Connecting the dots : a white paper on the cooccurrence of family violence and child maltreatment : working together to end commercial sexual exploitation of children in Georgia

Table of Contents
Executive Summary ..................................................................................................................................... 2 Part I: Defining the Problem, Engaging the Discourse ................................................................................ 5
Introduction .............................................................................................................................................. 5 Family Violence ......................................................................................................................................... 5 Child Maltreatment................................................................................................................................... 7 The Co-Occurrence of Family Violence and Child Maltreatment ............................................................. 8 Part II: Exploring the Effects, Outcomes, and Risk Factors ....................................................................... 10 Why the Exposure is Harmful to Children............................................................................................... 10 Psychological Effects and Outcomes....................................................................................................... 10 Health and Behavior Outcomes .............................................................................................................. 11 Risk and Protective Factors..................................................................................................................... 12 Effects of Family Violence on Parenting Practices .................................................................................. 13 Part III: Strategies for Intervention............................................................................................................ 15 Best Practice Elements............................................................................................................................ 15 The Coordinated Community Response Model...................................................................................... 16 The Greenbook Initiative ........................................................................................................................ 17 The Role of Prevention............................................................................................................................ 18 Conclusion............................................................................................................................................... 18 References .................................................................................................................................................. 19

Executive Summary
Family violence and child maltreatment are two very common problems that exist within communities throughout the world, yet often the presence of one can indicate the presence of the other. But, why does this happen? How does this happen? What can be done to intervene and even prevent future incidences? Moreover, what various social, behavioral, and psychological factors play a role in preventing or perpetuating these problems? Several studies have found that there is a significant amount of families that experience or have experienced both family violence and child maltreatment.1-3 Other research has indicated that the presence of violence in the home can increase the likelihood that child maltreatment will also occur.3 It is apparent that the severity of this issue warrants a comprehensive approach to assessment and action.
For many people, the home is not a safe environment. From 1997 through 2007, females were in the home for more than 40% of the incidents in which they fell, were struck by or against a person or object, or were cut or pierced.6 Similarly, children under the age of 15 years had a higher proportion of injuries to the head and neck during this time than any other age group surveyed.6 These findings are consistent with national family violence data which indicate that one in every four women will experience domestic violence at some point in her lifetime, and that more than three women are murdered by their husbands or boyfriends every day.7 More than half of all female victims of intimate partner violence (IPV) report that they have children under 12 years of age who live with them in the home, and 75% of battered women report that their children are also physically and/or sexually abused.7
National research indicates a strong connection between family violence and child maltreatment. The co-occurrence of domestic violence and child maltreatment has been found to be as high as almost 60 percent. Each year between 3 and 10 million children witness some form of domestic violence. A 2004 analysis of adverse childhood event data displayed a significantly higher likelihood of adults having experienced some form of child maltreatment when domestic violence was also present in the home.12 Additional studies have suggested that the presence of IPV increases the odds that all forms of child maltreatment (physical abuse, neglect, and psychological abuse) will also occur.3 Although the statistics on the co-occurrence of family violence and child maltreatment are compelling, there are a variety of factors that families often experience which can increase the likelihood that violence and maltreatment will occur. Recent studies have found correlations between poverty, parental unemployment and substance abuse being more common in homes also found to have domestic violence and child abuse present.12
The co-occurrence of family violence and child maltreatment impedes the healthy development of the child in several areas of functioning including behavioral, psychological, physical, and cognitive. Young victims often report frequently experiencing feelings of isolation, shame, guilt, and fear.12 Many children display symptoms of post-traumatic stress disorder, anxiety and depression, and some may even attempt suicide in adolescence or adulthood.12 Child victims also have higher than average rates of cognitive and emotional impairments which include interruptions in psychological and neurological development, feelings of low self-esteem, the use physical aggression, and problems completing school.12 Some of the most common physical health outcomes associated with exposure to family violence and maltreatment include failure to

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thrive, sleeplessness, eating disorders, poor motor skills, and psychosomatic symptoms.13 For early childhood health, family violence has been found to have considerable indirect effects on health outcomes and is associated with the primary caregiver's health and well-being (usually the mother) as well as quality of the child's interaction with the caregiver.15 Among adolescents, exposure to maltreatment and violence is associated with increased cigarette, alcohol, and other substance use along with participation in risky sexual behaviors.10 One particular study found higher self reports of fair or poor health among adolescents that had been the victims of neglect, physical abuse and sexual abuse, as well as higher rates of depression among victims of neglect and physical abuse.10
Child victims of family violence and maltreatment may also encounter additional adversities or barriers that place them at risk for a myriad of problems later in life. These risk factors include low socioeconomic status, neighborhood disadvantage, parents' abuse of drugs and alcohol, and criminality within the family.12 Additional factors such as living in a community with frequent exposure to drugs, guns and crime; being administered harsh or erratic discipline; and being isolated from the community, family, or school place young victims at a higher risk of perpetrating juvenile violence.16 But despite the harmful influences of violence, abuse and the additional risk factors, many victimized children do not exhibit signs of disturbance or negative behaviors and outcomes. This is only possible as a result of protective factors that act as a buffer against the harmful impact of family violence and maltreatment. The primary protective factors identified are the following: high intelligence of the child, internal locus of control, positive self image and high self esteem, and a determination to be different from the abusive parents or caregivers.12 Additional factors that have emerged through recent research include a positive relationship with a caring and supportive adult, having a strong commitment to school, having parents and peers who disapprove of antisocial behaviors, and being involved in a religious community.12
Family violence does not only have an effect on the development of child victims, but an effect on parenting practices as well. In fact, the quality of the relationship that parents have with child victims is a strong predictor of future development and outcomes.17 This particularly pertains to the child's relationship with the mother. Mothers who are victims of domestic violence appear to have higher depression levels, less education, less available social support, and live in households with lower socioeconomic status and higher levels of family dysfunction than mothers not exposed to domestic violence.17 This can have a negative impact on the quality of maternal parenting. With fathers and male caregivers being the primary perpetrators of family violence within the home, very little attention has been paid to the effects of the violence on their own parent-child interactions. The small amount of data that is available suggest that male batterers tend to be more inconsistent and harsher in disciplinary practices towards their children than battered women.19 In crafting models of intervention for family violence and child maltreatment, there is a growing need to address the parental role of batterers in order to establish comprehensive programming that accurately mirrors the needs of communities.20
Effective interventions have been shown to be one of the most important factors in children successfully surviving the violence and abuse they experience.16 Over the past thirty years, advocates have sought to design and implement interventions that address the unique needs of family violence victims, especially child victims. However, there is much debate and scarce research on which elements of an intervention produce the most positive results. Preliminary

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evidence suggests that incorporating the following elements are essential in creating comprehensive interventions: increasing protective factors and decreasing risk factors for child victims; increasing social capital for family units; working with perpetrators in their parenting role; and building the capacity of communities to prevent violence and maltreatment.
Recent research has pointed to the need for a "Coordinated Community Response" (CCR) system approach in which family violence services within a community form a collaborative initiative in order to increase communication and resource exchange between providers while closing service gaps and removing the burden from victims of locating appropriate services. In essence, service providers and agencies operate under one umbrella, and in some cases, even under one roof. There are multiple strategies which can be used in a CCR approach. The most commonly used include community partnering, community intervention, task forces or coordinating councils, training and technical assistance projects, and community organizing.23 When implementing a CCR system, the best approach is to use elements from several, if not all, of the different strategy types.
Despite the tremendous amount of progress that has been made in both understanding and addressing domestic violence and maltreatment, it is imperative that the role of prevention is not forgotten as programs continue to focus primarily on adult victims and crisis response.25 Unfortunately, prevention has largely remained absent from the current policies and programs in place, yet prevention holds the key in keeping future generations of men, women, and children safe from violence.25 Sporadic research regarding the role of prevention has concluded that targeting efforts towards adolescents and young adults of both genders provides for a way to identify and address pathways to violence early in an individual's life so that patterns of abuse or victimization do not emerge during adulthood.25 Adolescence is also the period where patterns of violent behavior and victimization can emerge based on exposure to violence and abuse, as well as the harmful effects associated with such exposure.25 The most vulnerable groups of young people most likely to develop these patterns of violence and victimization include youth transitioning from foster care and incarceration, young adolescents, serious offenders, and young parents.25 These groups are in need of specific interventions tailored to their unique and sometimes overlapping needs.
Engaging current discourse, identifying risk factors and outcomes, and presenting strategies for intervention and prevention is an important first step in creating a plan to end the co-occurrence of family violence and child maltreatment. The next step is to use the information that has been provided in order to craft a strategy for the future, as well as bring together key stakeholders who have an awareness of the problem and a commitment to using a comprehensive approach in order to address it. A multi-disciplinary, collaborative response should not only seek to end violence and abuse while serving the needs of victims, but should also promote efforts that will sustain healthy families and healthy communities.

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Part I: Defining the Problem, Engaging the Discourse

Introduction
Family violence and child maltreatment are two very common problems that exist within communities throughout the world, yet often the presence of one can indicate the presence of the other. But, why does this happen? How does this happen? What can be done to intervene and even prevent future incidences? Moreover, what various social, behavioral, and psychological factors play a role in preventing or perpetuating these problems? These questions regarding the co-occurrence of family violence and child maltreatment have plagued researchers for over 20 years. Several studies have found that a significant amount of families experience or have experienced both family violence and child maltreatment.1-3 Other research has indicated that the presence of violence in the home can increase the likelihood that child maltreatment will also occur.3 It is apparent that the severity of this issue warrants a comprehensive approach to assessment and action. This white paper will engage the current discourse on the co-occurrence of family violence and child maltreatment; discuss the physical, emotional, and behavioral effects and outcomes associated with exposure and perpetration; identify risk and protective factors; and present recommendations for intervention and prevention efforts based on nationally recognized best practice methodologies. In essence, this report seeks to "connect the dots" between a prevailing problem and effective solutions.
Family Violence
There is currently a persistent debate regarding how to define family violence in terms of what to include in the construct and on which specific actions or behaviors to focus. One research definition presents that family violence is acts of omission or commission by family members that result in physical abuse, emotional abuse, sexual abuse, neglect, or other forms of maltreatment which impede the healthy development of the individuals affected.4 Another definition, provided by the American Academy of Family Physicians (AAFP), states that it is the intentional abuse or intimidation of children, adults, or elders by another family member, intimate partner or caretaker for the purpose of gaining power and control over those victimized.4 The AAFP defines the abuse in many forms including physical abuse, sexual assault, psychological mistreatment, threats and intimidation, economic abuse, and violation of rights.4 This definition is considerably inclusive as it highlights the issue of power and control, as well as including psychological mistreatment as a form of abuse. The AAFP's definition is also similar to the definition of intimate partner violence (IPV), perhaps the most common form of family violence, defined by the Centers for Disease Control and Prevention (CDC). According to the CDC, intimate partner violence involves the physical, psychological, and/or sexual harm by a current or former spouse or partner.5 IPV can occur among both heterosexual and same-sex couples, and often varies in severity and frequency. Within this definition the CDC presents that IPV is divided into four main types: physical violence, sexual violence, threats of physical or sexual violence, and psychological violence.5 Physical violence is the purposeful use of physical force with the potential for causing injury, disability, harm, or death, and ranges anywhere from pushing and shoving to the use of weapons.5 Sexual violence involves the use of physical force

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to oblige a person to engage in a sexual act; an attempted or completed sex act with a person who is unable to understand the nature of the act; and abusive sexual contact.5 Psychological violence
includes, but is not limited to, the use of humiliation, controlling what a person can and cannot do, isolating a person from friends and family, and denying access to money or basic resources.5
Threatening behaviors are words, weapons, and gestures used against a person to communicate the intent to cause harm or death.5 Although there are many definitions of family violence, the
majority of which were not included in this discussion, it is important that a consistent definition
is used in order to examine trends over time, identify risk and protective factors, and inform
intervention and prevention efforts.
For many people, the home is not a safe environment. National statistics show that the home was the leading place where injuries most occurred from 1997 through 2007.6 Unfortunately,
being struck by or against a person or an object was one of the four leading causes of injury that occurred in the home during this time.6 The most common type of injuries reported were sprains or strains, followed by contusions or superficial injuries.6 From 1997 through 2007, females
were in the home for more than 40% of the incidents in which they fell, were struck by or against a person or object, or were cut or pierced.6 Similarly, children under the age of 15 years had a
higher proportion of injuries to the head and neck during this time than any other age group surveyed.6 These findings are consistent with national family violence data that indicate one in
every four women will experience domestic violence at some point in her lifetime, and that more than three women are murdered by their husbands or boyfriends every day.7 More than half of
all female victims of IPV report they have children under 12 years of age who live with them in the home.7
As with the definition, there is considerable variability in the many theories related to the factors
and development of family violence. Several of the more popular theories include: social learning theory, ecological theory, sociocultural theory, and feminist theory.4 Social learning
theory presents that individuals learn situations and targets for aggression through patterns of
punishments and reinforcements they experience, as well as through observation of the behaviors and consequences experienced by significant others.4 According to the theory, children who
observe or experience family violence are likely to repeat this same behavior in their own family relationships as adults.4 Ecological theory is a theoretical framework which addresses factors at
different levels of the human ecological system, particularly focusing on variables of a community such as social cohesion and social isolation.4 This theory emphasizes the importance of paying attention to these variables when addressing family violence.4 Several studies found
that communities with high rates of child maltreatment also had characteristics of social
disorganization (such as criminal activity) and lack of social coherence (lack of services and support networks).4 Similar to social learning theory, sociocultural theory presents that norms
within an individual's peer group and community can contribute to the likelihood that violence will be considered an acceptable alternative to dealing with conflict in the home.4 For example,
a man's peer group may support norms regarding sex roles that favor the superiority of men and
the subordination of women and children, thereby making it acceptable for a man to use violence within his family in order to maintain control.4 Perhaps one of the more controversial theories,
feminist theory supports the perspective that family violence is a gendered problem in which interactions among victims and perpetrators are profoundly influenced by gender and power.4
This theory places the responsibility for violence within the family on males operating in a

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patriarchal system that consistently denies equal rights to women and legitimizes violence against women and children.4
Child Maltreatment
According to the CDC, child maltreatment is defined as: "any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential harm, or threat of harm to a child." 8 Acts of commission, also referred to as child abuse, are intentional and deliberate and apply only to the action rather than the consequence of that action.8 Physical abuse, sexual abuse, and psychological abuse are all forms of maltreatment that involve acts of commission.8 On the other hand, acts of omission involve the failure to provide for a child's basic needs, or the failure to protect a child from harm or potential harm.8 Physical neglect, emotional neglect, medical neglect, and educational neglect are all examples of failure to provide for a child's basic needs, whereas inadequate supervision and exposing a child to violent environments are examples of failure to protect a child from harm.8
In 2007 alone, U.S. local and state child protective service agencies investigated approximately 3.2 million reports of child maltreatment, with about 794,000 of the children involved being identified as victims (a rate of 10.6 per 1,000 children).9 Of the maltreatment victims identified, 59% were victims of neglect, 11% were victims of physical abuse, 8% were victims of sexual abuse, and 4% were victims of emotional abuse.9 In that same year, about 1,760 children ages 0 to 17 years died from abuse and neglect.9 Of these deaths, 76% of the victims were under the age of 4 years, and 13% were between the ages of 4 and 7 years.9 Overall, the majority of female perpetrators are mothers and the majority of male perpetrators are fathers, and girls are at a slightly higher risk than boys for all forms of maltreatment.9 In a 2006 study conducted to assess the prevalence, risk factors and adolescent health consequences of child maltreatment, researchers found that self-reports of childhood maltreatment by young adult respondents were very common.10 Out of a nationally representative sample of 15,197 young adults surveyed, 41.5% reported that they were left home alone at least once during childhood when an adult should have been supervising them, indicating supervision neglect.10 Of the respondents that reported supervision neglect, 19% reported that this occurred more than three times during childhood.10 More than one in four respondents (about 28%) reported physical assault at least once, and about 14% reported that this occurred more than three times.10 Physical neglect, defined by a caregiver failing to meet basic needs such as food or clothing, was reported to have occurred at least once during childhood by about 11.8% of the respondents with around 5% reporting an occurrence of more than three times.10 Finally, around 5% of the young adults reported being sexually abused by a parent or adult caregiver by the time they entered sixth grade.10
According to the definition of child maltreatment provided by the CDC, exposure to violence or violent environments is a failure on the part of the parent or caregiver to protect a child from harm. Therefore, it is part of the child abuse continuum. But unfortunately, millions of children and youth are exposed to violence in their homes, schools, and communities each year in the United States. This exposure can either be indirect (witnessing a violent act) or direct (being the victim of a violent act). The 2008 National Survey of Children's Exposure to Violence

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(NatSCEV) found that more than 60% of children surveyed were exposed to violence within that past year.11 Researchers found that more than 25% had witnessed an act of violence, about 10% witnessed one family member assault another member, 6% had experienced sexual violence, and around 10% experienced some form of child maltreatment.11 About one in five girls between the ages of 14 and 17 years had been the victim of a completed or attempted sexual assault, and more than one-third of both male and female adolescents within that same age range had witnessed the assault of a parent.11 Nearly 87% of the children who reported lifetime exposure to violence also reported having been exposed to violence within the past year, indicating that these children were at a continual risk for being victimized.11 The researchers also found that children who were exposed to at least one type of violence, both within the past year or over their lifetimes, were at a much greater risk of experiencing other types.11 For instance, a child who had been physically assaulted within the past year was four times as likely to have also been maltreated and five times as likely to have experienced sexual violence within that same period.11 Data also showed that witnessing violence was an occurrence that increased as children grew older, and the most common type was violence in the community.11 More than 70% of adolescents surveyed reported witnessing violence against another person at some point in their lives.11 Unfortunately, the NatSCEV findings indicate that exposure to violence is a frequent occurrence for many children across the country.
The Co-occurrence of Family Violence and Child Maltreatment
National research indicates a strong connection between family violence and child maltreatment. The co-occurrence of domestic violence and child maltreatment has been found to be as high as almost 60 percent. Each year between 3 and 10 million children witness some form of domestic violence, and 75% of battered women report that their children are also physically and/or sexually abused. A 2004 analysis of adverse childhood event data displayed a significantly higher likelihood of adults having experienced some form of child maltreatment when domestic violence was also present in the home.12 The National Crime Victimization Survey estimated that more than 50% of law enforcement calls for severe domestic violence, usually intimate partner violence, were made by homes in which children resided who were less than 12 years of age. 3 Additional studies have suggested that the presence of intimate partner violence increases the odds that all forms of child maltreatment (physical abuse, neglect, and psychological abuse) will also occur.3 Zolotor et al's (2007) study of North and South Carolina mothers found that while 5% reported perpetrating severe intimate partner violence against their partners, more than 7% had reported being the victim of severe intimate partner violence.3 Among this sample, 30% of the children were the victims of one or more types of child maltreatment with mothers reporting that: 11% had received one or more forms of harsh physical punishment; more than 10% received one or more forms of harsh psychological punishment; around 1% were the victims of one or more forms of sexual abuse; and 11% had experienced one or more behaviors consistent with neglect.3 Also, mothers who reported more occurrences of intimate partner violence also reported higher rates of sexual abuse that their children experienced.3 Overall, one third of the mothers surveyed reported the presence of either intimate partner violence or child maltreatment in the home, and over 55% of those mothers who reported intimate partner violence also reported one or more forms of child maltreatment.3

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Although the statistics on the co-occurrence of family violence and child maltreatment are compelling, there are a variety of factors that families often experience which can increase the likelihood that violence and maltreatment will occur. Recent studies have found correlations between poverty, parental unemployment and substance abuse being more common in homes also found to have domestic violence and child abuse present.12 Interestingly, poverty (which includes low socioeconomic status) has been the most documented correlating factor of various overlapping forms of violence, including domestic violence and physical child abuse.12 The prevalence of prior substance abuse, mental illness and crime within the family has also been found to be higher in homes where one or more forms of domestic violence and/or child maltreatment have been reported.12 Particularly, the father's experience with these issues can play an even more significant role in whether there is a higher incidence of co-occurrence.12 Additional correlating factors for the co-occurrence of child maltreatment and family violence include insufficient household income, physical illness in the family, overcrowding in the home, breakup of the family, child behavior problems, recent or frequent family moves, lack of social support and resources, and community crime and violence.12
The exposure of the child to incidents of family violence is important to discuss when looking at the co-occurrence of child maltreatment for two reasons. One, children are often present in the home during these incidents, and two, exposure to violence is considered part of the child maltreatment continuum. Most of the existing research regarding children's exposure to family violence focuses on instances in which the child has been exposed to violence perpetrated against the mother frequently and chronically.13 However, this is not the only pattern of violence that children can be exposed to within the home. The victim can also be a stepmother or stepfather, dating partner of the parent (usually the father's partner), or live-in partner of the mother or father.13 Sometimes the mother is the perpetrator of the violence, and other times the child will observe the mother's use of violence in situations of self-defense.13 The severity and frequency of the family violence to which children are exposed can vary as well. Some children live in situations where the violence is less severe and parents or caregivers routinely shove, slap, and throw things at each other throughout the duration of their marriage or relationship.13 Other children may witness a sudden eruption of violence in the home, as a result of stressful events or the dissolution of the parents' relationship, yet the violence ends after a brief period of time.13 There are also numerous ways that a child can be exposed to violence. Although children can be direct observers of a violent incident in the home, they can also be participants and even sometimes the targets of an attack along with the victim.13 There is even a growing body of literature regarding children who witness occurrences of sexual violence in the home, and the percentage for these incidences has been found in some studies to be as high as 20%.13
The co-occurrence of family violence and child maltreatment impedes the healthy development of the child in several areas of functioning including behavioral, psychological, physical, and cognitive. The second part of this paper will focus on the effects and outcomes of family violence and child maltreatment, and will examine these effects based on the type and severity of the co-occurrence experienced combined with the stage of child development at the time of occurrence. An assessment will also be made of the various risk and protective factors associated with these particular effects and outcomes. The role of the parents (or primary caregivers) will also be discussed in regards to how family violence and child maltreatment affect parent-child interactions, as well as overall parenting style.

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Part II: Exploring the Effects, Outcomes, and Risk Factors

Why the Exposure is Harmful to Children
Although children exposed to family violence and child maltreatment cannot be described as having one specific pattern of response, research has provided evidence that the experience of one and/or both of these issues can have harmful effects on the health and well-being of a child. Children are also affected by family violence and child maltreatment both directly and indirectly. They are affected directly in terms of the physical danger involved with being present for incidences of family violence or experiencing maltreatment; the development of emotional and behavioral problems resulting from exposure over time; and the aggressive behavioral patterns that are learned and often perpetuated both within and outside of the home.13 The indirect effects include the impact of a victimized mother's poor physical and mental outcomes on parent-child interactions; the quality, or lack thereof, of the relationship with the paternal figure who is usually the perpetrator of the violence and maltreatment; and the inconsistent or harsh disciplinary practices administered by parents who may be stressed and distracted.13 Another area of concern is the idea that children raised in homes where violence and maltreatment occur may be more likely to perpetrate or become victims of violence as adults.13 Known as "intergenerational transmission" of violence, this idea is characterized by the notion that violent or victimizing family patterns are passed down from the parent to the child.13 While a fair amount of research supports the validity of this idea, further research is needed in order to determine the process by which these patterns are successfully as well as unsuccessfully passed from parent to child.13

Psychological Effects and Outcomes
There are numerous adverse psychological and psychosocial effects associated with exposure to family violence and child maltreatment. Young victims often report frequently experiencing feelings of isolation, shame, guilt, and fear.12 Many children display symptoms of post-traumatic stress disorder, anxiety and depression, and some may even attempt suicide in adolescence or adulthood.12 Child victims also have higher than average rates of cognitive and emotional impairments which include interruptions in psychological and neurological development, feelings of low self-esteem, the use of physical aggression, and problems completing school.12 A 2003 meta-analytic review of 118 studies regarding the effect sizes of psychosocial outcomes for children exposed to family violence and/or abuse found that there was a significant association between exposure and negative outcomes, with about 63% of child victims having poorer outcomes than an average child who had not experienced family violence or abuse.14 The review also determined that: there were similar levels of adjustment problems for children who had experienced maltreatment and witnessed family violence versus those who had just been exposed to family violence; children who were exposed to violence between parents demonstrated outcomes that were significantly worse than children who were exposed to other forms of interparental conflict; and that relative to other children, children exposed to violence between parents showed higher negative affect and cognition in response to hypothetical situations of interadult conflict.14 The results of the meta-analysis demonstrated that overall,

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exposure to violence and abuse was associated with significant disruptions in the psychosocial functioning of child victims.14

Health and Behavioral Outcomes
Some of the most common physical health outcomes associated with exposure to family violence and maltreatment include failure to thrive, sleeplessness, eating disorders, poor motor skills, and psychosomatic symptoms.13 For early childhood health, family violence has been found to have considerable indirect effects on health outcomes and is associated with the primary caregiver's health and well-being (usually the mother) as well as quality of the child's interaction with the caregiver.15 Also, the primary caregiver's depression and verbal aggression towards the child are both significantly related to child behavioral problems.15 Among adolescents, exposure to maltreatment and violence is associated with increased cigarette, alcohol and other substance use along with participation in risky sexual behaviors.10 One particular study found higher self reports of fair or poor health among adolescents that had been the victims of neglect, physical abuse and sexual abuse, as well as higher rates of depression among victims of neglect and physical abuse.10
There are several factors which can determine the extent of the health and behavioral impact that family violence and child maltreatment will have on young victims. Two of these factors include the age and developmental level of the child, as well as the child's gender. For infants in violent environments, their awareness of the emotional states of their caregivers combined with the neglect they may suffer as a result of not receiving from their distressed mothers the intense physical care needed can cause health problems such as being underweight, having problems eating and sleeping, inconsolable crying, and unresponsiveness to adults.13 They are also at a serious risk for being injured during incidents of family violence because of their physical fragility.13 Toddlers and preschool-aged children will often exhibit signs of emotional and behavioral problems, and may even behave more aggressively in order to express themselves and ward off real or imagined aggression towards them.13 Victims in this age group may also become demanding, talkative, clingy, anxious, sad, and have difficulty interacting with peers and adults.13 They may also regress in behaviors such as toilet training.13
Young, school-aged children often feel confused and conflicted about family violence and maltreatment, and as they mature tend to blame themselves for occurrences within the home. As they enter school, behavior problems become apparent as they begin to interact with teachers and peers, and aggressive behaviors are frequently displayed.13 They may also have conduct problems; become emotionally needy, fearful and anxious; and suffer from low self-esteem, sadness, and depression.13 These victims often have academic problems which can delay normal progression through school, as well as noticeable difficulties interacting with peers.13
During adolescence, the health and behavioral outcomes experienced by victims may be even more alarming as many of them have lived with family violence and maltreatment for many years and may exhibit evidence of longer-term effects.13, 16 Adolescent victims are more likely to drop out of school before completion, become pregnant at a young age, suffer from depression, attempt suicide, and engage in delinquent, violent and substance use behaviors.12 Eating disorders such as anorexia, bulimia or obesity can also develop, along with the use of aggressive

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behavior practices among peers modeled after violent patterns learned in the home.16 Adolescence is also the time where victims may begin entering into dating relationships, and exposure to violence and maltreatment may cause them to perpetuate the patterns of victimization and aggression learned from parents or caregivers, thereby continuing the generational cycle of violence.16
Gender differences can also contribute to the various outcomes experienced by young victims of violence and maltreatment. Several studies have indicated that victimized boys are more likely to exhibit externalizing behaviors and conduct problems than girls, and will use aggressive behavior with peers and other adults.13 Research has also determined that boys who witness violence between their parents are twice as likely to physically abuse their own wives in adulthood than boys who are not exposed to violence in the home.16 Girls victimized by violence and maltreatment have been found to exhibit more internalizing behaviors such as depression and anxiety, and in some cases exhibit more depression than boys.13 However, not all research findings support the pattern of girls exhibiting more internalizing behaviors than boys. Girls who live in homes with violence and maltreatment present will often run away from home as a means of escape; however this can lead them into further risk behaviors and victimizing situations such as commercial sexual exploitation (sometimes referred to as child prostitution) and survival sex. This fact is consistent with the finding that over 70% of females in the juvenile justice system report being physically and/or sexually assaulted during childhood, as well as coming from violent home environments.16
Risk and Protective Factors
Child victims of family violence and maltreatment may also encounter additional adversities or barriers that place them at risk for a myriad of problems later in life. These risk factors include low socioeconomic status, neighborhood disadvantage, parents' abuse of drugs and alcohol, and criminality within the family.12 Additional factors such as living in a community with frequent exposure to drugs, guns and crime; being administered harsh or erratic discipline; and being isolated from the community, family, or school place young victims at a higher risk of perpetrating juvenile violence.16 But despite the harmful influences of violence, abuse and the additional risk factors, many victimized children do not exhibit signs of disturbance or negative behaviors and outcomes. This is only possible as a result of protective factors that act as a buffer against the harmful impact of violence and abuse. Protective factors are individual qualities, experiences, and aspects of the social environment which increase the likelihood that a child will develop resilience.12 Although research focused on protective factors has been limited to date, a handful of studies have produced several factors that appear to protect children against the effects and outcomes of maltreatment and family violence. The primary protective factors identified are the following: high intelligence of the child, internal locus of control, positive self image and high self esteem, and a determination to be different from the abusive parents or caregivers.12 Additional factors that have emerged through recent research include a positive relationship with a caring and supportive adult, having a strong commitment to school, having parents and peers who disapprove of antisocial behaviors, and being involved in a religious community.12

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Effects of Family Violence on Parenting Practices
Family violence does not only have an effect on the development of child victims, but also has an effect on parenting practices as well. In fact, the quality of the relationship that parents have with child victims is a strong predictor of future development and outcomes.17 This particularly pertains to the child's relationship with the mother. Mothers who are victims of domestic violence appear to have higher depression levels, less education, less available social support, and live in households with lower socioeconomic status and higher levels of family dysfunction than mothers not exposed to domestic violence.17 This can have a negative impact on the quality of maternal parenting. Several studies have found that victimized mothers report more stress associated with parenting, display less warmth, and experience more conflict with their children.2 One particular study determined that the use of psychological aggression and corporal punishment by a mother experiencing intimate partner violence can actually act as a significant moderator of the relationship between a child's exposure to violence and negative behavioral outcomes.2 There are, however, studies that contradict the hypothesis that victimized mothers exhibit adverse parenting practices, with several of them finding no differences between victimized and nonvictimized women in their use of verbal and physical aggression, reasoning, and physical affection.2 A 2007 Canadian study found that mothers of children exposed to domestic violence actually showed a greater increase in positive discipline practices compared to mothers of children who had not been exposed.17 The same sample of victimized mothers also demonstrated less of a decrease in warm and nurturing behaviors over time than mothers who had not been victimized.17 These findings support the assertion among some researchers that mothers experiencing domestic violence may actually seek to compensate in interactions with their children by being more attentive and sensitive.17
There is a significant relationship between child maltreatment and adolescent motherhood. Ninety-six percent of adolescent mothers in one study had experienced some form of maltreatment during childhood.18 Adolescent mothers who are victims of family violence and maltreatment are an important population to consider in the assessment of the effects on parenting. Young mothers, particularly those living in urban areas, are at a relatively high risk for violence in their families and intimate relationships.18 Many adolescent mothers come from families with histories of both physical and sexual abuse, neglect, and family violence.18 In addition, the relationships with their male partners are often violent.18 Prevalence rates for intimate partner violence among pregnant or parenting adolescents range from 12% to 50%.18 Consequently, this population of young mothers is more likely to report physically abusing their own children than young mothers who had not experienced family violence and abuse.18
With fathers and male caregivers being the primary perpetrators of family violence within the home, very little attention has been paid to the effects of violence on their own parent-child interactions. The small amount of data that is available suggest that male batterers tend to be more inconsistent and harsher in disciplinary practices towards their children than battered women.19 But even if men do not physically abuse their children, they could still be considered as psychologically or emotionally abusive since they are responsible for their children's exposure to violence.19 This may cause fathers to develop feelings of parental incompetence, as well as feel stress associated with parenting.19 For example, more than half of male batterers in one survey reported that they believed their physical violence and verbal abuse made their children feel scared.20 In crafting models of intervention for family violence and child maltreatment,

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there is a growing need to address the parental role of batterers in order to establish comprehensive programming that accurately mirrors the needs of families.20
So now that the discourse has been engaged and the effects, outcomes and risk factors identified, what are the next steps in the process? The final part of this paper will focus on the elements needed to create an effective response in order to address the co-occurrence of family violence and child maltreatment. Best practice strategies will be highlighted, including a nationally recognized initiative specifically designed to combat this issue. Concluding thoughts will look toward the future and the tasks that lay ahead.

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Part III: Strategies for Intervention

Best Practice Elements
Effective interventions have been shown to be one of the most important factors in children successfully surviving the violence and abuse they experience.16 Over the past thirty years, advocates have sought to design and implement interventions that address the unique needs of family violence victims, especially the children. However, there is much debate and scarce research on which elements of an intervention produce the most positive results. Preliminary evidence suggests that incorporating the following elements are essential in creating comprehensive interventions: increasing protective factors and decreasing risk factors for child victims; increasing social capital for family units; working with perpetrators in their parenting role; and building the capacity of communities to prevent violence and maltreatment. To increase protective factors while decreasing risk factors, examining how the various risk factors operate in combination with the co-occurrence of violence and child abuse is an important first step towards developing strategies for young victims.12 The next step is to individualize treatment plans based on each victim's experiences with violence and abuse, looking for the protective factors that may already be in place as well as the risk factors that are present. A recent study found that increasing the number of protective factors for a child victim lowered the risk of several negative outcomes associated with various risk factors already present.12
Social capital is theoretical resources available to a family, such as human and financial resources, that help families prosper socioeconomically and/or overcome adverse situations.21 These resources include collective efficacy, strong social networks and a psychological sense of community, neighborhood cohesion, and parental investment in the child.21 Low social capital has been found to be a risk factor for violence, increased school dropouts, childhood injuries, poor behavioral and cognitive outcomes, and overall mortality.21 The concept had previously been studied on the larger community level, but recent interest has been raised among public health agencies and social scientists about how increasing social capital for individual families can improve well-being and lower the risk for violence and maltreatment in the home.21 Parents of maltreated children exhibit smaller social networks and less overall access to them, more social isolation, and report having lived in their neighborhoods for less time.21 Zolotor et al.'s (2006) study on the relationship between social capital and family reports of violence and maltreatment found that each 1-point increase in the social capital index was associated with a 30% decrease in the odds of maltreatment and violence.21 These findings provide evidence that higher levels of social support and social networks significantly correlate with lower rates of child maltreatment.21 Increasing the levels of social capital for at risk families can decrease the odds that violence, destructive behaviors and maltreatment in the home will be reported.21 By promoting safe communities, social programming and policies that foster healthy relationships between parents and children, social capital provides a model for how to improve the lives of families.21
Batterer intervention programs are a standard component of most coordinated response efforts designed to address family violence. However, there has been a growing need expressed to work with batterers in their individual role as parents. Recommendations for developing parenting

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intervention programs for perpetrators of domestic violence and child abuse include incorporating the program into existing batterer intervention programming as an additional stage of treatment to be completed after the standard intervention.20 The basic themes for the program which would guide curriculum development are that exposure to violence and abuse in the home is harmful to children, and that positive changes in behavior on the part of the batterer towards the other parent will ultimately benefit the child.20 A curriculum supported by these themes would seek to educate batterers about the damaging effects of domestic violence and maltreatment on the child and the other parent's practices, as well as work with them to make changes in their own parenting practices.20
A community's capacity to prevent violence is conceptualized in terms of collective efficacy, defined as the interaction among social networks that leads to a sense of shared trust and ability to take action.22 In the realm of family violence and child maltreatment, an ecological framework is used to describe the specific levels of those interactions among communities, families, and individuals.22 It is in the nature of the various interactions within and between these ecological levels that violence and maltreatment occur and co-occur.22 The belief is that neighborhoods can actually be strengthened by increasing their available resources, as well as increasing the connectedness within and between them.22 In building a community's capacity to effectively respond to violence, several elements are particularly important. First, capacity must be thought of in terms of social interactions, and bridges must be built among organizations and agencies for the purposes of sharing resources to meet needs and connecting communities into a broader social fabric.22 Second, it is important to learn how strong social ties on both the private and public levels can foster trust and social control which will enhance or build collective efficacy.22 Third, the role of state controls must be considered, and a proper balance between public, private, and state controls must be maintained.22 It is beneficial to note here that there is increased support for the notion of a single state agency or governing body initiating coordinated response efforts in collaboration with the public and private levels. Although collaboration occurs among all levels, the centralization of efforts and operations remains within that single agency in order to maximize organizational efficiency and accountability for resources expended. Whether a community achieves the goal of building its capacity to prevent violence is related to the extent that programs facilitate social interactions which provide resources to areas in distress, properly use state controls to provide a correct balance based on the needs of the community, and produce patterns of interactions that build trust and the ability for collective action.22 Much of the literature on capacity building supports the use of a coordinated community response model as an intervention that successfully incorporates these elements in order to develop programming aimed at addressing and preventing violence and maltreatment.22
The Coordinated Community Response Model
Recent research has pointed to the need for a "Coordinated Community Response" (CCR) system approach in which family violence services within a community form a collaborative initiative in order to increase communication and resource exchange between providers while closing service gaps and removing the burden from a victim to locate appropriate services. In essence, service providers and agencies operate under one umbrella, and in some cases, even under one roof.

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There are multiple strategies that can be used in a CCR approach. The most commonly used include community partnering, community intervention, task forces or coordinating councils, training and technical assistance projects, and community organizing.23 Community partnering is a decentralized model in which the family violence program identifies a strategic plan for action, and then partners community organizations' and individuals' work on various initiatives of the plan.23 The work is collaborative among various community partners for each initiative, although each initiative operates simultaneously within the community.23 The family violence program organizes and oversees all of the work taking place.23 Community intervention projects are designed for the purpose of enhancing the justice system's response to victims, and working with all sectors of the justice and mental health systems to safeguard family violence victims and end violence in the community.23 This approach is similar to community partnering in that a community-based organization is the central coordinating hub, yet differs in the sense that direct services are provided to perpetrators during their involvement in the justice system.23
Task forces seek to coordinate all components of the criminal justice and human services systems in order to improve practice, communication, and collaboration.23 Their work usually begins with an assessment of the current practices and resources within a community, followed by a report on system deficits and recommendations for improvement. The task force may then compile a work plan to implement change and increase coordination efforts. 23 Training and technical assistance projects are focused on improving human service and justice system practices through collaborative trainings targeted towards legal, community-based, and even medical service providers working directly with victims and their families.23 Finally, community organizing initiatives are those that invite members of the community and general public to become active participants in working to end family violence. Within these initiatives organizing strategies are utilized in order to enhance safety and achieve social justice for victims, expand the number of active participants involved in the work, articulate a universal message, transform the public discourse, and raise consciousness about family violence and child maltreatment.23 Community organizing initiatives are usually more effective at engaging communities of color and other marginalized groups in partnership.23 When implementing a CCR system, the best approach is to use elements from several, if not all, of the different strategy types.
The Greenbook Initiative
In 1999, the National Council of Juvenile and Family Court Judges produced a publication entitled Effective Intervention in Domestic Violence and Child Maltreatment Cases: Guidelines for Policy and Practice, which would eventually become known as the Greenbook.24 The document offers principles and recommendations for successful programming focused specifically on addressing the co-occurrence of family violence and child maltreatment through coordinated collaboration among the child protection system, domestic violence programs, and the courts.24 A multi-disciplinary approach is encouraged for programming strategies in order to improve outcomes for family violence victims and their children while holding batterers accountable for their use of violence.24 The primary purpose of the Greenbook Initiative project was to utilize federal funding sources to develop intervention programs in several communities which employed the various guidelines and recommendations outlined in the Greenbook.24 From 2000-2007 the U.S. Departments of Justice and Health and Human Services, in partnership with

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several private organizations, funded six demonstration sites across the country to implement the Greenbook's policies and practices.24 Preliminary findings from these original sites have been promising, and additional curriculum and tools have been developed as a result of each site's experiences. The Initiative has become a nationally recognized best practice intervention model for the co-occurrence of violence and maltreatment.
The Role of Prevention
Despite the tremendous amount of progress that has been made in both understanding and addressing domestic violence and maltreatment, it is imperative that the role of prevention is not forgotten as programs continue to focus primarily on adult victims and crisis response.25 Unfortunately, prevention has remained largely absent from the current policies and programs in place, yet prevention holds the key in keeping future generations of men, women, and children safe from violence.25 Sporadic research regarding the role of prevention has concluded that targeting efforts towards adolescents and young adults of both genders provides for a way to identify and address pathways to violence early in an individual's life so that patterns of abuse or victimization do not emerge during adulthood.25 Youth between the ages of 16 and 24 are at the greatest risk of domestic violence than any other age group.25 This group is most at risk because adolescence is a formative period where many youth are exposed to violence within their homes as well as within their dating relationships.25 Adolescence is also the period where patterns of violent behavior and victimization can emerge based on prior exposure to violence and abuse, as well as the harmful effects associated with such exposure.25 The most vulnerable groups of young people most likely to develop these patterns of violence and victimization include youth transitioning from foster care and incarceration, young adolescents, serious offenders, and young parents.25 These groups are in need of specific interventions tailored to their unique and sometimes overlapping needs. For prevention efforts targeted towards adolescents and young adults, programs should address the risks to individuals as well as the conditions of their community settings.25 These programs should also include elements for building individual skills and changing the social climate of a particular setting.25
Conclusion
Engaging current discourse, identifying risk factors and outcomes, and presenting strategies for intervention and prevention is an important first step in creating a plan to end the co-occurrence of family violence and child maltreatment. The next step is to use the information that has been provided in order to craft a strategy for the future, as well as bring together key stakeholders who have an awareness of the problem and a commitment to using a comprehensive approach in order to address it. A true multi-disciplinary, collaborative response should not only seek to end violence and abuse while serving the needs of victims, but should also promote efforts that will sustain healthy families and healthy communities.

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References
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20. Mandel D. Working with Batterers as Parents: What would a curriculum look like? Issues in Family Violence 2002;4(3). 21. Zolotor A, Runyan D. Social Capital, Family Violence, and Neglect. Pediatrics 2006;117(6):e1124-e31. 22. Sabol W, Coulton C, Korbin J. Building Community Capacity for Violence Prevention. Journal of Interpersonal Violence 2004;19(3):322-40. 23. Hart BJ. Coordinated Community Approaches to Domestic Violence. In: Strategic Planning Workshop on Violence Against Women. Washington, D.C.: National Institute of Justice; 1995. 24. Allo J, Ptak A. If I Knew Then What I Know Now: Project Leadership in Multi-System Change Efforts to Address the Co-Occurrence of Domestic Violence and Child Maltreatment. In: National Council of Juvenile and Family Court Judges; 2009. 25. Rosewater A. Promoting Prevention, Targeting Teens: An Emerging Agenda to Reduce Domestic Violence. In. San Francisco, CA: Family Violence Prevention Fund,; 2004.

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