ended responses both from diverse professionals who directly serve families who have experienced DV, and more peripheral service systems that interface with those primary agencies. Additionally, this study explored perspectives of providers across an entire state, illuminating and assessing the needs of families and service providers across diverse communities. This study employed an in- ductive approach to thematic analysis to explore the following research questions across one state: (a) What do providers experience as the most prevalent service needs for children and youth exposed to domestic violence? (b) What do providers experience as the most prevalent policy needs for children and youth exposed to domestic violence? (c) What do providers experience as the most prevalent research needs for children and youth exposed to domestic violence? (d) What do provi- ders report are the best strategies for protecting children and youth exposed to domestic violence? and (e) What do providers report are the best strategies for reducing the negative effects of domestic violence exposure for children and youth?

2. Method

An electronic statewide survey that solicited open-ended responses was conducted to engage directors of Ohio-based agencies providing services for children exposed to DV. The purpose of the survey was to examine how DV-exposed children were being served by agencies (e.g., types and delivery format of services offered, ages of children served, which evidence-based or promising programs were offered) and to seek information and ideas on how to better serve this population. Data were collected over a 4-month time period in 2016. This study was approved by the Institutional Review Board of a private Midwestern university.

2.1. Participants and setting

The Shelter and Program Referral List on the Ohio Domestic Violence Network website (http://www.odvn.org/survivor/shelter.

html) was first used to locate relevant agencies in the state that pro- vided DV services, resulting in a list of 205 agencies. After removing duplicate agencies that were listed in more than one county, a total of 75 agencies were included as the initial sample. Using an internet-based search, agency directors’ contact information was identified. From October 2016 to November 2016, directors were contacted by the re- search team via postal letter, email, and telephone and invited to complete the electronic Qualtrics survey (survey items described below). In November 2016, to maximize participation, outstanding respondents were invited to participate in a short-version form of the survey. All agencies invited to participate in the survey were sent weekly reminder emails.

Two particular questions on the survey requested that directors list (a) other agencies to which they referred children or youth who needed services not provided by their agency and (b) other agencies within their communities that provided trauma services to children or youth that they had not listed. Through November 2016, responses to these questions yielded an additional 47 agencies, which resulted in a total of 122 agencies across the state that could potentially provide services for youth affected by DV. Of the 122 agencies, 17 were excluded due to the study researchers being either unable to identify the agency itself or being unable to find sufficient contact information with which to ex- tend an invitation to participate in the survey, resulting in a total sample of 105 agencies that were asked to complete the survey. Out of those, 59 completed the entire survey (56.2%), 19 completed a portion of the survey (18.1%), 5 declined or refused to complete the survey (4.8%), and 22 did not respond to the study team’s calls or emails re- garding the survey (20.9%). A total of 78 respondents (74.3%) either completed or partially completed the survey. Among those, 44 (41.9%) provided qualitative responses to at least one of the survey’s open- ended questions and those data were used to synthesize the results presented in this study.

2.2. Survey items

The survey included questions about whether agencies offered ser- vices for children and their non-offending caregivers, whether the agency was able to meet the current demands for children or youth exposed to DV, whether respondents considered their agency to be trauma-informed, the types of services the agencies provided, and the specific evidence-based or promising programs used with children and youth. In addition, agencies were asked to respond via extended, open- ended response to the following questions: As the state of Ohio assesses statewide needs as they relate to DV-exposed children or youth, (a) what recommendation would you make about where to focus particular attention in terms of need related to services?; (b) what recommenda- tion would you make about where to focus particular attention in terms of need related to policy?; (c) what recommendation would you make about where to focus particular attention in terms of need related to research?; (d) What do you think needs to be done to better protect children or youth who are exposed to DV?; and (e) What ideas do you have about reducing negative effects of DV on Ohio’s children or youth? A total of 44 agency respondents offered responses to at least one of these extended questions.

2.3. Analysis approach

All extended text responses from agencies were downloaded from the electronic survey as text files and then uploaded into NVivo qua- litative data analysis computer software, version 11.4.2. Agencies’ collective set of responses were inductively coded by two doctoral-level research assistants using Braun and Clarke’s (2006) approach to the- matic analysis in order to examine both the semantic and conceptual patterning across agency participants’ responses. The coders in- dependently first analyzed verbatim responses with a combination of in vivo and open coding in order to inventory the range of individual

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concepts expressed by participants. Separately, the coders then sorted the in vivo and open codes into emergent categories by conceptual si- milarity and then organized those emergent categories into broader, internally cohesive themes. The coders then reconvened to review, compare, and combine their two resulting coding schemes and re- conciled conceptual discrepancies. This generated one cohesive the- matic scheme by which participants’ responses to the extended response survey questions were classified and organized, as discussed below.

3. Findings

3.1. Descriptives

Table 1 provides descriptive information about the 44 agency pro- viders in the current study. The total number of children reported to have received services in the State Fiscal Year 2016 was 85,213. Of note, because some children interact with multiple systems, it is pos- sible that some children may have been double counted using the four sources of data. Because data were de-identified, it is not possible to know the extent of possible double counting.

The majority of the sample (47.7%) identified themselves as ex- ecutive directors while 4.6% self-identified as clinical directors and 9.1% specifically as DV program directors or coordinators. Just over

18% reported as other directors (e.g., visitation director, shelter di- rector, child advocacy center director), and almost 7% reported as other coordinators (e.g., advocacy coordinator, general coordinator). Another 7% self-identified as other professionals such as administrative assistant or legal advocate. Approximately 45.4% of agencies reported that in addition to offering services for children, they also offered services to support the non-offending caregivers who were parenting the children. Over 60% indicated being able to meet current demands for DV-ex- posed youth to a large or very large extent, though 20% reported meeting children’s needs at a small or very small extent. In total, 84% of respondents considered their agencies to be trauma-informed and 59% indicated their agencies to be using at least one evidence-based or promising intervention or prevention program.

3.2. Thematic analysis findings

Across extended response survey questions, agency providers of- fered four key recommendations to: (a) build general education and awareness surrounding the consequences of children’s exposure to IPV; (b) implement a trauma-informed care framework across child-serving systems; (c) integrate culturally-humble practices across and within systems; and (d) collaborate across systems. Providers made these re- commendations in reference to four primary contexts of the clinical or therapy system (i.e., any behavioral or mental health services for DV- exposed children), family system (i.e., any points of intervention for the family as a whole, such as parenting classes, counseling or support for non-offending parents, or visitation services), school system (i.e., sup- portive services for DV-exposed children in educational settings and schoolwide prevention or intervention curricula), and judicial system (i.e., child welfare services as well as family and criminal court sys- tems). Table 2 displays an abbreviated summary of key study findings.

3.2.1. Education Providers (43%) discussed the importance of promoting general

education and awareness for service providers, school personnel, par- ents, and the broader community on how children are affected by witnessing DV. Advice for better protecting DV-exposed children in- cluded suggestions such as requiring annual trauma-focused training and continuing education credits for all professionals working with children affected by trauma. Responses particularly emphasized the importance of providing general education and awareness within the family system surrounding DV and its detrimental effects on children. As one provider suggested, “the best way to protect the child is to educate the parent about the effects of domestic violence on their children.” Another provider qualified, however, that such information should be carefully and thoughtfully delivered to parents in order to be accessible and thus useful:

Increase education available to parents about domestic violence and how it really relates to their children, but in an engaging way, as most of the information that is delivered today is still targeted toward victim- blaming and is unreceptive to the parent.

Other providers highlighted opportunities for schools to integrate socioemotional health-focused curricula to promote early education, starting in childhood, about healthy relationship dynamics. Some of- fered examples of curriculum content, including: healthy relationship skills, general emotion coping skills, ways through which to identify and express emotions healthily both in the self and in others, emotional intelligence, meditation and mindfulness, safe dating behaviors, and sex-positive and enthusiastic consent-focused sexual health education. Alluding to the preventive capacity of socioemotional education on children’s current and later relationships, one provider suggested that schools could offer “education for children beginning in elementary school regarding healthy relationships.” Another detailed:

Teach more social and emotional skills in school instead of just academic topics, [and] cover healthy relationship skills, sexual health, etc. Include different coping skills built into the curriculum. Some

Table 1 Characteristics of comprising study agencies (n = 44).

N %

Respondent job responsibility a

Executive Director 21 47.7 Clinical Director 2 4.6 DV Program Director or Coordinator 4 9.1 Other Director 8 18.2 Other Coordinator 3 6.8 Other 3 6.8 Missing 6 13.6

Services also offered to non-offending parent Yes 20 45.4 No 2 4.5 No answer 22 50.0

Extent to which able to meet current demands for DV-exposed children

Very small extent 3 6.8 Small extent 6 13.6 Moderate extent 7 15.9 Large extent 16 37.2 Very large extent 11 25.0 No answer 1 2.3

Would expand service area or services if additional funding were available

Yes 39 88.6 No 5 11.4 No answer 0 0

Consider agency to be trauma-informed Yes 37 84.1 No 6 13.6 No answer 1 2.3

Types of services offered Individual counseling for children Age birth to 2 4 9.1 Age 3 to 5 9 20.4 Age 6 to 12 10 22.7 Age 13 to 18 13 29.6

Community outreach 24 54.6 Safety planning 24 54.6 Material resources (transportation, children’s clothing, food, etc.) 23 52.3

Uses at least 1 evidence-based or promising intervention or prevention program

No 2 4.5 Yes 26 59.1 No answer 16 36.4

a Multiple respondents reported more than one job responsibility, rendering these categories (with the exception of “missing”) not mutually-exclusive.

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schools have implemented meditation rooms instead of detention halls with great results.

Beyond the family and school systems, multiple responses called for broad community-wide education. For example, one provider suggested that the state unroll a “public health campaign, to the same level as [those about] drugs and smoking, about the impact of violence on children in Ohio.” Another articulated the crucial role of such education in “taking away the belief that only certain people are affected by do- mestic violence and trauma.”

Providers spoke to the role of active research and its dissemination in promoting education and awareness of the long-term effects of DV, and intervention and prevention knowledge for professionals working with affected families. Providers offered specific research topic ques- tions of interest such as “What [should] relationships with fathers who batter mothers look like?” or “What is the correlation between domestic violence and issues with child learning?” Continued research related to the Adverse Childhood Experiences (ACEs) study (Felitti et al., 1998) and work by professionals like Dr. Bruce Perry (2009) were additionally recommended, as was ensuring the accessibility of such research:

Staff working in this field need to be well-informed and educated on the effects of all forms of violence and trauma on children and families they serve. Therefore, continued research is vital to keeping new and cutting-edge information on the effects of violence in the forefront of their minds as they are treating the children and families. Additionally, continued research is needed to find and refine best evidence-based practices to treat and care for those who have experienced violence and trauma.

3.2.2. Trauma-informed care Providers (36%) repeatedly discussed the need for trauma-informed

care across domains of training, policy, and direct services with which DV-exposed children and families interface. The school system was identified as a particularly crucial context of meaningful intervention to ameliorate the negative effects of DV exposure on children. For in- stance, one provider proposed “Have a trauma specialist assigned to a school district that can come to the school when an issue presents and help the school staff to better serve the child.” Another suggested trauma education for all school personnel interacting with children:

In the schools, I think there needs to be more education about children and the effects of domestic violence and how that appears in the institution. A better understanding of trauma for those allied pro- fessionals could lead to a more trauma-informed approach in the classroom.

Providers’ highlighted the need for all-encompassing trauma-in- formed approaches extended to the judicial system. For instance, one provider reported how challenges in collaborating with child welfare workers limit the entities’ joint capacities to effectively and sensitively address the needs of clients:

Children’s Services is not a solid collaborative partner. Our philo- sophy and processes are often in opposition, especially related to trauma-informed approaches and from a family advocacy and victim’s rights’ perspective (especially right of parenting under VAWA [the Violence Against Women Act]), which poses additional conflict and barriers to collaboration. Further, unaccompanied youth seeking ser- vices including shelter and advocacy are not allowed to remain in our services due to Children’s Services’ approach through their operation of the local Child Advocacy Center. Solutions for these partnerships will help extend services and remove current barriers.

Providers underscored the need for trauma-informed policies in the court and justice system, particularly among child welfare workers and in family and criminal court. Broad recommendations were made to increase the enforcement of DV statutes and, more specifically, for court officials to adopt a trauma-informed approach to visitation decision- making by considering how witnessing DV affects children’s overall well-being. One provider elaborated on how trauma-informed policy would also support more valid and thorough investigations and inter- ventions with DV-affected families in the child welfare system:

Child Welfare does not protect children! Children are ‘terrible’ witnesses to the crimes committed against them. Trauma symptoms, rather than explicit disclosures, need to be taken into consideration when investigating child sexual abuse or domestic violence cases.

Providers additionally warned that the neglect of children’s agency and rights within the justice system may compound the trauma of witnessing violence. One explained:

I think children need to have more rights. It seems that parents have rights and children have almost none. When children are removed from

Table 2 Key qualitative findings from respondent agencies (n = 44).

Theme Meaning Evidence

1. Education Responsive and empathic education is needed to help caregivers understand the effects that witnessing DV has on children. All children would benefit from schools integrating education about socioemotional health into their curricula. Furthermore, general education and awareness of how witnessing violence affects children is needed for broader society.

“Increase education available to parents about domestic violence and how it really relates to their children, but in an engaging way, as most of the information that is delivered today is still targeted toward victim-blaming and is unreceptive to the parent.” “The best way to protect the child is to educate the parent about the effects of domestic violence on their children.”

2. Trauma-Informed Care

Stakeholders in the court and justice systems, educators, school personnel, and other allied professionals should adopt policies that work to mitigate DV-exposed children’s trauma and consciously avoid re-traumatizing them. Professionals– particularly educators– should receive regular training to recognize trauma symptoms and understand the psychological, cognitive, and social effects of children’s trauma.

“Have a trauma specialist assigned to a school district that can come to the school when an issue presents and help the school staff to better serve the child.” “…Teach those who interact with children to know the signs of trauma at every developmental stage” and to provide “more information and education about the long-term effects of trauma on children and their development—cognitively and psychologically.”

3. Cultural Humility Child-serving systems must infuse other-oriented approaches into all levels of service provision that recognize how characteristics of family and community culture affect experiences of DV and trauma. This includes building awareness of the ways in which cultural identity and historical experiences can influence family interactions with systems of care.

“Focus should not just be on what services to offer. It should be on making sure the services provided are culturally competent and trauma-informed.” [there is need for] “mental health counselors for Deaf children exposed to trauma …”

4. Collaboration There remains ongoing need for the various service systems (e.g., education, child welfare, criminal justice, DV advocacy) caring for children and families affected by domestic violence to work jointly and synergistically to best address children’s and families’ needs.

“Intimate partner violence [domestic violence] collaborative approaches will help assure victims who are parents that the common goal is to ensure their right of parenting, support the family, protect the children, and reduce the risk of child removal until it is proven as the last resort and as a temporary measure with input from the victim/parent. There is still too much to lose and therefore victims do not come forward, allowing children to be exposed to violence longer.”

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the home, reunification is always the plan. There are times when children are removed from the home and then returned only to be re- moved again. This is too much trauma for the children and sends a message that their feelings do not matter. This is the same when talking about children participating in the court process and being able to ex- press their feelings and wishes.

Another provider echoed concern for how DV-traumatized youth may be treated in the justice system and the long-term effects of court decisions made without regard for how trauma and traumatic stress affect children over time:

Domestic violence programs for youth who are charged [need to] recognize that many youths who are charged with domestic violence are defending the family against a batterer or are lashing back at a batterer. Too often, the adult who is also charged in the incident has his charge reduced or dismissed and the child is adjudicated.

At the intersection of trauma-informed care and education advice, providers described the importance of disseminating information about trauma-informed care principles through training and education ma- terials. Providers emphasized the need to “teach those who interact with children to know the signs of trauma at every developmental stage” and to provide “more information and education about the long- term effects of trauma on children and their development—cognitively and psychologically.”

3.2.3. Cultural humility Other providers (20%) articulated the importance of cultural hu-

mility, defined as ongoing, other-oriented approaches to providing services that are mindful both that cultural factors affect an individual’s experience surrounding DV, and that culture is fluid and subjective (Tervalon & Murray-García, 1998). For example, one individual de- scribed a gap in services for children in the Deaf community, reporting unmet need for “mental health counselors for Deaf children exposed to trauma, with certification in EMDR [Eye Movement Desensitization and Reprocessing] and play therapy, sand tray therapy and other expressive therapies.” One provider differentiated between the mere presence of services versus those that integrate culturally humble and trauma-in- formed approaches, advising “Focus should not just be on what services to offer. It should be on making sure the services provided are culturally competent and trauma-informed.” Providers relatedly called for re- search to examine “cultural aspects and competency” such as better identifying service barriers faced by members of the Deaf community, the importance of linguistic translation and interpretation services (including sign language and closed-captioning) in DV–related care and educational materials, and effective services for trauma-exposed chil- dren with developmental disabilities and other special needs.

3.2.4. Collaboration A smaller portion of providers (14%) identified the need for colla-

boration across service systems tasked with addressing the needs of children exposed to DV. For instance, speaking to joint efforts between law enforcement and clinical services, one provider suggested the creation of Child Advocacy Centers with forensic investigators in every county across the state. For another, specific policies could be made to legally ensure that children are guaranteed school-based services de- spite relocation from their home districts to DV shelters: “[Enforce] strict guidelines and sanctions for school systems that will not provide services for children who have moved out of their home city to a shelter due to domestic violence.” Advocating for stronger collaboration with DV-affected families, an additional provider described barriers that preclude victims of DV from coming forward, thus promoting extended exposure of children to the violence:

Intimate partner violence [domestic violence] collaborative ap- proaches will help assure victims who are parents that the common goal is to ensure their right of parenting, support the family, protect the children, and reduce the risk of child removal until it is proven as the last resort and as a temporary measure with input from the victim/

parent. There is still too much to lose and therefore victims do not come forward, allowing children to be exposed to violence longer.

4. Discussion

4.1. Practice and policy implications

In the present study, professionals serving DV-exposed children across the state of Ohio provided the following policy, service, and research recommendation: targeted education initiatives focused on the consequences of child exposure to DV, implementation of a trauma- informed care framework across child-serving systems, integration of culturally-humble practices at all system levels, and cross-system col- laboration. Building from these themes, providers specified that these recommendations be integrated across four distinct systems: the clin- ical/therapy system, the family system, the school system, and the ju- dicial system.

4.1.1. Increasing education and policy around the effects of domestic violence, ACEs, and trauma-informed care

More than 40% of agency providers in this study articulated the importance of bolstering community knowledge about the effect of violence exposure and adverse childhood experiences (ACEs) on chil- dren’s development. Aligned with this recommendation, there are several examples across the United States where multidisciplinary education initiatives on ACEs and child violence exposure have been linked with policy enhancements and improved outcomes for youth (Forsadt, Cooper, & Andrews, 2015; Kagi & Regala, 2012; Ko et al., 2008; Purewal et al., 2016). For example, Washington State has im- plemented statewide legislation to facilitate ACEs educational training and awareness programs for helping professionals across several sec- tors, including social work, education, law enforcement, medicine, and the judicial system (Kagi & Regala, 2012). This policy-level approach to statewide ACEs education has resulted in trauma-informed adjustments to juvenile court policies and offender treatment, increased levels of protected funding for family-based home intervention services, and higher levels of cross-system collaboration.

In addition to recommending multidisciplinary ACEs education in- itiatives, providers in the present study also advocated for integration of trauma-informed care at all system levels. Trauma-informed care (TIC) is an orientation to service delivery that recognizes the cognitive, so- cial-emotional, behavioral, and neurodevelopmental impact of trauma on individual and community well-being (Leitch, 2017). At both the agency and individual/clinical level, the TIC model emphasizes a col- laborative approach to clients’ engagement with systems and promotes client safety, empowerment, and resilience. Although models of TIC vary, one common component of a trauma-informed approach with children and families is the implementation of processes and policies that support routine screening for traumatic exposures and related re- actions or symptoms to identify exposed children and intervene as early, and as comprehensively, as possible. Exposure to DV, especially early in life, can create a complex and idiosyncratic symptom picture that requires comprehensive screening and assessment in order to drive individualized, effective intervention. Consequently, many researchers and practitioners across sectors advocate for universal early and routine screenings for childhood exposure to violence in pediatric and other primary healthcare settings (Thackeray, Hibbard, & Dowd, 2010).

Although the comprehensive and cross-discipline nature of TIC has led to widespread appeal among service providers, challenges to TIC implementation remain, including difficulties operationalizing and as- sessing the success of TIC in practice settings and agencies’ limited funding and resources for implementation. As the vast majority of providers in this study indicated that they consider their agencies to be trauma informed, it is worthwhile to note that as of yet there is no uniform definition or understanding of what exactly this means and how it manifests in practice.

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Despite these challenges, however, evidence indicates that TIC ap- proaches have been effective in improving youth outcomes across sys- tems, including the child welfare system (Lang, Campbell, Shanley, Crusto, & Connell, 2016), schools (Dorado, Martinez, McArthur, & Leibovitz, 2016), inpatient psychiatric settings (Azeem, Auila, Rammerth, Binsfeld, & Jones, 2011), pediatric primary care settings (Purewal et al., 2016), and juvenile justice settings (Ford & Blaustein, 2013). One potential starting point for agencies seeking to adopt a TIC approach is to explore the model programs and assessment re- commendations advanced by the National Child Traumatic Stress Net- work (NCTSN) and replicate those that align with the agency’s re- sources and staff capabilities (Ko et al., 2008).

Finally, some respondents emphasized the need for cultural humi- lity within DV service provision for individuals such as those within the Deaf community, the developmental disability and other special needs communities, and those whose primary language is not English. These findings align with growing calls for intersectional approaches to the specific study of children’s exposure to DV (Crenshaw, 1993; Etherington & Baker, 2018). For instance, Rizo and colleagues, in their review on DV and developmental disability, note the absence of services tailored to DV-exposed children with intellectual disabilities (Rizo, Kim, Dababnah, & Garbarino, 2020). Sullivan (2009) had similarly noted, a decade prior, that while research has explored myriad violence ex- posures of children with disabilities, few studies have examined ex- posure to DV among children with disabilities. Although research has examined the discrete identities, or positionalities, of children exposed to DV, far less inquiry has investigated the intersectionality of multiple positionalities. Pivoting from a focus on individual identities to inter- sectionality may render programs and services for DV-exposed children more successful by continually tending to culturally nuanced intra- personal and family dynamics that affect how trauma is experienced, cognitively and emotionally processed, and thus best intervened upon.

4.1.2. Adopting paradigms of cross-system collaboration Respondents underscored the need for improved collaboration

across systems to best serve families affected by DV. In response to nearly all questions, respondents emphasized the need to cultivate or improve collaborations across service systems interfacing with DV-ex- posed children and families. Of specific concern was bridging gaps between the judicial (i.e., family court, child welfare) and DV service systems. As noted previously, nearly half of Ohio children exposed to DV also experience child maltreatment (Ohio Department of Job and Family Services, 2016). Awareness of the need for effective collabora- tion between these two systems garnered attention following the pub- lication of the Greenbook, also known as “Effective Intervention in Domestic Violence and Child Maltreatment: Guidelines and Practice” (National Council of Juvenile and Family Court Judges, Schechter, & Edleson, 1999). The Greenbook provides important, actionable practice guidelines around staff training, assessment, safety planning, and of- fender accountability to reduce fragmentation of services at the inter- section of the child welfare system, DV service system, and the judicial systems to improve care for children and families affected by DV. Al- though the Greenbook has shaped the development and implementa- tion of successful demonstration projects across multiple sites, the ex- periences of respondents detailed here underscore the need for further implementation of these collaborative practices (Banks, Landsverk, & Wang, 2008; Malik, Ward, Janczewski, 2008). The findings from our study, together with a recent review of research and literature (Holmes et al., 2019), underscore that much progress remains–despite the Greenbook being published over 20 years ago– in actually oper- ationalizing concepts of system collaboration in practice. Our findings illuminate areas that remain for further development and innovation, all of which provide an informative foundation for supporting com- munities in building system collaborations.

Other models of collaborative prevention and intervention pro- grams exist. The Centers for Disease Control funded, for example,

community coordinated response sites (CCRs) with the two-fold aim of both preventing DV and providing intervention services following a DV incident (Klevens, Baker, Shelley, & Ingram, 2008). CCRs engage in prevention activities through education campaigns about the scope and causes of DV, training professionals around effective screening, and disseminating information about DV–related policies and services (Klevens et al., 2008). CCRs also strive to improve intervention services by developing substantial and comprehensive cross-systems collabor- ations—implementing comprehensive information-sharing agreements, embedding DV units within law enforcement or child welfare entities, and providing cross-training across service sectors (Klevens et al., 2008).

As alluded to by participants in this study, the implications for such a robust cross-system collaborations are notable. Research from Washington’s Family Policy Council found that areas with collaborative community networks exhibited reduced levels of individual ACEs, as well as social and community problems, compared with regions that did not establish collaborative community networks (Hall, Porter, Longhi, Becker-Green, & Dreyfus, 2012). To best serve children and families affected by DV, continued efforts to build these cross-systems colla- borations are required.

Another such cross-system collaboration initiative specifically in Ohio is the Linking Systems of Care for Children and Youth Project (Linking Systems), a federal demonstration project currently funded in Montana, Virginia, Illinois, and Ohio. One primary objective of Linking Systems is to “build capacity within communities to meet the needs of youth exposed to violence” (Office for Victims of Crime, 2017). The Ohio project site, having entered the demonstration project in 2018, is working to build capacity through multidisciplinary statewide work groups, creation of a trauma-informed care resource directory, and development of a child violence exposure screening tool. Conducting a statewide needs assessment and gap analysis was an essential first step in the Ohio Linking Systems project, as the results ensured appropriate allocation of resources, evidence-informed decision-making, and col- laboration from survivors and stakeholders in both rural and urban areas of the state and from those with historically and philosophically diverging approaches to service provision.

Other collaborations demonstrate the potential utility of person- or family-centered data-sharing frameworks to best care for vulnerable children and families. For example, the Los Angeles County Department of Health Services houses a countywide pilot program titled Whole Person Care aimed at integrating public health and social services data for vulnerable residents who interact with multiple service systems (justice, housing, behavioral health, etc.). By building an information technology infrastructure that merges data at the level of person or family, real-time information is shared across multiple service systems to minimize gaps in communication across those systems and provide real-time care for clients (Armstrong, Elson, & Weir, 2019). Such person-centered data-sharing initiatives could demonstrate utility for families and children affected by DV who would likely benefit from more seamless coordination between, for example, housing authority, child welfare, family court, and education systems. Concerns about sharing data about a victim, for example, across agencies who may also be working with the perpetrator are notable and warranted. However, existing information-sharing programs have been successfully im- plemented in other child-serving systems and may offer useful gui- dance. For instance, in Ohio, Hamilton County’s IDENTITY project merges data from the County’s Child Welfare Information System with Cincinnati Children Hospital’s Electronic Health Record data in order to safely share cross-system information about children in protective custody (Greiner, Beal, Dexheimer, & Krummen, 2020).

4.1.3. Implementing social-emotional and relationship education curricula and school prevention programming

Several service providers advocated for school curricula on healthy relationships and social-emotional skills, suggesting that such

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programming may prevent further violent victimization and/or perpe- tration in this population. This recommendation aligns with previous research demonstrating a linkage between DV exposure and adolescent dating violence (Choi & Temple, 2016; Park & Kim, 2018). As providers in this study suggest, it is possible that early primary prevention pro- gramming on relationship violence may reduce the incidence of chil- dren continuing the cycle of family violence through their own in- volvement in dating violence and adult DV. Indeed, healthy relationship programming in schools has been linked with lower levels of violent victimization and perpetration in dating relationships among DV–exposed teens specifically (DePrince, Chu, Labus, Shirk, & Potter, 2013; Wolfe et al., 2003), as well as in general adolescent populations (Foshee et al., 2005; Wolfe et al., 2009). Thus, primary prevention ef- forts in schools may offer one avenue to address the intergenerational cycle of family violence experienced by some children in DV house- holds.

4.2. Study limitations

The current study contributes valuable knowledge from service providers themselves of how to better serve children and families af- fected by DV, but limitations must be noted. First, though efforts were made to survey a representative statewide sample of agencies through the Ohio Domestic Violence Network website and snowball referrals, approximately one quarter of contacted agencies did not participate. The resulting final sample may be biased in ways pertinent to the aim of this study; for example, agencies with less time and employee resources may have been less likely to respond but, for those reasons, more likely to identify a unique subset of needs not articulated by other partici- pants. The current study did not survey service recipients themselves, and thus the voices of those most affected by gaps in service provision and policy are missing. Future larger-scale studies may employ a mixed- methods design utilizing random sampling of both service providers and recipients in a broader sampling frame to generate more re- presentative and transferable findings. Such a combined quantitative and qualitative approach may also elucidate how characteristics of in- dividual providers and agencies (e.g., role in agency, philosophical approaches to treatment, urban or rural location, extent of alignment with law enforcement, whether or not agency serves a culturally-spe- cific sub-population) may affect the tenor and content of their quali- tative responses. Finally, findings are bound by the state of Ohio and, due to variation in the fabric of DV–related intervention and funding priorities, may not translate to other states or regions in the country.

Despite the challenges presented by this study’s regional specificity, there are still broad implications that can be drawn for programs be- yond the state of Ohio. For example, other states may consider con- ducting a statewide needs assessment and gap analysis–similar to the Ohio Linking Systems collaborative approach–as an essential step in developing a more robust multidisciplinary set of child-serving systems statewide. Furthermore, Ohio is among ten states that has statewide implementation of the Safe & Together Model, a collaborative program provided by child welfare and DV advocate teams to serve dually-ex- posed children and their families (Mandel, 2010; Safe & Together Institute, 2020). Although the benefits of the Safe & Together Model are considerable, our paper highlights that continued collaborative efforts among child-serving systems are still needed, and other states who use the Safe & Together model may share similar needs.

5. Conclusion

This study illuminates critical service needs of children victimized by domestic violence as articulated by Ohio agency providers who work with those children and families. Agency participants call for more general awareness of domestic violence and its deleterious con- sequences for children and, relatedly, the necessity of adopting trauma- informed and culturally humble approaches to working with families.

Finally, participants emphasized integrating cross-system collabora- tions to provide family-centered care to best treat children’s trauma. Although the findings of this Ohio-based study are promising, future research efforts are warranted. Domestic violence is a pressing public health problem across the United States, and additional investigation should identify salient gaps in service provision and research across other states and regions. Importantly, integrating the voices of children and families themselves are crucial to identifying additional short- comings. Together with robust data systems that monitor family needs and collaboratively coordinate to deliver resources, these initiatives may foster optimal outcomes for children who experience the trauma of witnessing domestic violence.

CRediT authorship contribution statement

Kristen A. Berg: Methodology, Formal analysis, Project adminis- tration, Writing – original draft. Anna E. Bender: Formal analysis, Investigation, Writing – original draft. Kylie E. Evans: Writing – original draft, Validation, Writing – review & editing. Megan R. Holmes: Conceptualization, Methodology, Investigation, Supervision, Funding acquisition. Alexis P. Davis: Writing – review & editing. Alyssa L. Scaggs: Data curation. Jennifer A. King: Writing – review & editing, Validation.

Appendix A. Supplementary material

Supplementary data to this article can be found online at https:// doi.org/10.1016/j.childyouth.2020.105414.

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