Family Violence Research,
Assessment and Interventions:
Looking Back, Looking Ahead
Edited byJames E. McCarroll, PhD
John H. Newby, PhD
David M. Benedek, MD
Robert J. Ursano, MD
Nancy Vineburgh, MAInterviews byJames E. McCarroll, PhD
John H. Newby, MSW, PhD

Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Tel: 301-295-2470; Fax: 301-319-6965
www.usuhs.mil/csts | www.CSTSonline.org

Table of Contents
Foreword
Introduction
Contributors
Editors

vii
ix
xi
xviii

Section Introduction: Child Maltreatment
PARENTING
Sandra T. Azar, PhD
The Social-Cognitive Theory of Parenting: A Brief Review of theWork of Sandra T. Azar (Fall 2005)
The Social-Cognitive Theory Applied to Maltreating Parents(Interview with Sandra T. Azar, Fall 2005)
The Social Information Processing (SIP) Model Applied toTeaching Parenting Practices (February 2010)
The Social Information Processing (SIP) Model Applied to Neglectful
Parenting (Interview with Sandra T. Azar, February 2010)
Ernest N. Jouriles, PhD
Child Maltreatment in the Context of Domestic Violence (July 2006)
The Co-Occurrence of Child and Spouse Abuse in Families(Interview with Ernest N. Jouriles, July 2006))
Effects of Domestic Violence on Children: Behavior and Memory(July 2009)
Helping Children in Domestically Violent Families(Interview of Ernest N. Jouriles, July 2009)

3
6
10
16
25
32
36
47

John J. Eckenrode, PhD
Home Visiting: Research Review and Implications for Family Advocacy
Programs (Fall/Winter 2004)
xx
Home Visiting Revisited: One Spoke in the Wheel, Not the Silver Bullet 55(Interview with John J. Eckenrode, Spring 2005)

iv Family Violence Research, Assessment and Interventions

Primary Prevention of Child Maltreatment (January 2010)
Developments in Evidence-Based Home Visiting Program to Prevent
Child Maltreatment (Interview with John J. Eckenrode, July 2009)

65
69

BRAIN DEVELOPMENT AND MALTREATMENT
Bruce D. Perry, MD
The Effects of Violence on the Brain of the Developing Child(January 2008)
The Role of Genetics in Children’s Brain Development (January 2008)
Healthy Families, Healthy Communities(Interview with Bruce D. Perry, January 2008)
The Neurosequential Model of Therapy (May 2009)
Effects of Military Deployment on Children(Interview with Bruce D. Perry, May 2009)

77
80
82
86
91

CHILD NEGLECT
Howard Dubowitz, MD
Meeting Children’s Basic Needs: A Conceptual Model of Child Neglect 105(March 2007)
Conceptualization and Measurement of Child Neglect
110(Interview with Howard Dubowitz, (March 2007)
Project SEEK — A Safe Environment for Every Kid (January 2010)115
A Safe Environment for Every Kid: The SEEK Study
127(Interview with Howard Dubowitz, January 2010)
LONG-TERM EFFECTS OF CHILD MALTREATMENT
Desmond K. Runyan, MD, DrPH
Highlights of Recent LONGSCAN Project Findings(March 2010)
The LONGSCAN Project(Interview with Desmond K. Runyan, February 2010)

127
132

Section Introduction: Domestic Violence
ASSESSMENT IN DOMESTIC VIOLENCE RESEARCH
Lee W. Badger, PhD, MSW
Using Standardized Clients for Problem Assessment(Interview with Lee W. Badger, August 2007)

139

Contents v
Contributors

Mary Ann Forgey, PhD
Knowledge into Action: Brief Review of Research of Mary Ann Forgey 145(April 2006)
Domestic Violence: Understanding the Patterns, Consequences,and Risk Factors (Interview with Mary Ann Forgey, April 2006)
147
The Development and Evalu­ation of an Evidence-Based
Domestic Violence Assessment Procedure for the Army
153
(February 2010)
Research Procedures in the Development and Evalu­ation of an EvidenceBased Domestic Violence Assessment Procedure for the Army
158
(Interview with Mary Ann Forgey and Lee W. Badger, February 2010)
Jacquelyn C. Campbell, PhD, RN, FAAN
Abuse of Active Duty Military Women (October 2006)
Health Consequences of Abuse of Women(Interview with Jacquelyn C. Campbell, October 2006)
Typology Research in Interpersonal Violence
L. Kevin Hamberger, PhD
Review of Research of L. Kevin Hamberger (July 2009)
Intimate Partner Violence: Function, Treatment and Typologies(Interview with L. Kevin Hamberger, July 2009)

167
171

177
181

HEALTH OF DOMESTIC VIOLENCE VICTIMS
Kathleen Kendall-Tackett, PhD
Trends in Interpersonal Violence
187(Interview of Kathleen Kendall-Tackett, August 2007)
Sleep, Fatigue, and Trauma History in New Mothers (February 2010) 192
Effects of Adverse Experiences on New Mothers
194(Interview with Kathleen Kendall-Tackett, February 2010)
MUTUAL DOMESTIC VIOLENCE
Suzanne C. Swan, PhD
Women’s Violence: Research of Suzanne C. Swan and David L. Snow
(January 2006)
The Nature and Patterns of Women’s Violence(Interview with Suzanne C. Swan, January 2006)
Context, Levels, Motivations, and Effects of Men’s and Women’sViolence (May 2009)

197
201
204

vi Family Violence Research, Assessment and Interventions

Victim-Perpetrator Relationships in Domestic Violence(Interview with Suzanne C. Swan, May 2009)

208

ADULT PSYCHOLOGICAL ABUSE
K. Daniel, O’Leary, PhD
Adult Psychological Abuse (March 2009)
Psychological Aggression and Psychological Abuse: Is Therea Difference? (Interview with K. Daniel O’Leary, March 2009)
Section Introduction: Mental Health

213
218
223

DEPRESSION
William R. Beardslee, MD
Depression in Children: An Emphasis on Prevention(Summer 2005)
The Impact of Depression on Children and Families(Interview with William R. Beardslee, Summer 2005)
Extending Programs to Prevent Depression to Communities(September 2009)
Preventive Interventions for Depression and to Promote
Resilience in Children and Families(Interview with William R. Beardslee, September 2009)

225
232
239
245

ALCOHOL AND INTERPERSONAL VIOLENCE
Christopher M. Murphy, PhD
Alcohol and Interpersonal Violence (September 2008)
Domestic Violence and Alcohol Misuse(Interview of Christopher M. Murphy, September 2008)
Review of Associations between Alcohol Use and Interpersonal
Violence (January 2010)
Domestic Violence Counseling: Men, Women, and Substance Abuse(Interview with Christopher M. Murphy, January 2010)

255
258
263
267

Foreword
For over a decade, the Center for the Study of Traumatic Stress (CSTS)
and its Family Violence and Trauma Project has supported the research goalsof the Family Advocacy Program (FAP) of the U.S. Army. We at the CSTS
are pleased to introduce a benchmark of this work, Family Violence Research,
Assessment and Intervention: Looking Back, Looking Ahead, to readership invested in the health, welfare and resilience of Soldiers and Families.
Family Violence Research, Assessment and Intervention: Looking Back,
Looking Ahead is a collection of interviews that have appeared in Joining
Forces Joining Families, a newsletter published by the CSTS to foster researchknowledge and practice among the FAP professional community. This newsletter regularly features an interview with a renowned scholar and practitioner on an important topic concerning family violence and child maltreatment. Family Violence Research, Assessment and Intervention: Looking Back,
Looking Ahead features many of these interviews along with a backgrounddiscussion of the interviewee’s research and methodologies.
Since the start of Operation Iraqi Freedom and Operation Enduring
Freedom, many military families from the active Army component, Army
National Guard and Army Reserve have experienced multiple deployments,
combat injury, and loss of life. These stressors disrupt family routines, affectparenting and undermine a family’s sense of safety — factors that often leadto family and relationship dysfunction.
Family Violence Research, Assessment and Intervention: Looking Back,
Looking Ahead presents a wealth of scientific approaches that are relevant
and applicable to working with populations at risk for family maltreatment.
In light of the present interest in bridging military and civilian health andmental health care to reach soldiers and families who live in communities
throughout the United States, this book can enrich clinical care and advocacy, and contribute to the health and resilience of Army Soldiers and Families
in wartime and peacetime.
Robert J. Ursano, M.D.
Professor of Psychiatry and Neuroscience
Chair, Department of Psychiatry
Uniformed Services University
Director, Center for the Study of Traumatic StressIntroduction
Family Violence Research, Assessment and Intervention: Looking Back,
Looking Ahead is a product of the Center for the Study of Traumatic Stress(CSTS) and its Family Violence and Trauma Project (FVTP). The CSTS ispart of the Department of Psychiatry of Uniformed Services University of
the Health Sciences. The CSTS serves as the academic arm and a componentsite of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
For over a decade, the FVTP has addressed the prevalence and trendsof spouse and child maltreatment in the U.S. Army. One important meansof communicating relevant and current research information to the Armyhas been through publication of a newsletter, Joining Forces Joining Families.
This newsletter informs Army leadership and the Army’s Family Advocacy
Program of the scientific and medical aspects of family maltreatment.
In Family Violence Research, Assessment and Intervention: Looking Back,
Looking Ahead, we present a collection of interviews that took place during 2004 through 2010. The interviews are with 15 prominent scholars andpractitioners who have conducted significant spouse and child maltreatment research emphasizing prevention and intervention. A companion
piece describing the background of their research is also included. A number of scholars have been interviewed again for this book adding researchand clinical care insights for the practitioner as well as the researcher. Importantly, the implications of their work stretch beyond violence to topics
such as parenting, assessment of functioning, neuroscience, home visiting,research methodologies, and others.
We hope that Family Violence Research, Assessment and Intervention:
Looking Back Looking Ahead will be a valuable resource for family healthand mental health practitioners in both our military and civilian communities, and that it will encourage continued research and best practices toprevent, mitigate and foster recovery around family violence, child maltreatment and spouse abuse.
James E. McCarroll, PhD
Family Violence and Trauma ProjectCenter for the Study of Traumatic StressContributors
Sandra T. Azar, PhD: Dr. Azar is a clinical psychologist and a Professor of
Psychol­ogy at The Pennsylvania State University where she teaches and conducts research. She received her PhD in psychology from the University ofRochester in 1984. Her distinguished career includes member­ship on theeditorial board of numerous scientiﬁc journals and she has received manyfederal grants from the U.S. and Canada. Her research interests include childabuse and neglect, gender and aggression, parenting, family interactions, developmental aspects of self–control, adolescent depression, and legal processes and families. Currently, her work centers on the relation between cognitive processes and parenting, particularly under adverse conditions suchas poverty and parental disability.
Lee W. Badger, PhD, MSW: Prior to her retirement in 2008, Dr. Badger wasProfessor and Nicholas J. Langenfeld Endowed Chair in Social Research at
the Graduate School of Social Service at Fordham University, New York City.
She received her MSW (1977) and PhD (1987)degrees from the Universityof Alabama. Before moving to New York, she served for many years on thefaculties of the University of Alabama Medical and Social Work schools.
For over twenty–five years, she focused her research on the recognition andtreatment of mental disorders, particularly depression, and the development
and testing of psychosocial interventions in primary care. Her more recent
focus has been on the patterns, types, and consequences of intimate partner violence, especially within the United States Army. An author of over 40
articles, monographs, and book chapters, she has received research support
from, among others,the National Institute of Mental Health, the John D. andCatherine T. MacArthur Foundation, and the United States Department of
Education FIPSE program.
William R. Beardslee, MD: Dr. Beardslee is the Director of the Baer Prevention Initiatives, Chairman Emeritus of the Department of Psychiatry
at Children’s Hospital in Boston, and Gardner Monks Professor of Child
Psychiatry at Harvard Medical School. He is a Senior Scientist at the Judge

xii Family Violence Research, Assessment and Interventions

Baker Children’s Center in Boston. Dr. Beardslee has directed the Preventive
Intervention Project, a ten year study of response to public health preventive interventions for families facing depression. Dr. Beardslee serves on the
Carter Center Task Force on Mental Health, and served on the Institute ofMedicine’s Board of Children, Youth and Families, and on two of its committees: the Committee on Prevention of Mental Disorders and Substance
Abuse Among Children, Youth, and Young Adults, and the Committee on
Depression, Parenting Practices, and the Healthy Development of YoungChildren. He has received many awards for his work including the Blanche F.
Ittleson award for outstanding published research contributing to the mental
health of children, the Catcher in the Rye Award for Advocacy for Children,and the Agnes Purcell McGavin Award for Prevention of Mental Disorderin Children, all from the American Psychiatric Association. He received the
Irving Philips Award for Prevention, from the American Academy of Childand Adolescent Psychiatry. He is the author of over 150 articles and bookchapters and two books.
Dr. Beardslee is the Director of the Baer Prevention Initiatives, Chairman Emeritus of the Department of Psychiatry at Children’s Hospital in
Boston, and Gardner Monks Professor of Child Psychiatry at Harvard Medical School. He is a Senior Scientist at the Judge Baker Children’s Center in
Boston. Dr. Beardslee has directed the Preventive Intervention Project, a ten
year study of response to public health preventive interventions for families
facing depression. Dr. Beardslee serves on the Carter Center Task Force on
Mental Health, on the Institute of Medicine’s Board of Children, Youth andFamilies, and on two of its committees: the Committee on Prevention of
Mental Disorders and Substance Abuse Among Children, Youth, and Young
Adults, and the Committee on Depression, Parenting Practices, and the
Healthy Development of Young Children.He has received many awards forhis work including the Blanche F. Ittleson award for outstanding publishedresearch contributing to the mental health of children, the Catcher in the Rye
Award for Advocacy for Children, and the Agnes Purcell McGavin Award
for Prevention of Mental Disorder in Children, all from the American Psychiatric Association. He received the Irving Philips Award for Prevention,from the American Academy of Child and Adolescent Psychiatry. He is theauthor of over 150 articles and book chapters and two books.
Jacquelyn C. Campbell, PhD, RN, FAAN: Dr. Campbell is the Associate
Dean for Faculty Affairs/Professor, at the Johns Hopkins University. Dr.
Campbell’s research on family violence and violence against women has
included risk factor assessment for intimate partner homicide, abuse during pregnancy, marital rape, physical and mental health effects of intimate

Contributors xiii

partner violence, prevention of dating violence, and interventions to prevent
and address domestic violence. She has been the principal investigator on
numerous federal grants and served on the congressionally appointed U. S.
Department of Defense Task Force on Domestic Violence. Her research results have been used for health policy recommendations to state, national,
and interna­tional organizations. Dr. Campbell, a member of the National Institute of Medicine, is the recipient of the 2006 Pathfinder Award for NursingRe­search from the Friends of the National Institute of Nursing Research. Dr.
Campbell has authored and co–authored more than 250 articles and bookchapters, as well as written and edited seven books on battered women andfamily violence.
Howard Dubowitz, MD: Dr. Dubowitz is Professor of Pediatrics and the
Director of the Center for Families at the University of Maryland Medical
School in Baltimore, Maryland. He received his medical training at the University of Cape Town, South Africa, completed an internship in Israel, a pediatric residency at Boston City Hospital, and a fellowship in child abuse andneglect at Children’s Hospital, Boston. Dr. Dubowitz, who holds a Master of
Science degree in epidemiol­ogy from the Harvard School of Public Health,is widely published and renowned for his clinical work, teaching, research,
and advocacy. Among his numerous professional honors, he is the recipient of the American Academy of Pediatrics’ Special Achievement Award. Dr.
Dubowitz is one of the principal investigators of the LONGitudi­nal Studies
of Child Abuse and Neglect (LONGS­CAN), a 20 year study in its 19th yearof data col­lection.
John J. Eckenrode, PhD: Dr. Eckenrode is a Professor of Human Development and Director of the Family Life Development Center at Cornell University. He received his Ph.D. from Tufts in Psychology, and after five years
at the Harvard School of Public Health, came to Cornell in 1983. His work
has concerned stress processes, child maltreatment, adolescent development, and prevention. In addition to conducting research with David Oldson the Nurse Family Partnership program, he is founder and director of the
National Data Archive of Child Abuse and Neglect, a facility funded by theChildren’s Bureau to promote the secondary analysis of child maltreatment
data. He is a fellow of the American Psychological Association, Division 7.
Mary Ann Forgey, PhD, LCSW: Dr. Forgey is an Associate Professor at
Fordham University Graduate School of Social Service. She teaches a rangeof social work practice courses and recently developed a new elective inmilitary social work. Her research within the Army has focused on patterns

xiv Family Violence Research, Assessment and Interventionsof intimate partner violence (IPV) and evidence based IPV assessment. She
received a Fulbright Scholar Award in 2005 to Ireland, where she taught
and conducted research about IPV assessment in collaboration with University College Dublin. Her IPV research has been published in Violence
and Victims, Journal of Family Violence and the Journal of Social Work
Education. In addition to her teaching and research, Dr. Forgey has developed and conducted training programs in IPV for numerous organizations
including the NYPD and NYC Administration for Children (ACS). Prior
to her academic career, Dr. Forgey served as the Director of Army Community Services and Family Advocacy Program Manager for the US Armyin Wiesbaden, Germany.
l. Kevin Hamberger, PhD: Dr. Hamberger is Professor of Family and Community Medicine at the Medical College of Wisconsin and an affiliate of the
Injury Research Center at the Medical College of Wisconsin. He received his
Ph.D. in Clinical Psychology from the University of Arkansas in 1982. Since
that time, he has conducted treatment and research programs with domestically violent men and women and developed and evaluated health care provider training programs to deliver violence prevention services to patients.
He has published over 100 articles and chapters and six books and serveson the editorial board of six scientific journals. In addition, Dr. Hamberger
has been recognized by Division 43 the Division of Family Psychology of
the American Psychological Association, the Wisconsin Coalition Against
Domestic Violence, and the Institute on Violence, Abuse and Trauma forleadership, innovation and substantial contributions to the field of family
violence.
Ernest N. Jouriles, PhD: Dr. Jouriles is Professor and Chair of the Department of Psychology at Southern Methodist University in Dallas, Texas. He
received his Ph.D. in psychology from the State University of New York at
Stony Brook in 1987. Dr. Jouriles conducts research on children’s responses to domestic violence and why some types of marital conflict are moredetrimental to children than others. Developing interventions is a primary
focus of his research. His research on violence in adolescent romantic relationships focuses on developing new methods of assessing relationship violence, understanding risk factors, and evaluating preventive interventions.
Dr. Jouriles, whose publications include over 60 scientific articles and bookchapters, presented at the Department of Defense Domestic Violence Intervention/Treatment Protocol Development Working Meeting. His researchhas been funded by numerous federal and state agencies.

Contributors xv

Kathleen Kendall–Tackett, PhD: Dr. Kendall–Tackett is a health psychologist and an International Board Certified Lactation Consultant. She receiveda Bachelor’s and Master’s degree in psychology from California State University, Chico, and her Ph.D. from Brandeis University in social and developmental psychology. She is a Clinical Associate Professor of Pediatrics at Texas Tech University School of Medicine in Amarillo, Texas, and Acquisitions
Editor for Hale Publishing. Dr. Kendall–Tackett is a Fellow of the American
Psychological Association in both the Divisions of Health and Trauma Psychology, and is Associate Editor of the journal Psychological Trauma. She isa founding officer of the American Psychological Association’s Division ofTrauma Psychology. Her awards include the Outstanding Research Study
Award from the American Professional Society on the Abuse of Children,and she was named 2003 Distinguished Alumna, College of Behavioral andSocial Sciences, California State University, Chico. Dr. Kendall–Tackett is author of more than 230 journal articles, book chapters and other publications,and author or editor of 20 books in the fields of trauma, women’s health,depression, and breastfeeding. Her Web sites are www.UppityScienceChick.
com and www.BreastfeedingMadeSimple.com.
K. Daniel O’Leary, PhD: Dr. O’Leary is a Distinguished Professor of Psychology and Director of Clinical Training at Stony Brook University. He received the Distinguished Scientist Award from the Clinical Division of theAmerican Psychological Association in 1985, and he was installed in the National Academies of Practice in Psychology in 1986. He has published over
235 articles and twelve books. His current research focuses on the etiology
and treatment of partner aggression, and the link between marital discordand depression.
Christopher M. Murphy, PhD: Dr Murphy is Professor of Psychology at the
University of Maryland, Baltimore County. He also directs the New Behaviors Program at the Domestic Violence Center of Howard County, Maryland. This Center consists of comprehensive clinical training, service, andresearch programs focusing on perpetrators of intimate partner violence.
Dr. Murphy’s research focuses on cognitive–behavioral and motivational interventions for abusive behavior in intimate adult relationships, factors thatpredict successful response to partner violence treatment, emotional abusein relationships, and the links between intimate partner violence and theuse of alcohol and drugs. His work has been supported by grants from the
National Institute of Mental Health and the National Institute on Alcohol
Abuse and Alcoholism. Dr. Murphy has authored more than 50 articles andbook chapters on the topic of intimate partner violence.

xvi Family Violence Research, Assessment and Interventions

Bruce D. Perry, MD, PhD: Dr. Perry is the Senior Fellow of The Child
Trauma Academy, a non­profit organization based in Houston, Texas, that
promotes innovations in service, research and education in child maltreatment and childhood trauma (www.ChildTrauma.org). Dr. Perry has
conducted both basic neuroscience and clinical research. His focus overthe last ten years has been integrating concepts of develop­mental neuroscience and child development into clinical practice. Dr. Perry is the author of over 300 journal articles, book chapters and scientific proceedings,
and recipient of numerous profes­sional honors. He attended medical andgradu­ate school at Northwestern University, completed a post–doctoral
fellowship in psychiatry at Yale University School of Medicine in 1987,
and a fellowship in child and adolescent psychiatry at the University of
Chicago in 1989.
Desmond K. Runyan, MD, DrPH: Dr. Runyan is Professor and Chair ofSocial Medicine and Professor of Pediatrics and Epidemiology at the University of North Carolina at Chapel Hill. He is the Director of the LONGSCAN Coordinating Center. The LONGSCAN project is a 20–year studyof the impact of child maltreatment, now in its 19th year. The Center coordinates the five different, but overlapping longitudinal studies at Baltimore,
Chicago, North Carolina, San Diego and Seattle. Dr. Runyan’s work involves
the application of clinical epidemiology to the problem of violence againstchildren. His research has focused on the impact of societal intervention
on the mental health functioning of the child victims and the impact of
the foster care system, court testimony, and the medical examination on
the children. He also directs is a 5–year effort to assess the effectiveness ofa specific parenting education program, The Period of PURPLE Crying, toreduce or eliminate the problem of shaken baby syndrome for the state ofNorth Carolina. Dr. Runyan is also the National Program Director for theRobert Wood Johnson Foundation Clinical Scholars Program. This program seeks to prepare leaders in health care who can function in academia,
in government service, and in private settings to help improve healthcare
for all Americans.
Suzanne C. Swan, PhD: Dr. Swan is an Associate professor in the Department of Psychology and the Women’s and Gender Studies Program at the
University of South Carolina. She received her Ph.D. in social and personality psychology from the University of Illinois. Prior to coming to the University of South Carolina, she was the director of Family Violence Programs
at the Yale School of Medicine’s Department of Psychiatry. She conducts
research in the area of intimate partner violence, with particular interests

Contributors xvii

in women who use violence in intimate relationships, and preventive interventions with college students to reduce interpersonal violence on college
campuses.

xviii Family Violence Research, Assessment and Interventions

Editors
David M. Benedek, MD
David M. Benedek, MD, is a Professor and Deputy Chair of the Department of Psychiatry, Uniformed Services University of the Health Sciences(USUHS). He is also an Associate Director of the USUHS Center for the
Study of Traumatic Stress. He received his BA from the University of Virginia in 1986 and his MD from the USUHS School of Medicine in 1991.
After internship and residency in psychiatry at Walter Reed Army Medical
Center, he was assigned as Division Psychiatrist, First Armor Division, Germany. In this position, he delivered mental health support to US and NATO
Troops for Operation Joint Endeavor (1996) in the former Yugoslavia. In addition to his operational experience in Bosnia and Croatia, Dr. Benedek has
deployed to Cuba, Iraq and Kuwait in conjunction with the Global War on
Terrorism. In 2004 he was appointed Consultant to the U.S. Army Surgeon
General for Forensic Psychiatry. He has authored or co-authored over 80
scientific publications, and has presented on numerous aspects of military,
disaster, and forensic psychiatry at regional, national, and international professional conferences. He was the co-editor of the recently published American Psychiatric Association Clinical Manual for the Management of PTSDJames McCarroll, PhD
Dr. McCarroll received his PhD in Psychology from the University of
Arkansas in 1970 and his MPH from the Harvard School of Public Health in1978. He completed an internship in clinical/counseling psychology at the
US Army Silas B. Hays Hospital, Fort Ord, California, 1978-79. From 1979
to 1982 he was the Chief of Mental Health at the U.S. Army Hospital, Berlin.
He was the Assistant Chief of Psychology at the Walter Reed Army Medical
Center from 1982 to 1988. In 1988, he joined the staff of the Department ofMilitary Psychiatry, Walter Reed Army Institute of Research where he was
Deputy Chief for Administration and also conducted a research program in
the psychiatric effects of traumas and disasters with the Center for the Studyof Traumatic Stress (CSTS), Department of Psychiatry, Uniformed Services
University of the Health Sciences. He retired from the US Army in 1995
and joined the CSTS staff. He has published widely on family maltreatment,
military medicine, and the psychological effects of exposure to traumatic
events.
John H. Newby, PhD
John H. Newby, PhD, received his BA in Sociology and his MSW fromHoward University, Washington, DC. He received his PhD from CatholicEditors xix
Contributors

University, Washington, DC, specializing in social work education. Dr. Newby spent 27 years in the U.S. Army as a social work officer. He was Chief ofSocial Work Service at Dewitt Army Community Hospital, Fort Belvoir, VA
and the 5th General Hospital, Stuttgart, Germany. Dr. Newby also served as
the Director of the Human Resources Directorate, Walter Reed Army Medical Center (WRAMC) and was a research social worker in the Departmentof Psychiatry, Walter Reed Army Institute of Research. He was a memberof the U.S. Army Surgeon General’s Minority HIV Advisory Group andserved as a member of the District of Columbia’s HIV Prevention Community Planning Committee in which he reviewed grant proposals for funding by the District of Columbia Agency for HIV/AIDS. Dr. Newby joined
the staff of the Department of Psychiatry, Uniformed Services University of
the Health Sciences in June 1996. He is a Research Assistant Professor andworks on the Family Violence and Trauma Project.
Nancy T. Vineburgh
Nancy T. Vineburgh, M.A. is Assistant Professor in the Department of
Psychiatry at The Uniformed Services University of the Health Sciences in
Bethesda, Maryland, and Associate Director of the Center for the Study ofTraumatic Stress (CSTS) where she oversees its Office of Public Education
and Preparedness.
Ms. Vineburgh is an expert in health communication, health marketingand public education. She has created numerous, high profile public education campaigns that have generated national and international attention:
Fight the Bite, the nation’s first health campaign for Lyme Disease awareness;
Courage to Care, an electronic campaign addressing the well-being of deployed soldiers and their families; Can a Depressed Parent Be a Good Parent,
You Bet, the nation’s first campaign on parental depression sponsored byChildren’s Hospital Boston; Where to Draw the Line, a three year campaign
for National Alcohol Screening Day sponsored by NIAAA and SAMHSA.
She helped develop an educational campaign, Courage to Care Courage toTalk, whose educational resources address communication around the injuries of war that was featured in two Pentagon media venues.
Her work has earned numerous awards including Woman of the Future by Hartford Woman Newspaper in recognition for her broadcasting on
women’s health; The Combined Health Appeal Media Award and Connecticut’s Arthritis Foundation Public Education Award for her work related to
Lyme Disease education. Her work in the field of military health communication has received the American Graphic Design Award for three consecutive years, 2007, 2008 and 2009.
Ms. Vineburgh received her B.A. from Connecticut College in New Lon-

xx Family Violence Research, Assessment and Interventions

don, Connecticut, her M.A. in counseling from St. Joseph College, West
Hartford, Connecticut, and attended Harvard University Graduate Schoolof Education. She is a member of the Washington School of Psychiatry, theAmerican Public Health Association, the Employee Assistance Professionals
Association and Employee Assistance Society of North America.
Robert J. Ursano, MD
Robert J. Ursano, MD, is Professor of Psychiatry and Neuroscience andChairman of the Department of Psychiatry at the Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland. He is Director of the Center for the Study of Traumatic Stress and the editor of the
medical journal Psychiatry, Interpersonal and Biological Processes. He was
educated at the University of Notre Dame and Yale University School of. Dr.
Ursano served as the Department of Defense representative to the National
Advisory Mental Health Council of the National Institute of Mental Health.
He is a Fellow in the American Psychiatric Association, the American College of Psychiatrists, and the American College of Psychoanalysts. He was
the first Chairman of the American Psychiatric Association’s Committee on
Psychiatric Dimensions of Disaster. Dr Ursano is a member of the National
Academies of Science, Institute of Medicine, Committee on Psychological
Responses to Terrorism; and the National Institute of Mental Health Task
Force on Mental Health Surveillance after Terrorist Attack. He has received
numerous awards including the Department of Defense Humanitarian Service Award, the Lifetime Achievement Award from the International Traumatic Stress Society, and the William C. Porter Award from the Associationof Military Surgeons of the United States. Dr. Ursano is widely published in
the areas of Post-Traumatic Stress Disorder and the psychological effects ofterrorism, bioterrorism, traumatic events and disasters and combat with hasover 200 publications including co-author or editor of seven books.

SECTION INTRODUCTION

Child Maltreatment
In this section, we present interviews and summaries of research of six individuals who have published extensively on child abuse and neglect.
Sandra Azar discusses the use of cognitive and behavioral principles inchild rearing. While much of her work has been devoted to helping motherswith cognitive difficulties, the principles apply equally to any parent.
Ernest Jouriles has helped women in families in which there is co–occurrence of child and adult maltreatment. Dr. Jouriles’ research has been
directed toward understanding the complex relationships between domestic
violence and physical aggression against children. Particularly interestinghas been his work on children’s perceptions of violence by parents and therelation of such appraisals to the type of problems exhibited by children.
John Eckenrode has been one of the pioneers of research on home visitation by nurses and the long–term effects on children and families. He
addresses such issues as qualifications of service providers and how home
visiting can be targeted to mothers at the highest risk for child maltreatment
and other family problems.
Bruce Perry has worked and taught extensively about the effects of maltreatment on the developing brains of children. His neurosequential model
provides basic understanding of how maltreatment affects children and how
the model can be used to help them recover and develop.
Howard Dubowitz is one of the world’s experts on child neglect. His
work has been directed at teaching health care providers how to prevent,screen for, recognize risk factors, and work with neglectful families. A majoremphasis of his work has been on the involvement of fathers in families,
particularly in areas where child neglect is likely to occur.
Desmond Runyan is a principal investigator for the longitudinal studyof child abuse and neglect (LONGSCAN), a 20–year study of the impact ofchild maltreatment. His research and clinical work has focused on a wide
variety of problems affecting the lives of children. His chapter describes the2 Family Violence Research, Assessment and Interventions

LONGSCAN project and some recent results of that study.
Each of these authors has a particular focus, but much of their research
includes both prevention of child maltreatment, intervention strategies, andthe design of service delivery systems. This section has overlap with domestic violence. Too often, the child maltreatment and domestic violence prevention and treatment communities do not work together due to lack offunding, training, or legal restrictions. Through the course of this book, thereader will note the importance of the need to consider child maltreatment
and domestic violence as all part of the same problem of family malfunction.

BACKGROUND OF RESEARCH OF SANDRA T. AZAR, PHD

The Social-Cognitive Theory of Parenting:
A Brief Review of the Work of Sandra T. Azar
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 8, Issue 4, Fall 2005
Dr. Azar is widely published in the topics of child maltreatment and parenting. She has written extensively on the termination of parental rights by the
courts due to child maltreatment. She advises mental
health professionals to be extremely cautious in theirevaluations and statements because of the lack ofdata that exists in this arena. Such caution is particularly advised given the diversity of today’s families
and the fact that existing databases on families arelargely based on studies of middle class, two-parent
families and lack information on single parents, lowsocio-economic class families, very young families, or other complex family
situations.
Her work advances an assessment approach that focuses on parental behavior and functioning as opposed to a model that emphasizes personality and intelligence. Accordingly, she strongly encourages more research inbuilding a more extensive database of information about families and parenting. She believes that many current models are inadequate to explain theprocesses involved in parenting and that a newer, broader model is needed.
Her model is cognitive-behavioral and is based on the principle thatthoughts influence behavior. Parenting is viewed within a general stresscoping model, which examines what the individual brings and what is required. Expectations about the self tend to be flexible and allow a wide range
in which to enact the role of parent. She asks, “Is parenting a doable task? If
so, what are its demands?” The social and cognitive tasks to be negotiatedare relational and generally involve capacities that are required for many
domains of adult development. The emphasis in her model is on improving

4 Family Violence Research, Assessment and Interventions

the capacity to problem-solve and to remain cognitively flexible in the faceof changes in the child and the changing contexts of life. Having realistic expectancies for the parenting role and the capacity to recognize where these
expectancies may be ineffective and to re-adjust them are key to parental development. Her cognitive-behavioral model will work across the many varying circumstances of parenthood in today’s world in that it does not requirea biological basis, just the capacity to learn the parental role and to have gone
into it with accurate perceptions of what that role entails.
The following review is taken from a chapter entitled “Adult Development and Parenthood” (Azar, 2002) in which Dr. Azar describes her perspectives on parenting. Additional references are provided.
How does one learn to be a parent?
Azar reviews two opposing theories of parenthood. The first sees parenthood as a stage in normal adult development. In this view, parenting is seen
as essentially instinctive. As a result, criticism of the parent is highly likely
in the event of failure. (How could one fail at something that is instinctive?)
Azar argues against the parenting-as-normal-development theory. She presents the view that an individual’s life course is flexible, random, and driven
by context. Parenting, a unique context for the development of psychologicalmaturity, involves stresses that can lead to personal growth or to maladaption. For some, parenting may be overwhelming and result in child maltreatment, depression, and other negative outcomes. For others, the stresses ofparenting are within their “developmental reach” and this stage can lead topersonal growth, greater maturity, and improved parenting skills.
What affects parenting?
In Azar’s view there are three major areas that impact parenting. The firstis the environment (or the context of parenting). Differences in parenting
would be expected in a high-crime area compared to parenting in the suburbs in terms of how much control is exercised over a child. The second is
the child. Different parenting strategies and challenges would be expected
for a special needs child, an adopted child, a foster child, or a child from a
spouse’s previous marriage. The third area is that of the parents. In today’s
world, there are many decisions to be made about parenthood and the rolerequirements imposed on parents by society. The heterogeneity of the parental role defies narrow boundaries typically seen in developmental literature. She addresses the Whether, Who, How, When, Where, and How Long ofparenting. Each of these is a question and a choice point to be considered inassessing their impact on the relation between the parents and the child.

Sandra T. Azar, PhD 5

Key Points
The social and cognitive tasks for a parent are relational and involve
capacities that are required for many domains of adult development.
Azar’s model focuses on parental behavior as opposed to one thatemphasizes personality and intelligence.

References
Azar ST. (2002). Adult development and parenthood. A social-cognitive
perspective. In J. Demick and C. Andreoletti (Eds.). Handbook of Adult
Development. New York: Plenum Press, 391–415.
Additional Reading
Azar ST. (2002). Family research and the law: Can family research help
Solomon? Contributions and challenges. In J. McHale & W. Grolnick(Eds.). Retrospect and Prospect in the Psychological Study of Families.
Mahwah, NJ: Erlbaum, pp. 283–320.
Azar ST & Cote LR. (2002) Sociocultural issues in the evaluation of theneeds of children in custody decision making. What do our current
frameworks for evaluating parenting practices have to offer? International Journal of Psychiatry and the Law; 25: 193–217
Azar ST, Benjet CL, Fuhrmann GS, & Cavallero L. (1995). Child maltreatment and termination of parental rights: Can behavioral research help
Solomon? Behavior Therapy; 26: 599–623.
Azar ST, Lauretti AF, & Loding BV. (1998). The evaluation of parental fitness in termination of parental rights cases: A functional-contextual
perspective. Clinical Child and Family Psychology Review; 1: 77–100.

6 Family Violence Research, Assessment and Interventions

INTERVIEW WITH SANDRA T. AZAR, PHD

Social-Cognitive Theory Applied to
Maltreating Parents
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 8, Issue 4, Fall 2005
Dr. McCarroll: How did you get started in child maltreat­ment work?
Dr. Azar: My ﬁrst studies as an undergradu­ate were on memory and therole of cognitive mediation. That’s where my interest in social cognitioncame from, but even then I was inter­ested in poverty and at-risk children.
Dr. McCarroll: You have worked in many different areas of child maltreatment.
Dr. Azar: Child maltreatment is an inter­disciplinary topic and includes
pediatricians, social workers, public policy people, and others. The ﬁeld justdoes not lend itself to a tradi­tional psychological approach.
Dr. McCarroll: How would you explain the concept of child maltreatment toa lay audience, to people who say “How could this kind of thing happen?” or“How could somebody do that?”
Dr. Azar: Parenting is a very complex cognitive task. Often, we just say,“Parenting is instinct.” Parenting is a job, but often in our society we do notsee it that way. Parents have to juggle: “The kid needs to learn how to keep his
shoes tied. I’ve got to get the other three children to school. I’m tired. They
kept me up last night because one of them had a fever.” Each of those stresses
requires cognitive capacity to solve. But, when you put them all together inindividuals who may be limited in some capacities or may have difficulty
being ﬂexible, the task becomes impossible.
There are multiple causes for child mal­treatment. In some cases I see
it as a learning deﬁcit. Some people have grown up in families where thestandards for parenting are dif­ferent from the norms of the rest of society.
These parents are isolated and lack resources and social support and havedistorted scripts for the parenting process. They may misinterpret a child’s
behavior, which can lead them to a perception of exceptional malevolenceon the child’s part. They may think, “This child is doing this on purpose andis trying to get to me.” That kind of appraisal will heighten their arousal andlead them to do things they might not otherwise engage in.

Sandra T. Azar, PhD 7

Dr. McCarroll: How do you work with a parent who experiences those distortions?
Dr. Azar: All my work has been aimed at challenging those distortions,but it’s a very tricky task. To them, their distortions are as familiar and as natural as breathing. As a result, you have to produce lots of exemplars before
people shift their thinking and are willing to realize that it is their thinking
that gets them into trouble.
The process that I use can work in ten or twelve weeks with home visitors and groups. Groups are very important because people are much betterat seeing distortions operating in other people than in themselves. If people
can engage in the process of exploring why they are in trouble and how theymight change their behavior, you can change these distortions in a short spanof time. But, you need to be very skilled at tenderly moving them throughthe challenging process.
The work involves modeling. I show them how thoughts inﬂuence behavior. Different thoughts produce very different outcomes. I get them to help
me think about generating their ideas. I may present scenarios. For example,“You save up for weeks to buy a new white dress, and you are very happy
wearing it. Then little Johnny comes toddling toward you with this glass of
red liquid and spills it all over your new white dress.” I get them to imagine very slowly that situation and ask them to tell me what they are feelingphysically and then what is going on in their head. “What thoughts are you
having about Johnny?” Typically, you get things like, “It’s not fair. Why me?
I never get to have nice things. This kid really doesn’t care. He did this on
purpose. He’s just like his father.” I will try to give some links to other people
in their lives who do not care about them or who treat them unfairly. Then
I will work on discriminating the child from those other people and teaching them self-statements that will cool the ﬁre of their anger and frustra­tionwith the child. Examples are, “He’s only two. He doesn’t know any better. It’s
my job to stay calm in these moments.” Then I help them problem-solve.
“What could I do next time to prevent this?” For a while during the therapy
the child is invisible. It is the parents’ needs, their wishes, their hopes, theirthoughts that take prominence. It is my job is to help them see how thosethoughts are detrimental.
I always tell my clients, whether they are child abusers or not, that they
have to be the central character in their story. When they stop being the central character in their story then they are just reacting to everything aroundthem as opposed to creating the action. A lot of the work involves metaphors. Metaphors help people process and retain information.

8 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Can you give us examples of some of your favorites?
Dr. Azar: In trying to explain the concept of child development andage-appropriate tasks and behaviors, I might approach a mother and placesomething in front of her. I’ll say, “Here’s a carburetor. I want you to ﬁx thiscarbure­tor.” And the mother will laugh and look at me. I then say, “Don’t
laugh! You cannot leave this room until you get this carburetor ﬁxed.” (Occasionally, I run into one who can.) I use that metaphor when a motherbrings up a developmentally inappropriate behavior she has demanded in achild. I’ll say, “Maybe you are asking him to ﬁx a carburetor. That’s what it islike for children.”Dr. McCarroll: How would you recommend that people measure parenting?
Dr. Azar: Parenting may not be the core of the evaluation. First and foremost should be a careful functional analytic view of the incident being evaluated. Try to understand its antecedents and look for clues from that. One canask, “What speciﬁcally does this parent have difficulties with? Is it disci­pline?
Is it daily organization of the child’s life? Is it providing nutritious meals?”
There may be hundreds of parenting education classes, but they do slightly
different things and often there is no recognition of the speciﬁc needs of theparents. Another problem may be the way in which material is presented.
Some parents have learning disabilities. We need to present infor­mation in
multiple modalities to help them process it. In some cases, you can roleplay and be more active in the intervention as opposed to giving a lecture
about how children develop. I talk about kids’ “paycheck.” Parents pay kids
for things they do not like to see. If the kid has a choice between playing quietly and hit­ting his sister and the parent’s attention is the paycheck, then they
are going to hit their sister because Mom will be over there in a second. I try
to illustrate the importance of reward and praise to keep a behavior going.
You have to be a bit charismatic and approach parents in ways that they havenot been approached before, such as by legal and child protection people.
Parents have to believe that you think that inside there is a good person.
Therapeutic practice requires an engage­ment process with parents. Thatmeans hearing their deﬁnition of what their difficulties are and how theyframe the problem and then try­ing to link that frame to what we know may
be core etiological factors. The parent’s cognitive map is so important. What
we present is not going to register if their schema about parent­ing is disparate from the helper’s view.
Dr. McCarroll: What are the most crucial needs in the child maltreatment
ﬁeld?
Dr. Azar: We need more research. It is hard to get funded as a child abuse

Sandra T. Azar, PhD 9

researcher be­cause we don’t have a diagnosis like those who study depression or schizophrenia. It’s harder to deﬁne what our problem is.
There is also a lack of dissemination of research results. We have somevery promising approaches for assessment and intervention. In spite of existing empirical data, much of what is being carried out in most localities
does not ﬁt those models.
Dr. McCarroll: Do you see public policy regarding child maltreatment focusing on the right problems?
Dr. Azar: The recent addition of family vio­lence into the Centers for Disease Control has been a good policy move. Placing family vio­lence in thebailiwick of public health is a good public policy move. This is one of theways we can help to fortify families to strengthen them against risk.
Dr. McCarroll: Can you tell us what you are working on now?
Dr. Azar: I am trying to explore some elements of cognitive incapacities
that might produce risk to children. Here, I am focusing on neglect, not onchild abuse. However, I do not see child abuse and neglect as disparate. They
are both failures in judgment. One involves a little more impulsivity; theother a little more passivity in terms of children’s needs. They both involvenot being able to identify problems and respond to them appropriately.
Dr. McCarroll: We certainly appreciate your time. You have been very generous. We look forward to your continued good work.
Dr. Azar: Thank you.
Key Points
Parenting is a very complex task. Often, we just say, “Parenting isinstinctive.”
I tell my clients that they have to be the central character in theirstory. When they stop being the central character, then they are
just reacting to everything around them as opposed to creating theaction.

10 Family Violence Research, Assessment and Interventions

REVIEW OF RECENT RESEARCH OF SANDRA T. AZAR, PHD

The Social Information Processing (SIP)
Model Applied to Teaching Parenting
Practices
By James E. McCarroll, PhD
February 2010
Dr. Azar has continued her research on improving parenting practices.
She views parenting as a learned skill, not something that comes naturally.
Her model for understanding the development of parenting skills is throughthe use of cognitive and behavioral principles. This model is called social
information processing (SIP) (Azar, 1986; Crittenden, 1993; Milner, 1993,2003). SIP includes knowledge structures, executive functioning, and thecognitive product of the interaction of the other two. This approach can beused for prevention as well as amelioration of parenting deficits and provides a unified cognitive model to guide research as well as parenting interventions (Azar & Weinzierl, 2005). The authors target parental oversightsthat can lead to unintentional injury as well as child maltreatment. These
parental oversights include both errors in parental judgment and contextual
variables.
Categories of contextual factors playing a role in both child maltreatment and injuries are the following:■■ Socio-cultural variables such as poverty and social isolation;■■ Caregiver variables such as mental illness substance abuse, unrealistic
and failure of supervision; and■■ Child variables such as impulsivity, inattention, and high activity levels(see Peterson & Brown, 1994, for more discussion of these factors).
Azar and colleagues see parental behavior on a continuum from poorcaregiving due to their behavior or omission to positive caregiving that facilitates child development. Some of the skills required in parenting include
the following five areas:■■ Problem solving with a balance of positive and negative strategies anddisciplining;■■ Social cognitive skills such as appropriate expectations of children’s capacities;■■ Self-control including impulse control;Sandra T. Azar, PhD 11■■ Stress management including relaxation; and■■ Social skills such as empathy.

Many more examples are given in Azar and Weinzierl (2005). These abilities and skills are examples of some of the many complex requirements forgood parenting and for risks when they are not practiced.
The provision of services to parents with cognitive difficulties (PCD) includes managing risk to children as well as enhancing their ability to function as good parents. Dr. Azar works to build the capacity of such parents,
to improve organizational responses to them, and to train and support theneeds of persons who work with these parents. This work is called humancapacity building. It provides a theory that facilitates the development ofsensitive intervention techniques and linkages between agencies, such as
child protection agencies and other organizations that serve parents andtheir children.
The model presented by Azar and Weinzierl (2005) is expanded in a later
paper devoted to improving the human capital of service workers and parents with cognitive difficulties (Azar & Reed, 2009). Child protective services (CPS) responses to child welfare cases often are crisis-oriented. Parents
with cognitive difficulties (PCD) may not be responsive to such efforts atthat time due to the nature of their own difficulties. Much more work by
the CPS worker may be required to help the PCD. Azar and Read’s description of PCD include deficits in attention, risk assessment, perspective taking,planning, frustration tolerance, and trial and error learning that lead to dayto-day problems in giving care to children. Such daily difficulties can leadto neglect as seen in the failure to monitor children, maintain home cleanliness, children’s medical care, hygiene, and school attendance. Recognitionof the cognitive difficulties of parents can lead to training that can improvetheir capacity to make decisions and comprehend what is required of them.
Dr. Azar’s recent work has been directed at the promotion of cognitive capacities in service providers. SIP theory provides a basis for considering theservice provider’s cognitive system and their potential to make errors and beless effective in service provision when the PCD case appears, but is unidentified. This can lead to a failure to identify the challenges the parent faces.
Azar and Reed discuss cognitive disabilities and why special efforts should
be given to address their needs as related to the CPS system. The following
is taken from their paper.
Low IQ is typically the chosen measure of cognitive disability. PCD areoverrepresented in the CPS population compared to the general population(US Department of Health and Humans Services, 2007). Their CPS involvement is often for child neglect (see for example Ethier, Couture & Lacharité,12 Family Violence Research, Assessment and Interventions

2004). Parents with low IQ may exhibit inappropriate expectancies of selfsufficiency from their children, poorer problem-solving capacities, and morenegative appraisals of their children’s behavior. Low IQ may not be detectedby CPS workers or the parent may not want to admit to it. Azar argues, however, that there are certain cognitive difficulties, called selective information
processing, that lead to parenting risk (Azar & Weinzierl, 2005).
While there are many programs for children with disabilities, few exist for adults. Also, professional workers may have negative biases toward
PCD, which can result in discriminative ideas and practices toward them.
Examples are concern over the pregnancy of a PCD and doubts about theirability to take care of children such that their parental rights could be terminated.
Azar and Read argue for building human capacity to take place on multiple levels in social service systems. SIP is the theoretical basis for strengthening human capacity. It is based on three components: (1) schemas of theservice worker that include their role, expectations of parents, stereotypes,
and other knowledge structures that can bias them against the parent, (2)executive functioning such as attention and memory, and (3) judgments
about causes of behavior. Azar and Read discuss the first and third elements
assuming that most workers have adequate executive functioning, although
this can be degraded when under stress.
The skill building for increasing the human capacity of the service worker
are the identification of skills of the PCD, process strategies that will be useful in working with the PCD, breaking down the biases of the service worker
and promoting empowerment of the PCD. The first of these, identificationof skills, can occur through formal screening or testing, but also throughwhat Azar and Reed call “in-the-moment” identification. An example of thisis noticing and working through a communication difficulty. Instruments
for identifying and measuring cognitive challenges are limited such that anin-the-moment strategy is likely to be the worker’s primary tool. This strategy is directed toward communication with the PCD, determining if the
PCD understands the meaning of the communication and that the PCD can
ask for assistance when it is needed. This latter point is important as PCD
can adopt what Azar and Reed call a “cloak of competence” in which they
portray themselves as understanding when they do not.
Worker process strategies include using different means of communicating with the PCD. Often auditory skills are weak or are not enough forthe parent to grasp instructions. A multimodal approach that includes visual, sensory, and motor strategies can facilitate understanding along withconcrete examples and practice. Development of this strategy by the worker
should include learning to accommodate different learning styles of PCD

Sandra T. Azar, PhD 13

and the use of other supports to help the parent with the material. This is along-term need that may require community support such as prompts froma service office for appointments.
The second level of development of worker process strategies includes
understanding the function that the behavior of the PCD may serve. For
example, not attending appointments may be taken for lack of motivation
when the fact is that the PCD could not tell time, manage time, or read a bus
schedule. This training can be accomplished by teaching the service worker
to look for the antecedents to the behavior. In addition to building skills forworking with the PCD, the worker is required to have triage and referral
skills and knowledge of helping agencies in the community that can provide
supports to the PCD.
Breaking down biases and promoting empowerment of the PCD is thelast area suggested by Azar and Read for building the human capacity of theworker and the PCD. Common biases of workers are beliefs in parental incompetence, expectations of failure of the parent, a view that parents cannot
act as agents on their own behalf and that they are not amenable to intervention. Training for the worker would include sensitizing them to explicit andimplicit biases and how to promote empowerment of the PCD. There aremany empowerments that can be considered based on the idea that PCD
can have input to decision-making and interventions that may also lead toward self-determination. These efforts challenge the worker’s expectations
for the PCD. More realistic expectations by the worker can work to decrease
their feelings of helplessness and withdrawal from service. Continued training and supervision are also important elements of the work to build thehuman capacity of the worker.
Azar and Reed have presented a theory and practical plans to increasehuman capacity of the service worker and the PCD in an effort to improve
the CPS case management of PCD. The increased worker skills and knowledge can facilitate development of the PCD by reducing worker burnout
and decreasing the concerns of PCD about raising their children or losing
custody of them.
Many of the points made by Dr. Azar were illustrated in a People Magazine article, October 5, 2009. This is the story of a PCD raising her gifted
sixth grade daughter. They work as a team to manage the household and takecare of each other. A service coordinator from a local non-profit organization works to provide support for them and others with intellectual disabilities. This article notes that according to the 2005 U.S. Census, 132,000 people
with intellectual disabilities were caring for children in their homes. Experts
believe that the number is much higher.
Dr. Azar’s work underscores the importance of approaching several fields

14 Family Violence Research, Assessment and Interventions

simultaneously and creatively to challenge existing systems in order to makethe lives of children, parents, and service providers better.
Key Points
Dr. Azar views parenting as a learned skill, not something thatcomes naturally.
Parents with low IQ may exhibit inappropriate expectancies of selfsufficiency from their children, poorer problem-solving capacities,
and more negative appraisals of their children’s behavior.
Recognition of cognitive difficulties of parents can lead to trainingthat can improve their capacity to make decisions and comprehend
what is required of them.

References
Azar ST. (1986). A framework for understanding child maltreatment: An
integration of cognitive behavioral and developmental perspectives.
Canadian Journal of Behavioural Science; 18: 340–355.
Azar ST & Read KN. (2009). Parental cognitive disabilities and childprotection services: The need for human capacity building. Journal of
Sociology & Social Welfare; XXXVI: 127–151.
Azar ST & Weinzierl KM. (2005). Child maltreatment and childhood injury
research: A cognitive behavioral approach. Journal of Pediatric Psychology; 30: 598–614.
Crittenden PM. (1993). An information-processing perspective on the behavior of neglectful parents. Criminal Justice and Behavior; 20: 27–48.
Ethier LS, Couture G & Lacharité C. (2004). Risk factors associated with thechronicity of high potential for child abuse and neglect. Journal of Family Violence; 19: 13–24.
Milner JS. (1993). Social information processing and physical child abuse.
Clinical Psychology Review; 13: 275–294.
Milner JS. (2003). Social information processing in high-risk and physicallyabusive parents. Child Abuse & Neglect; 27: 7–20.
Peterson L & Brown D. (1994). Integrating child injury and abuse-neglectresearch. Common histories, etiology, and solutions. Psychological Bulletin; 116: 295–315.

Sandra T. Azar, PhD 15

U.S. Department of Health and Human Services Administration on Children Youth and Families. (2008). Child Maltreatment: 2006. Washington
D.C.: U.S. Government Printing Office.

16 Family Violence Research, Assessment and Interventions

SECOND INTERVIEW WITH SANDRA T. AZAR, PHD

The Social Information Processing (SIP)
Model Applied to Neglectful Parenting
By James E. McCarroll
February 2010
Dr. McCarroll: You have continued to write and work in the area of cognitive behavioral approaches to parenting.
Dr. Azar: I have. My work has been directed at understanding the factorsthat lead to missteps in parenting, the extreme being child abuse and neglect(see Azar & Weinzierl, 2005). Parental missteps can also underlie injuries inchildren in that preventive measures might have kept some of the incidents
from happening. However, some might have been maltreatment or a failure
to protect children. There is overlap in the two literatures.
Dr. McCarroll: The errors in parental judgment, contextual variables, andparental oversight are part of your model. You also talk about knowledge
structures, executive functioning, and appraisal processes.
Dr. Azar: The model can be used for prevention as well as amelioration.
The Azar and Reed (2005) article expands this model to improving humancapital. I think about cognition in neglectful behavior by parents. We werelooking at low IQ mothers. There is an association between neglect and parental intellectual limitations. That pulled me into the neglect area a little
more deeply because they are more at risk for child neglect. This work haslately been at the macro level. I worked on developing a coalition across thecountry on programs that provide support for parents with cognitive challenges. I have also worked with the city of Philadelphia when they wanted
to improve their services for child neglect. For example, I am presenting aseries of workshops for brand new case workers in Philadelphia to sensitize
them to the needs of cognitively challenged parents. Some of these parents
might have had head injuries or are low in IQ. The workers see a lot of noncompliance with services and frustration in the parents. It may merely bethat the parent does not understand what they are being asked to do andthey are getting frustrated with the case worker. Most of this work is directed
towards looking at what needs to be done in the child protection system towork better and to communicate better with the parents who are cognitively
challenged. That is the group where there is a risk of disconnect between theparents and the professionals involved.

Sandra T. Azar, PhD 17

I feel like you can theorize, but then you have to take it into the realworld. I have become a consultant to the city of Philadelphia because of thework I have done around cognition in parenting and their deep desire tobetter meet the needs of cognitively challenged parents. I never intended to
be studying low IQ mothers. The people who are working with the cognitively challenged feel like my work has a lot of relevance for what they are
dealing with. I have suddenly become the spokesperson for that group. An
example of that is a recent article in People Magazine about a cognitively
challenged parent successfully raising a gifted daughter when given the rightkind of services. Expectations are important in this field. Sometimes it is alittle daunting. Some people are inspired by such work and some are overwhelmed by these ideas.
The grant I have now is testing the model that is presented in the Azar andWeinzierl (2005) article, a model of child neglect. I am interviewing mothersof pre-schoolers in Philadelphia testing the validity of the model for neglect.
It is the same model that I tested for child abuse, but extending it to neglect.
Parallel with that, I have also been thinking about special needs parenting
and about how we might assist the child protective system to be more sensitive to special needs parents. Sometimes, they do not understand what workers are asking them to do. The programs that are provided are not adapted forparents with special needs, but are rather generic ones. Azar and Reed (2009)is a description of what needs to be done to train professionals.
The funding for my grant, Maternal Intelligence, Social Information Processing, and Neglect, came from the National Institute of Child Health andHuman Development (NICHD). We are going to study 167 mothers of 3-5
year olds. Half of them will have had a substantiated child neglect case andhalf of them will not. We will oversample mothers in both groups who are
more cognitively challenged, mothers whose IQs are in the lower ranges.
We are going to try to get at neglect in two ways. One way is to use substantiated child protection records of neglect cases to decide on neglect versus no neglect for the two groupings and the second is more of a continuum
perspective. For example, we will evaluate the home for evidence of the cognitive and physical material stimulation available for a child. For example,
how many books are around, how many toys that you learn language with,how barren is the home, how monotonous is the environment around thechild in visuals, how much time do they spend with the TV on? It is a collation of what child development thinks of as cognitive stimulation in thehome environment. Lack of stimulation is one element of neglect.
We will also look at home safety, home hazards, injury attitudes, homecleanliness and a lot of other variables. Neglect will thus be a latent variable
that is measured on a continuum. One of the questions is whether we can18 Family Violence Research, Assessment and Interventions

predict from the social-cognitive factors, the social information processing(SIP) factors, the substantiated neglect mothers from the non-neglectfulmothers. And then, do social information processing variables predict thelevel of neglect-like behavior? I think it is going to be a solid test of themodel’s utility for understanding neglectful parenting.
Dr. McCarroll: Is it a longitudinal study?
Dr. Azar: It is not at this point, but I could see that that would be the next
iteration. Right now, it is just looking at differences. While this is not longitudinal, there will be a sizeable sample in which to look at these factors in aneglectful population. Neglected children are an understudied population.
Dr. McCarroll: How are you going to check their IQ?
Dr. Azar: We will do an abbreviated WAIS with each of the mothers andwe will expand the social information variables with standardized tests. For
example, we are going to use the Wisconsin Card Sorting Test (http://www4.
parinc.com/ProductSearch.aspx?q=wcst) to look at cognitive flexibility. That
adds a measure of executive functioning and will allow us to obtain moredata on core cognitive functioning. We are also using the Alternate Uses Test
(http://www.indiana.edu/~bobweb/Handout/d1.uses.htm). It looks at divergent thinking as well. It is an old test that was used to look at creativity. It
is really simple. You give the person objects and then ask them to generate
how many uses the object has other than the typical uses. You give them anewspaper, you give them a shoe and you ask them how many other things
could you use this for and it looks at their ability to kind of think outside thebox a little. When you are parenting you have to think outside the box. So,
these measure the cognitive the flexibility and cognitive complexity piecesof the model.
Dr. McCarroll: What are the social-cognitive capacities that are required tobe effective as a parent?
Dr. Azar: We are using the ones that I typically use in my model. There
are many variables: belief systems about children, problem solving capacity,
cognitive flexibility, cognitive complexity, and attributional style and attributional biases toward children. But, we are also looking at it more broadly.
One of the other things this project is looking at is whether this is a moreglobal problem than just one specific to parenting. We have some pilot data
to suggest that that is a reasonable hypothesis. That is, are these parents unrealistic in all relationships? Are they making these misattributions in all theirrelationships? Are they poor problem solvers around a myriad of things, everything from finances to problems with friends or bosses at work or thoseSandra T. Azar, PhD 19

kinds of things? For example, we have created an unrealistic expectation
across relationships questionnaire.
So, we are looking at the broadness of these social information processing problems rather just than the specificity of them to parenting. So, when
you ask me, “What are the variables for parenting?” I would say these are theones, but now we are saying that this is a more general social information
problem.
We are talking about rigidity across the kinds of judgments this parent
is making. Is it a broader spectrum of deficits or disturbances, I would rather say disturbances, in these adults that are going to be problematic? Thatwould argue that we need to target across them to improve life. For example,
suppose I am a poor problem solver and my landlord tells me I am going tobe evicted. I have a higher probability of being homeless if I cannot problem
solve in the situation (i.e., if I cannot organize my environment in such a way
to protect my children and give them a roof over their heads). Parents whoare inflexible in their cognitive capacities are not going to have the safety
net that other parents have. They cannot get themselves out of a corner once
they are backed into it. If they cannot access the resources, they are more indanger of becoming neglectful of the basic needs of their kids.
Similarly, if I am not good in my expectations about relationships, I am
probably going to get into more fights with the people around me and thatis going to also create less social support, which, again, detracts from the resources I might need for my family and would again heighten the probability
that neglect might take place.
Part of supervising is being able to monitor on a moment-by-momentbasis your child’s behavior. So, if you have poor monitoring capacities, you
are going to have more difficulty monitoring your kids and this leads to neglect.
Dr. McCarroll: How will the grant proceed beyond the assessment? How doyou see it unfolding?
Dr. Azar: The first goal is to document that you can differentiate neglectful families. We have selected instruments that are not hard to learn. I am
training bachelor’s level people to collect the data. This could provide a battery for case workers. I think the child welfare system has been lacking some
simple ways of training case workers to assess families. I purposely tried to
select things in the work that I do and the way I create them that they could
be used by case workers or by psychologists who are doing evaluations of
the parents. These tests would help us both identify at-risk parents for prevention purposes or for the child welfare system itself to identify and target
where the parents might need some assistance. I do not argue that the ones

20 Family Violence Research, Assessment and Interventions

I am looking at are all the ones we need for a battery, but right now there arevery few that child case workers are using. So, if all goes well and these factors do in fact differentiate parents then we will be able to train case workers
to use these kinds of batteries as they assess parents and then target particular interventions, depending on their incapacities.
Dr. McCarroll: How are you going to recruit the controls?
Dr. Azar: We will go to Head Start and to day care programs. The other
innovative thing about this project is that we are going to get some geographic data about the environment around the parents. We are going to get
our usual measures of social support, life stress, and how many resources theparent has, but we are also going to get neighborhood data. Philadelphia isa well mapped city. Penn State has data bases that will be used to constructvariables of risk for the parent like how many grocery stores are available
in their neighborhood, how much crime is in their neighborhood, and how
many resources like parks are there in their neighborhood. We will have an
aggregate score for the risks and resources in the mother’s immediate neighborhood.
For me, being an intercity mother is like being in a video game and you
need to know at what level they have to play the game. So, for a mother who
is low on cognitive ability and poor in problem solving, if she runs out offood and the only things that are close by her are 7-Eleven type stores, she’s
going to run out of food faster. This part of the project is going to look at
the social and resource context the parents live in and look at the risk withincontexts. Using Geographic Information Systems we can get maps of eachmother’s neighborhood. With someone’s address, we can get such things as
the average income of people on the street, how many murders were there
within a six-block radius, how many parks you have available within fiveblocks.
When you talk about neglect, context may be important. If there is no
food pantry or doctor’s office or bus routes nearby or if the mother does notknow where the bus routes are, then you have a context where even the best
functioning mother might not do well. We are going to try to sample acrossthe city so we get information on various neighborhoods. We are going tocollect data about her knowledge as well.
We hope to learn whether within child protection if IQ matters or if
more selected cognitive problems interact with high risk contexts. If we canvalidate the model’s utility, we will also have a battery that we can then use
to evaluate parents. Based on our findings, the model will also have validity
for developing interventions.

Sandra T. Azar, PhD 21

Dr. McCarroll: The Army has a big program for people with disabilities
called the Exceptional Family Member Program. It is for any soldier orfamily member who has mental health, medical, or physical problems. Your
model might be applicable to a military context.
Dr. Azar: It really might. When a military spouse is deployed. It may bethat the husband and wife are a very well functioning dyad when he is home,
but when he is sent overseas and she is left alone to try to fend for herself,
she could have problems coping with a system she does not understand. Thatwould make sense.
Dr. McCarroll: But, regardless of disabilities, these principles apply generally
to parenting.
Dr. Azar: I agree. I am looking at parents with IQs in the 65 to 79 range.
The higher number, 79, is not in the mentally retarded range, but you stillmight see high densities of poor cognitive flexibility and poor problem solving. I have gotten some pretty scary answers from PhDs on my unrealistic
expectations questionnaire.
Dr. McCarroll: I was thinking, too, that when people are under stress some aspects of cognitive functioning are subject to degradation or to breakdown.
Dr. Azar: Yes. I was also thinking of persons with head injuries. This is
not my area of expertise, but there is some literature on executive functioning problems in homeless men and a lot of them were vets. I have had casesof head injuries where the family got no explanation of what the injured
person might be like, no explanation of what his brain injury was going tomean for his interpersonal functioning.
In problem solving, people need to be able to think two steps ahead. I
remember I had a young mom who was not eating well. When she was pregnant with twins the doctor kept asking her to eat better and she would behaving macaroni with butter. When the babies were born they were very
lethargic and did not look great, but she looked at me and said, “Look, they
have all their toes and fingers. You were wrong. I didn’t need to eat reallywell.” There is not a complexity to the way they think.
Dr. McCarroll: I wondered if one of the goals of your project is to identify
risk levels.
Dr. Azar: I am hoping that it would help us to identify risk, but like violence prediction it is hard to identify low frequency behaviors. Also, we aretalking about behaviors of omission, which are more difficult to predict. We
have to keep that in mind that our predictive models will always have limitations.

22 Family Violence Research, Assessment and Interventions

Dr. McCarroll: What are the limitations of training case workers to do thekind of work your model calls for?
Dr. Azar: Most importantly, we need to pick people who can work gently
with clients and who are very observant. Cognitive work requires a deep respectfulness for the person that you are talking to because you are challenging
their thinking. You have to do it in a kind of Colombo way. He got his point
across, but he did it in a gentle and back-off-at-any-moment kind of way.
If you have people who can be patient and do that, I think you could train
them. You probably would need masters’ level supervisors who can do the
behavioral programming and pull the person out of the mire ever so often.
Sometimes a professional gets frustrated when they are being unsuccessful.
They need someone who checks their cognitions. We are just as susceptible tocognitive distortions as are other people. I mean, when we go to houses thatsmell, where kids are poorly clothed, people are not clean, and there are rat
droppings around, that has an impact on the person who goes there.
Trainees and workers need somebody who can help them sort throughwhat is going on and can stand back from it and help them keep moving
with the case. The problems are usually a lot more chronic when it comesto neglect. They are typically not acute, which means you are not going to
see massive success immediately. This work really requires a certain kind of
mentality in that you look for the success in small increments.
Dr. McCarroll: Would you give your case workers in training a mini course
in cognitive-behavioral psychology? I liked your concept of “in-the-moment”
reactions..
Dr. Azar: Yes. They need to learn more behavior modification techniques.
They need to be able to do functional analysis, to take every skill and break
it into smaller steps and then break it down again if they need to. Then, theyneed good cognitive behavioral skills to use when they hit bumps in the roadwith a mother. They always need to ask why she thinks something happenedin order to see if there is some cognitive obstacle to proceeding with the
behavioral techniques you want her to use.
The training issue also bears on the fidelity of the program. It is so mucheasier to work with some one in supervision when you have a video of themworking. I can point out that they look disgusted by what the client said andthe clients feel that. It is not surprising that the client does not respond likeyou would like her to. I remember a supervision case in which the mother
had her head on her hands leaning on the chair. Her chin was on the desk.
The two supervisees were busy doing their behavior mod chart and weretotally oblivious to this mother’s being disgruntled and unable to engage.
They ignored it.

Sandra T. Azar, PhD 23

Dr. McCarroll: Thank you, Dr. Azar. I wish you good luck on your grant.
Well, your work is inspiring.
Dr. Azar: OK. Thank you so much.
Key Points
There is an association between neglect and parental intellectual
limitations.
Lack of stimulation is one element in neglect. In a household,how many books are around, how many toys that you can learn
language with, how barren and monotonous is the home, how muchtime do they spend with the TV on?
The social-cognitive capacities that are required to be effective
as a parent include:— Belief systems about children,— Problem solving capacity,— Cognitive flexibility,— Cognitive complexity, and— Attributional style and attributional biases toward children.
Parents who are inflexible in their cognitive capacities are notgoing to have the safety net that other parents have. They cannot
get themselves out of a corner once they are backed into it.  

References
Azar ST & Read KN. (2009). Parental cognitive disabilities and childprotection services: The need for human capacity building. Journal of
Sociology & Social Welfare; XXXVI: 127–151.
Azar ST & Weinzierl KM. (2005). Child maltreatment and childhood injury
research: A cognitive behavioral approach. Journal of Pediatric Psychology; 30: 598–614.

24 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF ERNEST N. JOURILES, PHD

Child Maltreatment in the Context ofDomestic Violence
By James E. McCarroll
Joining Forces Joining Families Volume 9, Issue 3, July 2006
Scientific literature on family violence has documented the co-occurrenceof domestic violence and child maltreatment. However, the occurrence of one does not mean that the otheris automatically present (see, for example, Jouriles &LeCompte, 1991). Dr. Jouriles’ research has been directed toward understanding the complex relationships between domestic violence (e.g. violence directed
at or between spouses or adult partners) and physicalaggression toward children.
In an early study of families in which battered mothers had requested
sheltering for themselves and their children, boys were more often the victims of parental aggression than girls (Jouriles & Norwood, 1995). Thisaggression toward boys seemed to occur due to their tendency to exhibit
more externalizing behavior (e.g., oppositional, aggressive, non-compliant,rule-breaking) than girls, but this was not the whole story. Both fathers andmothers were more aggressive toward boys than toward girls. Mothers’ aggression toward boys tended to be more in response to externalizing behaviors whereas fathers were more aggressive toward sons even when differences between boys’ and girls’ externalizing behavior was taken into account.
Further research by Jouriles and colleagues explored differences in mothers’, fathers’, and children’s reports of parental aggression toward children(Jouriles, Mehta, McDonald, et al., 1997). They studied families in which
the parents sought clinical services for their children’s behavior problems.
Children reported lower levels of parental aggression than that reported byeither parent. Investigators noted that in the absence of a “gold standard”, it
is impossible to determine which family member reports are the most accu-

26 Family Violence Research, Assessment and Interventions

rate. [Editor’s note: The term gold standard denotes the highest possible levelof value. A gold standard test is not infallible, just the best that is known.
Unfortunately, applicable gold standards in medical practice or behavioral
science are rare.]
There are many complex issues to be addressed when obtaining datafrom both children and parents. Family members may describe the same actof aggression differently. Children may fear punishment or removal fromthe family if they disclose parental abuse. There may be downward biases inparents’ reports of aggression related to its severity. For example, they may
be more likely to report spankings than beatings. The authors concluded
that it was not possible to unambiguously determine the prevalence of aggression from a single family member’s report (either parent or child). Theysuggested that assessment of aggression should include, at a minimum, independent reports from multiple family members and an assessment of factors that might bias their reports.
An intervention study to reduce conduct problems among children ofbattered women residing in shelters tested the effects of providing support
to the mothers and teaching them child management skills (Jouriles, McDonald, Spiller, et al., 2001). Assessments of child behavior were conducted
at five different points over a 16-month period following the mothers’ departure from the shelter. Compared to children who received usual shelter
services, children in the intervention condition improved at a faster rate,
the proportion of children showing clinical levels of conduct problems decreased, and mothers showed greater improvements in child management
skills.
A study of the effect of witnessing interpersonal violence on 8 to 14
year old children residing in battered women’s shelters found five different
patterns (clusters) of child maladjustment that could reach clinical levels(Grych, Jouriles, McDonald, et al., 2000). These clusters were made up of
combinations of high levels of externalizing (aggression and disruptive behavior) and internalizing (anxiety and depression) behaviors, mild distress,
and no problems reported. Patterns of the clusters were similar for girls andboys. High levels of externalizing problems were much more common thaninternalizing problems. Children who reported clinically significant levelsof depression and anxiety (internalizing problems) were also more likely todemonstrate elevated externalizing problems, but the reverse was not true.
The amount and type of aggression experienced by children and their perception of parental conflict distinguished among the groups of children. Theirreports of interparental violence and parent-child aggression appeared to fit
a dose-effect model, at least for fathers’ behavior (father aggression towardmother and toward child).

Ernest N. Jouriles, PhD 27

Another finding was that mothers were less violent toward their partners
than were fathers. Possible explanations for this were: 1) mothers’ violence
toward their spouse may be in self-defense, 2) fathers who are abusive may
tend to draw away from their children and thus be viewed in a more negative
light by the children, and, 3) fathers may not be biologically related to thechild and may therefore be perceived differently.
Perceptions and appraisals of conflict differ both methodologically andstatistically. Some reports seem to be more valid when collected from thechild (e.g., internalizing feelings) whereas parents may be better raters of
the child’s externalizing behaviors. Finally, Jouriles’ studies showed that asignificant percentage of children living in shelters do not exhibit distress orsigns of behavioral maladjustment. Understanding why such children continue to function well despite the stress is an important question and one on
which there is little research.
Children’s perceptions of violence by parents may differ depending on
the context and their appraisals of interparental conflict, which affects theexistence and type of problems exhibited by children (Jouriles, Spiller, Stephens, et al., 2000). In this research, children were asked to report their own
appraisals of interparental conflict using three measures: self-blame, threat,
and fear of abandonment. Self-blaming correlated with mothers’ reports ofexternalizing child problems. All three measures correlated with child selfreports of anxiety and depression. Importantly, child age moderated relations between the report of the children and mother’s reports of child adjustment problems.
The authors stressed the importance of considering children’s appraisals in a developmental framework and that age should be considered whenattempting to understand relations between children’s appraisals of interparental conflict and child adjustment problems. For example, younger children are more likely to blame themselves and feel more threatened and more
fearful of abandonment in response to conflict than are older children.
If domestic violence and child maltreatment exist in the family, there is
no research that shows that one treatment approach is better than another(Jouriles, McDonald, Slep, et al., 2005). An approach has not been demonstrated that is successful in simultaneously treating both domestic violence
and child maltreatment.
Jouriles and colleagues raise a number of clinical, legal, and ethical issues
in assessing child abuse in a domestically violent family (Jouriles, McDonald,
Slep, et al., 2005). If there are children in the family, assessment of domestic violence may uncover child maltreatment, which (by law) necessitates areport to Child Protective Services. In addition, such findings can prompt
feelings of intrusiveness and coercion on the part of the parents as well as28 Family Violence Research, Assessment and Interventions

fear of having a child or children removed from the home and the possibilityof legal sanctions against the abuser. Parents may also worry about financial
losses due to the removal of a parent or possible loss of income from having
to attend treatment or court. Children may worry about whether they had arole in the abuse, fear having a parent taken away or being removed themselves, and the threat of further violence toward them or toward a parent.
Clinicians worry about how to work with a family given the requirements of
the law as well as their own physical safety should the parental abuse holdthe clinician responsible for disruption or breakup of the family.
In a recent publication, Jouriles and colleagues (Jouriles, McDonald,
Slep, et al., 2005) conclude that:■■ Children in domestically violent families are at increased risk for physicalchild abuse compared to children in homes without domestic violence.
■■ The most typical pattern of co-occurrence of child and spouse abuse appears to be one in which the adult partners are mutually aggressive andone or both of the adults maltreats the children.
■■ Assessment for child abuse in physically violent families is prudent for
both treatment planning and prevention of further violence.
■■ Assessment is best conducted when there are well-developed policies toassist both clinicians and clients in avoiding pitfalls of such assessmentin the process of domestic violence services.
[Editor’s note: The research presented here by Jouriles and colleagues was
conducted on women and children in domestic violence shelters and involved severe interparental and parent-to-child maltreatment. The investigators point out that it is not clear whether or in what circumstances the resultsof this research can be applied to other populations of parents and children.
Nevertheless, their work has been thoughtful, and deals with a problem (cooccurrence of domestic violence and child maltreatment) that affects themilitary services as well as the larger US society. The reader must be careful
about generalizing these results to non-shelter populations. However, we believe that their work deserves consideration for its results and recommendations, particularly for assessment, prevention, and intervention in situations
in which both child and spouse maltreatment occur.]
Assessment of Domestically Violent Families: Practical Considerations
Based on Research by Jouriles and Colleagues
Dr. Jouriles’ research has practical implications for assessment that canbe incorporated into the Army Family Advocacy Program. We offer the following points for your consideration.
■■ Child maltreatment should be carefully defined and assessed. It can include acts of commission (e.g., hitting, slapping, shaking) and omission

Ernest N. Jouriles, PhD 29(neglect). Neglect has many subcategories (medical, educational, emotional). Child maltreatment is also characterized by its context (e.g., withor without domestic violence) and its frequency and severity.
■■ Problems that children experience in domestically violent families do
not arise solely from witnessing domestic violence. These children are
also often child abuse victims. Children exposed to domestic violence
should be assessed to determine (1) whether the children were victims
or participants in the incident, and (2) their appraisal (understanding)of the events.
■■ What does a child’s witnessing of domestic violence imply for assessment
and treatment? Often, children intervene in domestic violence in an attempt to stop the violence. Distinguishing between parental conflicts
that are irresponsible or inappropriate versus incidents that are harmful for children can be difficult, but is important to the assessment. One
must also consider the behavior of the parent to the child in making a
judgment about whether the family conflict is harmful to a child.
■■ Reports of spouse and child maltreatment vary greatly by the reporter.
Therefore, multiple sources of information are needed for the assessment. In addition, it is important to consider the child’s age and developmental level.
■■ Is maltreatment a within-individual phenomenon (father abuses adultand child) or a between individuals phenomenon (father abuses adultpartner, adult partner abuses child)?
Research suggestions■■ What are the factors that predict physical aggression toward girls versus
boys in distressed households (Jouriles and LeCompte, 1991)?
■■ Why is the battering of women associated with an increased amount of
parental aggression toward sons but not daughters (Jouriles & Norwood,1995)?

30 Family Violence Research, Assessment and Interventions

Key Points
Dr. Jouriles’ research has been directed toward understanding thecomplex relationships between domestic violence and physicalaggression toward children.
Children’s perceptions of violence by parents may differ dependingon the context and their appraisals of interparental conflict, which
affects the existence and type of problems exhibited by children
Assessment is best conducted when there are well-developed
policies to assist both clinicians and clients in avoiding pitfalls ofsuch assessment in the process of domestic violence services.

References
Grych JH, Jouriles EN, McDonald R, Swank PR, McDonald R, & Norwood
WD. (2000). Patterns of adjustment among children of battered women.
Journal of Clinical and Consulting Psychology, 68:84–94.
Jouriles EN & LeCompte S. (1991). Husbands’ aggression toward wives andmothers’ and fathers’ aggression toward children: Moderating effects ofchild gender. Journal of Clinical and Consulting Psychology, 59:190–192.
Jouriles EN, McDonald R, Spiller L, Swank PR, Norwood WD, Stephens
N, Ware H, & Buzy WM. (2001). Reducing conduct problems amongchildren of battered women. Journal of Clinical and Consulting Psychology, 69:774–785.
Jouriles EN, McDonald R, Slep AMS, Heyman RE, & Garrido E. (2005).
Child abuse in the context of domestic violence: Prevalence, explanations, and practice implications. Paper presented at the Department of
Defense Domestic Violence Intervention/ Treatment Protocol Development Working Meeting, 9–11 August 2005.
Jouriles EN, Mehta P, McDonald R, & Francis DJ. (1997). Psychometricproperties of family members’ reports of parental physical aggression
toward clinic–referred children. Journal of Clinical and Consulting Psychology, 65:309–318.
Jouriles EN & Norwood WD. (1995). Physical aggression toward boys andgirls in families characterized by the battering of women. Journal of
Family Psychology, 9:69–78.
Jouriles EN, Spiller L, Stephens N, McDonald R, & Swank PR. (2000).

Ernest N. Jouriles, PhD 31

Variability in adjustment of children of battered women: The role ofchild appraisals of interparent conflict. Cognitive Therapy and Research,
24:233–249.

32 Family Violence Research, Assessment and Interventions

INTERVIEW WITH ERNEST N. JOURILES, PHD

The Co-Occurrence of Child and Spouse
Abuse in Families
By John H. Newby, PhD
Joining Forces Joining Families Volume 9, Issue 3, July 2006
Dr. Newby: How did you get involved in research on the co-occurrence ofchild and spouse abuse in families?
Dr. Jouriles: My interest in this topic began in graduate school. A lot
of my research involves children living in families characterized by spouseabuse or domestic violence. These children appear to be at a higher risk forproblems than other children. Some of the problems are related to domestic
violence. But, it became clear to many people working in this area that childmaltreatment was also occurring in many of these families and was likely
contributing to the children’s problems.
Dr. Newby: When you use the term child abuse or child maltreatment inyour work do you mean all categories of child maltreatment?
Dr. Jouriles: Typically, I do not. The type of child maltreatment focusedupon in most of this research is child physical abuse. There are a few studies that look at other forms of maltreatment, but the vast majority address
physical abuse.
Dr. Newby: How common is child maltreatment in domestically violent
families?
Dr. Jouriles: There is a lot of variability in the frequency reported in theliterature due to how child maltreatment is defined. However, most studies
suggest that the rate is greater than 40%.
Dr. Newby: Does that 40% include families in which the violence ranges
from very mild to very severe?
Dr. Jouriles: There is an association between the frequency and severity of domestic violence and the likelihood of parental aggression toward
children. The more frequent and severe the domestic violence between theparents, the more likely there is to be parental aggression toward children.
Most of the research on the co-occurrence of child abuse and domestic violence focuses on families that have sought help from a shelter because of thedomestic violence. When such help is sought the domestic violence is oftenvery frequent and severe.

Ernest N. Jouriles, PhD 33

Dr. Newby: What are some of the reasons for the co-occurrence of childabuse in families that experience spouse abuse?
Dr. Jouriles: Some of the risk factors for spouse abuse and child abuse aresimilar. Family variables that correlate with spouse abuse also seem to correlate with child abuse. Examples include substance abuse within the family
or a history of violence in the parents’ family of origin. Certain personality traits such as hostility or poor impulse control are observed in families
where both spouse abuse and child abuse occur.
Dr. Newby: Are there specific issues that you consider in the assessment andtreatment of families seeking help for co-occurring child and spouse abuse?
Dr. Jouriles: Yes. The assessment should include the possibility of morethan one type of violence occurring in the family. More people are becoming
aware of the link between domestic violence and the maltreatment of children. I am still surprised by the number of people who primarily deal withdomestic violence and are reluctant to assess the situation for child maltreatment. Part of this has to do with the reporting requirements for childmaltreatment. The same requirements do not apply for domestic violence.
Clinicians also need to be concerned about the safety of family members. It
is important to assess whether any family member is in immediate danger.
Dr. Newby: What is the priority in the treatment regimen in these families?
Dr. Jouriles: It depends on what is going on in a particular family. I am
not aware of research indicating that when both child and spouse abuse areoccurring, one set of problems is dealt with before others. You have to handle each individual family on a case-by-case basis.
Dr. Newby: Are you aware of any research comparing differences between
incidents of child abuse in domestically violent versus non-domestically violent families?
Dr. Jouriles: I am aware of research indicating that child abuse is much
more prevalent in domestically violent families compared to non-domestically violent families. Anecdotally, I can tell you that within domesticallyviolent families, there are ways that children get abused that are directly connected to incidents of spouse abuse and domestic violence. For example,
children may be abused when they attempt to intervene in episodes of domestic violence.
Dr. Newby: Are there specific patterns of spouse or child abuse that occur indomestically violent families?
Dr. Jouriles: You can find examples of almost any configuration of par-

34 Family Violence Research, Assessment and Interventions

ents hitting each other and one or both parents hitting the children. It isan area that a lot of people have talked about, but there has not been muchresearch on the subject.
Dr. Newby: Have there been any successful interventions relative to curtailing the co-occurrence of child and spouse abuse in families?
Dr. Jouriles: I am not actually aware of any interventions that have been directly tailored for dealing with co-occurring child and spouse abuse. The Project Support intervention that Renee McDonald and I developed and have been
evaluating does work with women and children exiting domestic violence shelters. We work on child management skills and have found that there is a reduction in parental aggression towards children as a result of the intervention. Also,
women who take part in the intervention are less likely to return to the batterer
who was responsible for them seeking shelter. Clearly, there is a need for more
research focusing on families with co-occurring child and spouse abuse.
Dr. Newby: Could you comment on the belief that witnessing domestic violence by children should be considered emotional maltreatment?
Dr. Jouriles: From my own research as well as the research of others there is a
lot of evidence suggesting that witnessing domestic violence is harmful, and themore violence that is witnessed, the more harmful it is going to be. However, you
can also make the argument that parents do a lot of things that are potentiallyharmful to children and generally should not be not considered child maltreatment. For example, smoking in front of a child could be harmful. In defining
child maltreatment where do you draw the line? Witnessing domestic violenceis certainly not good for children, but is it really a form of child maltreatment in
the same way we think of physical abuse or neglectful parenting? I’m not sure.
Dr. Newby: You seem to be saying that there should be some caution regarding the diagnosis of emotional maltreatment relative to children who witness domestic violence.
Dr. Jouriles: We are starting to do some research on this in our lab. Sometimes I wonder whether a child witnessing a push, grab or shove would be moreharmed than the child witnessing yelling and screaming. If we start routinely
defining the witnessing of domestic violence as a form of child abuse, I suspectthat we would end up getting a lot more child abuse cases and the system would
have to be ready to handle the increase.
Dr. Newby: What are your future research plans on the co-occurrence ofchild and spouse abuse in families?
Dr. Jouriles: We are continuing to work on some of our intervention re-Ernest N. Jouriles, PhD 35

search that involves families identified because of domestic violence and who
have co-occurring child abuse. We are trying to reduce parental aggression andthe violence that these children are exposed to including aggression that may beoccurring between their parents even though the parents are temporarily separated. Since most of my past intervention research has been done with womenand children, I am also interested in working more directly with the men inthese families.
Dr. Newby: How would you do that?
Dr. Jouriles: Fathering has received much less research attention than it warrants, particularly fathering by men who engage in violent behaviors. There
are some complex issues occurring in some of these families. For example,
you may have a man in the family who is abusive towards his partner, but
has a warm caring relationship with his children.

Dr. Newby: What has been your experience in trying to reach the husbands
and fathers of women and children residing in shelters?
Dr. Jouriles: Given that safety is always a huge concern for women and children in domestically violent families, it is a delicate situation. There are someagencies that primarily work with men in violent relationships. They have encouraged us to start working with them. Doors are being opened to possibly conduct research and develop interventions with abusive husbands and fathers.
Dr. Newby: Thank you for this interview.
Dr. Jouriles: You are welcome.
Key Points
The more frequent and severe the domestic violence between theparents, the more likely there is to be parental aggression toward
children.
There is a lot of evidence suggesting that witnessing domestic
violence is harmful, and the more violence that is witnessed, themore harmful it is going to be.

36 Family Violence Research, Assessment and Interventions

REVIEW OF RECENT RESEARCH OF ERNEST N. JOURILES, PHD

Effects of Domestic Violence on Children:
Behavior and Memory
By James E. McCarroll, PhD
July 2009
Our first interview and summary of Dr. Jouriles’ research focused on theco-occurrence of child maltreatment and domestic violence. Complex relationships are involved in this work: children witnessing domestic violence,
aggression of the father toward the mother, and aggression toward the children. Specific topics discussed in those articles indicated the importance ofassessing for different types of maltreatment, particularly of children andhow to consider treatment issues for both children and adults. Particularlyinteresting was his description of Project Support, a program for working
with mothers during their stay and after leaving a domestic violence shelter.
This work is directed at improving parenting skills and lowering parental
aggression toward children.
An important part of this work was also directed toward understanding children’s perceptions and appraisals of conflict. Children’s concepts ofthe conflict depend on its context and those appraisals can affect children’s
subsequent behavior. In this research, children were asked to report on three
concepts: self-blame, threat, and fear of abandonment. These measures correlated with depression and anxiety, but were moderated by the child’s age.
The authors urged the importance of considering children’s appraisals in understanding their adjustment problems.
Dr. Jouriles’ and colleagues have published several new studies. McDonald and colleagues examined the effects of different kinds of family violence
on children’s internalizing and externalizing behaviors (McDonald, Jouriles,
Tart, et al., 2009). Children and their mothers (n=258) recruited from domestic violence shelters completed measures of men’s intimate partner violence (IPV), women’s IPV, partner-child aggression, and mother-child aggression. Mothers reported their children’s internalizing and externalizing
behaviors and children reported their appraisals of threat in relation to IPV.
Since the women were all severely abused by their male partner, one of the
purposes of this study was to examine whether additional forms of family
violence contributed to children’s adjustment problems. After controlling formen’s IPV, each of the additional forms of violence was associated with children’s externalizing problems. Mother-child aggression was more stronglyErnest N. Jouriles, PhD 37

associated with externalizing problems for boys than for girls. Partner-childaggression was associated with internalizing problems and with children’s
threat appraisals. The authors noted that IPV seldom occurs without otherforms of violence and that all of them contributed to children’s adjustment
problems.
Treatment programs for children should assess and treat all forms ofviolence, especially mother-child aggression. Large numbers of children arebrought to domestic violence shelters each year. In the sample reported here,
in the 6 months prior to the study, almost half of the children had been
subjected to severe violence by their mother’s partner and about one third
by the mother. There are many barriers to providing services for childrenof mothers who come to domestic violence shelters. For example, women’s
shelters have limited resources for assessing and helping abused children(McDonald, Jouriles, Tart, et al., 2009). It is also possible that such action
could have negative consequences for the mother if the child were to be
identified through a report to child welfare agencies, including the motherlosing custody of the children. Such outcomes could deter the women fromseeking help. Also, it is very difficult to offer services to children in the midstof what is often a chaotic situation for the mother. These are not simple issues. Intimate partner violence and child maltreatment often co-occur; thesolutions and the consequences for both adults and children are serious.
Many other complex results and suggestions for both services and researchwere suggested by McDonald et al.
McDonald and Grych (2006) continued to explore children’s appraisals of interparental conflict: are the appraisals of 7-9 year olds reliable anddo they mediate the association between exposure to interparental conflict
and their adjustment problems? The authors found that children’s appraisals of interparental conflict could be reliably measured and that perceptionsof threat and self-blame function similarly in 7-9 year old children as they
do in adults. This study has important implications for understanding children’s appraisals of conflict: perceptions of threat and self-blame occur earlyin life and can affect children’s development and behavior.
Jouriles and colleagues continued their research on cognitive functioning in young children and their explicit memory (Jouriles, Brown, Silver,
et al., 2008). Explicit memory is the ability to capture, process, and store
new information (Schacter, 1987). In this study, the authors explored therelationship between explicit memory and intimate partner violence (IPV).
Children’s explicit memory was negatively affected by IPV even when controlling for aggression towards the children themselves and demographic
variables. Parent-child aggression was not related to any measure of explicit
memory functioning above the effects of IPV and mother’s partner living in38 Family Violence Research, Assessment and Interventions

the household. The frequency of IPV was positively related to children’s explicit memory. When the mother’s positive parenting was low, as measured
by the Positive Parenting scale of the Parent Perception Inventory (Hazzard,
Christensen & Margolin, 1983), IPV was related to poorer memory function. When positive parenting was high, there was a weaker relation between
IPV and explicit memory function. Thus, mothers can decrease some of thenegative effects of IPV on children through positive parenting such as playing with the child, spending time with the child, listening, and talking, anddoing things together that the child likes. However, the potential negative
effects of IPV on children’s developing brains cannot be discounted.
The understanding of the beginning and continuation of psychologicaland physical aggression in couples is an important area of research and practice. It has been well established that pre-marital psychological aggression
predicts later aggression in marriage (see for example, Murphy & O’Leary,
1989; O’Leary & Slep, 2003). Links were explored between psychological andphysical relationship aggression and later psychological distress among 125
high school students over an 8-week period (Jouriles, Garrido, Rosenfield,
et al., 2009). Psychological aggression was much more frequent than physical aggression. On one measure, 91% of participants reported experiencing
at least one act of psychological aggression (mean-10.1) and 27% reported
physical aggression (mean=1.1) during the study period. There were no difference in males and females in their appraisals of the unpleasantness of
psychological and physical aggression. Among those who experienced bothtypes of aggression, psychological aggression was rated as more unpleasantthan physical aggression, and psychological aggression was less likely to be
rated as the partner “playing around.” Both psychological and physical aggression were correlated with psychological distress. (It has been frequently
found that adult women find psychological aggression more damaging totheir mental health than physical aggression (see for example Arias and Pape,
1999). Possible reasons for the harmfulness of psychological aggression suggested are that it occurs more frequently than physical aggression and wasperceived as more intentionally hurtful (Jouriles, Garrido, Rosenfield, et al.,2009). Psychological aggression was also associated with relationship anxiety: worry about being alone with their partner, worries about their partner
doing something bad to them, and wanting to avoid their partner. Relationship anxiety is a relatively new concept. It is correlated with depression andtrauma. The authors suggest that it may be a useful concept to help identify
adolescents in abusive relationships.
Physical aggression was inconsistently associated with psychological distress. This may have been due to the short period of reporting (8 weeks) or
the adolescents in this study were not at high risk for physical aggression.

Ernest N. Jouriles, PhD 39

The finding of physical aggression being attributed to “playing around” wasintriguing to the investigators and thought worthy of further study.
Key Points
Intimate partner violence and child maltreatment often co-occur;
the solutions and the consequences for both adults and children areserious.
The dynamics of the co-occurrence of child maltreatment anddomestic violence are complex including children witnessing
domestic violence, aggression of the father toward the mother, andaggression toward the children.
Large numbers of children are brought to domestic violence shelters
each year. Treatment programs for children should assess and treat
all forms of violence, especially mother-child aggression.
Children’s appraisals of interparental conflict can be reliably
measured and their perceptions of threat and self-blame function
similarly in 7-9 year old children as they do in adults.
Mothers can decrease some of the negative effects of IPV on
children through positive parenting such as playing with the child,spending time with the child, listening, and talking, and doing
things together that the child likes. However, the potential negative
effects of IPV on children’s developing brains cannot be discounted.

References
Arias and Pape, 1999). Psychological abuse: Implications for adjustment
and commitment to leave violent partners. Violence & Victims; 14:55–
67.
Hazzard A, ChristensenA, & Margolin G. (1983). Children’s perceptions ofparents’ behavior. Journal of Abnormal Child Psychology; 11:49–59.
Jouriles EN, Brown AS, Silver C, McDonald R, Rosenfield D, & Leahy MM.
(2008). Intimate partner violence and preschoolers’ explicit memory
functioning. Journal of Family Psychology; 22:420–428.
Jouriles EN, Garrido E, Rosenfeld D, & McDonald R. (2009). Experi-40 Family Violence Research, Assessment and Interventions

ences of psychological and physical aggression in adolescent romantic
relationships: Links to psychological distress. Child Abuse & Neglect;
33:451–460.
McDonald R & Grych JH. (2006). Young children’s appraisals of interparental conflict: Measurement and links with adjustment problems. Journalof Family Psychology; 20:88–99.
McDonald R, Jouriles EN, Tart CD, & Minze LC. (2009). Children’s adjustment problems in families characterized by men’s severe violence
toward women: Does other family violence matter? Child Abuse &Neglect; 33:94–101.
Murphy & O’Leary, 1989. Psychological aggression predicts physical aggression in early marriage. Journal of Consulting and Clinical Psychology; 57:579–582.
O’Leary & Slep, 2003). A dyadic longitudinal model of adolescent dating
aggression. Journal of Clinical Child and Adolescent Psychology; 32:314–
327.
Schacter DL. (1987). Memory, amnesia, and frontal lobe dysfunction. Psychobiology; 15:21–36.

Ernest N. Jouriles, PhD 41

SECOND INTERVIEW WITH ERNEST N. JOURILES, PHD

Helping Children in Domestically Violent
Families
By James E. McCarroll, PhD
July 2009
Dr. McCarroll: Much of your research has been on the effects of domestic
violence on children. Children living in a home with severe domestic violence are also at risk for maltreatment.
Dr. Jouriles: When intimate partner violence (IPV) and child maltreatment co-occur, both contribute independently to child problems. Intimate
partner violence is harmful for kids, maltreatment is harmful for kids, andboth in combination are more harmful than either of them alone. I thinkthat is important.
Dr. McCarroll: Can we make the assumption that children exposed to interpersonal adult violence are traumatized?
Dr. Jouriles: I would not go that far. There are different types of violence
exposure. You could make the argument that a child is exposed to violence
if they are living in a home where the parents are violent even if the children are not directly seeing the violence. The children can be aware of theviolence because of what their siblings say or because they notice bruises
on a parent. Also consider that some define violence as an act of physicalaggression that has occurred in a given time frame. Others use very different definitions that might include more frequent and severe violence. I
am not sure that exposure to a push, shove, or grab between parents would
traumatize kids.
Dr. McCarroll: Your papers use the terms externalizing and internalizing inreferring to the behavior of children. Would you describe what you mean bythese terms?
Dr. Jouriles: Externalizing often involves behaviors associated with diagnoses of Conduct Disorder, Attention Deficit Hyperactivity Disorder, or Oppositional Defiant Disorder. It involves aggressive behaviors such as stealing,
noncompliance, not following rules, and other antisocial activities. Thosebehaviors are often considered more prevalent among boys than girls in thegeneral population, but we find that in violent families often both boys andgirls are engaging in those types of behaviors.

42 Family Violence Research, Assessment and Interventions

Internalizing consists of depression, anxiety, and a lot of what we think
about in terms of trauma symptoms.
Dr. McCarroll: Do you see children with both externalizing and internalizing behaviors?
Dr. Jouriles: You definitely see children with both. A lot of studies on
the classification of child psychopathology have identified these two broad
dimensions — externalizing and internalizing — but, it is often the case thatthey go together. That is, when a child has externalizing problems, they aresometimes exhibiting internalizing problems as well. There is also a developing literature on relational aggression, a type of aggressive behavior thathas to do with turning one’s friends against someone else such as by spreading rumors. That type of aggression is often associated more with girls thanboys, although both genders tend to engage in it.
Dr. McCarroll: How do you approach treatment with children and parents
with these problems? In one of your articles, you suggested staffing domestic
violence shelters with people who can help the children.
Dr. Jouriles: That would be an ideal situation, but work done at a shelteror during a short stay is only the tip of the iceberg. We need to keep working
with the families after they leave the shelter. Violent families are often multiproblem families. That is, violence is one of many problems in these families.
It can be overwhelming figuring out where to start. But, in working with thewomen, we found a very powerful effect if we stuck with them, after they left
the shelter, and tried our best to help them over time.
Dr. McCarroll: The military has a huge investment in new parent support
programs including home visitation. How did you teach parenting skills to
the mothers in the limited time available to you? What was important andhow did you do it?
Dr. Jouriles: While they are at the shelter the mothers often are dealing
with many other urgent concerns. We try to develop a rapport with them sothey trust that we have the family’s best interest in mind. We also try to help ingetting the families resources. Once they leave the shelter we start home visitswith them. During the initial home visits, we just try to help them get settled
and back on their feet. We eventually start working on child management
skills with the idea that these women can play an important role in helping
children recover the effects of living in a severely violent family. Our intervention is very hands-on in that we describe child management skills, model
the skills for the mothers, and role play with them. Then we bring in the kids
and practice with them. There is a lot of repetition; it’s not a parenting class.

Ernest N. Jouriles, PhD 43

Dr. McCarroll: Can you detail some of those skills that you consider the mostimportant?
Dr. Jouriles: We spend a lot of time just trying to enhance the parentchild relationship. Some of the skills have to do with just being able to spend
time with the kids that is rewarding to both the mothers and the children.
We also teach how and when to praise, to comfort their kids, to develop listening and communication skills, and to play with their kids. We also teachstrategies to discourage antisocial child behavior that do not involve physical aggression. Examples are time out and removing privileges effectively todecrease the likelihood of antisocial child behaviors. This strategy can bevery effective when you have a child that is already acting out in a significant
way. You need both.
Dr. McCarroll: Is there a hierarchy of teaching to the mothers? Do you focus
first on to controlling the antisocial behavior or on the positive parenting?
Dr. Jouriles: We usually start with the positive parenting, but if there is an
emergency situation we would do what is necessary to handle it.
Dr. McCarroll: Have these women moved to a new home out of the violenceor do you find them going back into the same home?
Dr. Jouriles: Most of our work has started with women who are trying to
set up a residence independent of their violent partner. But, most of them
have one foot in and one foot out of the relationship. When there are kids
involved it gets complicated.
Dr. McCarroll: You noted in your papers the need to work with the severely
violent men.
Dr. Jouriles: If there is a man involved in the family or if the woman doesreunite with the man, we talk with the woman about involving the man in thesessions that we offer. A lot of these men are already in domestic violence treatment programs. The parenting part is in addition to it. We are not trying to keep
anything secret and the woman’s safety is always of primary importance.
Does our intervention stop the violence? I would not say that it does in allcases, but I do think that it reduces it. We make the women aware of just how the
exposure to violent adults can have a negative influence on their kids no matter
who is committing the violence.
Dr. McCarroll: You wrote about the need to learn about the experiences ofchildren in families. What kinds of experiences are you interested in learning about?
Dr. Jouriles: When we talk with children about what is going on with their

44 Family Violence Research, Assessment and Interventions

parents. The siblings often have very different views. Some are very frightenedby their parents’ violence whereas to others it is more of an annoyance. We havealso found that, even in families where there is severe intimate partner violence,the violence is often not the most important issue going on in the kids’ lives.
There is a lot we can learn from talking with the kids to get a better understanding how they are fairing within these families.

Dr. McCarroll: One of your recent articles was on the effects of exposure toviolence on children’s explicit memory. What is explicit memory?
Dr. Jouriles: Explicit memory is used interchangeably with working memory. Explicit memory is very important in a lot of developmental tasks, including
doing well in school and following instructions. When a parent gives multiplecommands, a child needs to keep everything straight in their mind.
I believe that the effects of a parenting intervention are perhaps more broadthan most of the studies indicate. For example, in our research, to date, we havelooked at the effects of IPV specifically on externalizing problems and internalizing problems. We have also found that living in these violent families seems
to be linked to memory processes. I think that is very intriguing. An importantquestion is if a psychosocial intervention, such as parenting, will have effects
that go beyond the externalizing or internalizing problems into, for example,
memory processes. We need to broaden our approach and our measurement,
especially for kids in these multi-problem situations.
Dr. McCarroll: The literature on the effects of war on children seems to showthat disturbances of children typically follow the disturbances of the parent.
In other words, if the mother is distressed the child will be distressed. In yourstudies you are working with the mother to ameliorate the effects of stress on
the kids, and yet one would suspect that the mothers are having problems,
too. Do you think that positive parenting training is therapeutic and a formof intervention for the mothers themselves?
Dr. Jouriles: I do think so, at least with some of the families with which wehave worked. The mothers are very happy with the fact that they can do things
to help their kids. It is important to keep in mind that with our parenting interventions we spend a lot of time working specifically with the mother on issues
that she is experiencing. About half of our sessions are devoted to the parenting
intervention, but the other half are devoted to helping the mom. A lot of themoms are basically starting their lives over in a new residence, in a new neighborhood. We help the mother to get settled and to make good decisions about
what is going on in her life and in her family’s life. From my perspective what wewant to do is to find out what works and to do our best to offer programs thatwork for these families.

Ernest N. Jouriles, PhD 45

Dr. McCarroll: Deficits in explicit memory were shown in your studies bycareful measurement. How would a parent or a teacher recognize that achild is having memory problems that require some kind of intervention
versus kind of dealing with the normal ebb and flow of what happens in theclassroom or day-to-day in a family’s life? How would they notice them? Are
these effects subtle or are they more easily seen?
Dr. Jouriles: If a parent or teacher notices that the child is having difficulties
keeping things straight or following commands or forgetting easily, I think thatthat would be a clue that there may be an issue. In the classroom there is a lot
more opportunity to see if there are difficulties with memory just because of thetasks that kids are asked to do. There are different tasks in which we can help
children with attention and with memory processes. We can get the children
back on the right track.
Dr. McCarroll: How would you recommend that they do that? By getting an
appointment with a primary care doctor or with a psychologist?
Dr. Jouriles: The family could ask the pediatrician if this is unusual. “Is thissomething I should be concerned about?” The pediatrician is a good gatekeeper.
Also, school personnel often can be very helpful not only pointing a parent in
the right direction, but in getting converging evidence as far as whether thisis a problem both at home and at school. The school counselor can help because their services are not going to cost the parent anything. Schools have staff
trained to test for such problems. But, with regard to parenting and parent-childinteraction, especially with pre-schoolers and young school age kids, a lot canbe done to promote positive child behavior just by the positive parenting andbeing very aware of how you are parenting. Parents can teach children manydifferent things. Most of us want our kids to do well and not just to behave well.
We can help our kids make better decisions and take care of themselves such as
by cleaning up after themselves and exercising and eating well. All of these canbe influenced by parenting.
Dr. McCarroll: Child maltreatment and IPV are usually handled in different social and legal systems. When there is co-occurrence, how can agencies
work together to protect children?
Dr. Jouriles: I believe that individuals who work with intimate partner violence need to assess for the possibility of child maltreatment and people who work
primarily with child maltreatment also need to consider intimate partner violencein the families. A good starting point is to assess for its co-occurrence. However, I
think that very little of that is going on in agencies around our country.
Dr. McCarroll: Thank you.
Dr. Jouriles: You are welcome.

46 Family Violence Research, Assessment and Interventions

Key Points
When intimate partner violence (IPV) and child maltreatment cooccur, both contribute independently to child problems.
Explicit memory is very important in a lot of developmental tasks
including doing well in school and following instructions. When aparent gives multiple commands, a child needs to keep everythingstraight in their mind. Living in these violent families seems to belinked to problems in children’s memory processes.

BACKGROUND TO RECENT RESEARCH ON HOME VISITING TOPREVENT CHILD MALTREATMENT

Home Visiting: Research Review and
Implications for Family Advocacy Programs
By James E. McCarroll, PhD, and Robert J. Ursano, MD
Joining Forces Joining Families, Volume 8, No. 1, Fall/Winter 2004
In this review of a series of articles we summarize recent research reports onhome visiting and its relation to preventing child abuse and neglect including some of the research of John J. Eckenrode. Dr. Eckenrode is interviewed
in separate articles in this volume.
A series of articles on Hawaii’s Healthy Start Program (HSP) was recently
featured in Child Abuse & Neglect (Duggan, McFarlane, Fuddy, et al., 2004;
Duggan, Fuddy, Burrell, et al., 2004; Windham, Rosenberg, Fuddy, et al.,
2004; Chaffin, 2004). The Healthy Start Program (HSP) is a national prevention program for families at risk for child maltreatment. These articles raise
important research questions for Army home visiting programs and Armyprofessionals charged with their oversight.  
The articles in Child Abuse & Neglect were based on a three-year follow-up of home visiting of at-risk families on the island of Oahu, HI. The
research methodology was a randomized trial. The first study (Duggan,
McFarlane, Fuddy, et al., 2004) addressed whether home visiting prevented
child maltreatment. The second study (Duggan, Fuddy, Burrell, et al., 2004)
examined the impact of home visiting on parental risk factors (e.g., maternal
mental health, substance abuse, partner violence) and whether the intervention affected a mother’s interest in and utilization of community services toaddress risk factors. The third study (Windham, Rosenberg, Fuddy, et al.,2004) investigated the relationship between parent and child characteristics
and mothers’ reports of child maltreatment in the first three years of thechild’s life. An invited commentary summarized the three studies and provided suggestions for further research (Chaffin, 2004).
The three studies examined the same sample, 643 at-risk families en-

48 Family Violence Research, Assessment and Interventions

rolled in HSP from November 1994 to December 1995 in six home visiting
programs. Families were identified as at-risk by a variety of sources: information from prenatal care providers, review of the mother’s medical record,
and assessment at the hospital when the child was born. A semi-structured
assessment instrument, the Kempe Family Stress Checklist (Kempe, 1976),
also determined risk. Family enrollment was voluntary. The study randomly
assigned families to either the HSP (n=373) or to a control group (n=270).
Home visits were conducted in the HSP group by paraprofessionals working
under professional supervision. All home visitors had a high school diploma. Supervisors had a master’s degree in a public health, health, or a humanservice field and three years experience in client service and administration
or a bachelor’s degree and five years of relevant experience.  
Home visitors were given five weeks of initial core training and additional training including explicit examples of how parental risks might belinked to home visiting goals and intervention activities. The home visitors
were trained in a range of services to help parents address existing crises,
to model problem-solving skills, and how to access services (e.g., income,nutrition, domestic violence, parental substance abuse and poor mental
health). They also provided parenting education, modeled effective parentchild interaction, and ensured that the child had medical care. Services weredirected to the mother and the father, if possible. The HSP model called for
3–5 years of home visiting in which families who were enrolled at the initiallevel were visited weekly. There were explicit criteria for promoting the family to a higher level based on increased family stability and identification ofa positive support system. With promotion to higher levels, the frequency ofhome visiting was decreased to biweekly, monthly and quarterly.  
Control families did not receive the home visiting intervention, but were
evaluated using the same methods as HSP families. Outcome data were collected in annual maternal interviews using self-reports of abuse and standardized measures, observations of the home environment, and records
indicative of child abuse and neglect (Duggan, McFarlane, Fuddy, et al.,2004).
Child maltreatment was defined primarily by the mother’s report of her
own psychologically and physically abusive behavior toward the child on the
Parent-Child Conflict Tactics Scale (CTS-PC) (Straus, 1995; Straus, Hamby,
Finkelhor, et al., 1998). The authors were mainly interested in identifying
severe physical assault and assault on the child’s self-esteem. Factor analysis(a method for grouping variables) of the CTS-PC showed that severe physical abuse (burned or scalded the child on purpose, grabbed child by theneck or choked, threw or knocked down the child, and hit child with fist or
kicked hard). Assaults on the child’s self-esteem included items normally

John Visiting
J. Eckenrode,
PhD 49Background to Home
Research

considered psychologically abusive (called child dumb or lazy, mother said
she would leave child, and swore or cursed at the child) plus one physicalabuse item (slapping the child on the face, head, or ears). Because of the
inclusion of one physical abuse item with psychologically abusive items, theauthors called this cluster assaults on the child’s self-esteem. These items reflected maternal behavior that was demeaning and potentially damaging to
the child’s developing sense of self-worth. Official records of child maltreatment were also used, but the number of reports was very low and hence may
have underestimated child maltreatment incidents.
Strong risk factors for Severe Child Physical Maltreatment (Chaffin,
2004)■■ Parental depression■■ Mother having no partner  ■■ Mother involved in violent relationship■■ Child small for gestational age

Strong Risk Factors for Assaults on Child’s Self-Esteem (Chaffin,
2004)■■ Maternal depression■■ Mother having no partner■■ Mother involved in violent relationship■■ Mother’s illicit drug use■■ Mother’s perception of child’s demands■■ Child’s age

At the end of the three-year evaluation, the home-visited and control
groups did not differ significantly on either maternally reported child abuseor substantiated reports of child maltreatment. There was a modest impact
in preventing child neglect (Duggan, McFarlane, Fuddy, et al., 2004). The
program had no significant effect on the mothers’ desire for and use of community services. Also, home visiting had little impact on parental risks forchild maltreatment in the first three years of a child’s life (Duggan, Fuddy,
Burrell, et al., 2004). The study showed the same risk factors are associatedwith child maltreatment regardless of home visiting. Severe child physicalassaults were significantly associated with maternal depression, with themother having no partner, and the mother’s involvement in partner vio-

50 Family Violence Research, Assessment and Interventions

lence as a perpetrator, not solely as a victim (Windham, Rosenberg, Fuddy,
et al., 2004).  
In addition, both the child’s age (highest for 2-year olds) and the childbeing small for gestational age were related to severe child physical assaults.
Interestingly, severe physical abuse was not associated with the mother’s age,education, race, parity, or household income level.  
Assaults on the child’s self-esteem were associated with maternal depression, the mother having no partner, the mother’s involvement in partner
violence, illicit drug use, the child’s age (increased over time from year 1
to year 3), and the mother’s perception of the child’s demands (Windham,
Rosenberg, Fuddy, et al., 2004). The child’s demand level was measured bymother’s assessment of the child’s temperament and behavior.  
There were numerous findings related to the role and performance of thehome visitor. It appeared from HSP records that home visitors might havelacked skills, training, and supervision. Home visitors seldom noted concern
about possible child maltreatment (Duggan, McFarlane, Fuddy, Burrell, etal., 2004) or parental risk factors for child maltreatment (Duggan, Fuddy,
Burrell, et al., 2004). Despite the fact that home visiting services were tohave been developed based on a case plan that addressed the risks identified
in an assessment interview, the authors found that many programs driftedfrom their original intent. Most families had only one or two goals and thesewere sometimes broadly stated (e.g., “To be happy!”). These were seldom
translated into measurable objectives. For this reason, home visiting activities could not be linked to the achievement of family goals and objectives.
Overall, there was also no significant program effect on any of the major parental risk factors for child maltreatment. One of the responsibilities of thehome visitor was to recognize the need for professional interventions and to
make appropriate referrals. There was little evidence that home visitors werealert to the mothers with the highest levels of abusive behavior. Often, home
visitors neither developed a plan to address important factors in the life of
the family, nor linked home visiting activities to family goals and objectives(Duggan, Fuddy, Burrell, et al., 2004).
Chaffin’s commentary (Chaffin, 2004) asks whether it is time to re-thinkhome visiting as a mechanism to reduce child maltreatment and emphasized the following points. There is a need for randomized clinical trials in
psychosocial research. While there are government requirements for datafrom randomized clinical trials to demonstrate the safety and effectivenessof food, drugs, and medical (and veterinary) treatment, no such requirements exist for psychosocial interventions and there is no approving agency
to certify their effectiveness. Practitioners are accredited, but interventions
are not. Child abuse prevention programs are often based upon and justi-

John Visiting
J. Eckenrode,
PhD 51
Background to Home
Researchfied by advocacy, theory, fashion, guesswork, weak program evaluations andhope. Chaffin addresses how science values skepticism and facts, whereas
advocates often have a predetermined agenda and seek facts that buttresstheir agenda. The price paid for this is often a high level of funding, a senseof mission among the practitioners, and a willingness to accept evaluation
data only if the results are positive. The following are among Chaffin’s interpretations (Chaffin, 2004) of these studies.  
■■ Partner violence, substance abuse, and parental depression are strongrisk factors for future child maltreatment. However, these are the areasthat home visitors most often feel least equipped to address.
■■ Focusing the efforts of home visitors on the known risk factors of theclients may be a better strategy for reducing child maltreatment thanthe empowerment philosophy. Empowerment models may serve clients
poorly by requiring them to self-assess their own risks and intervention
needs accurately in order to receive help.
■■ Empowerment models have strengths that should not be lost. Amongthese strengths are: establishing collaborative relationships, securing client motivation and buy-in, and avoiding authoritarian service styles thatdrive clients away.  
■■ Universal programs (targeting all families rather than selecting high-riskfamilies) may be an inefficient use of resources, as many of these families
may never mistreat their children.
■■ The effectiveness of home visiting has not yet been demonstrated. Further study is needed to document which elements of home visiting programs work for which families and for which problems.
■■ Home visiting programs should not be considered proven models thatcan be taken off the shelf and be reliably expected to reduce maltreatment. They might better be considered interventions still requiring testing and development.
■■ Further research should be directed to (Duggan, McFarlane, Fuddy, etal., 2004):■■ Study home visiting in a more sophisticated way. The elements for more
direct study include home visitor communication skills, visit content,
and service quality.  
■■ Include a range of child abuse and neglect indicators in studies rather
than relying on substantiated reports or hospitalizations to infer program success. The use of protocols and formal referral arrangements forfamilies with multiple and complex problems would help the home visitors focus on the most important problems rather than trying to solve all
the needs of the families.
■■ Have clear goals and tested models for research that can provide essential

52 Family Violence Research, Assessment and Interventions

information that will improve the effectiveness of the programs.

■■ Implement and study a variety of home visiting models and programs aswell as a variety of home visiting research efforts.

■■ Have control groups since studies purportedly showing program effec-

tiveness in uncontrolled studies can be highly misleading. Historically,
many home visiting programs show improvement in parental risk factors
in families, but so did control families. Without the control comparisons,program success is assumed rather than demonstrated and is ultimately
harmful to the program and the families.
■■ Integrate home visiting into a larger array of community services. In the
Army this could be an easy task, but its effect on child maltreatment must
be documented. Such a project is potentially more feasible in the Armythan in the civilian community due to the concentration of on-post services. However, integrating service delivery with the outside community
is more difficult. Nevertheless, in order to determine where families gofor help and whether such help is effective in reducing child maltreatment and parents’ risk levels remains to be demonstrated.
■■ Study the effects of participant attrition. In the research reported here,
about half the study families dropped out by the end of the first year
(Duggan, McFarlane, Fuddy, Burrell, et al., 2004). There was no difference in attrition between study and control groups. Understanding thereasons for program dropout has potentially important implications for
program success. An important project that could be undertaken by the
Army is to relate program attendance and participation to dropout rates
and other measures of the success of home visiting programs.
■■ Study father involvement. Father involvement was found to be low inthese studies even though about two thirds of fathers had been assessed
as being at-risk of perpetrating child abuse. The Army has a much greater
opportunity to involve fathers in home visiting programs than does thecivilian community. Research opportunities abound in this area, as there
is essentially no literature at this time on the effects of such programs on
fathers.
■■ Focus the efforts of home visitors on the risk factors that can be modified. This requires the home visitor to learn the proximate causes of childmaltreatment, relate them to parent and child risk factors, and develop aplan to address them.
Supervision, training, and ongoing monitoring of the home visitor appear to be critical elements of any home visiting program. While gettingfrom plan to goal may be difficult to demonstrate, it is entirely possible forhome visitors to document observations and their attempts to address theJohn Visiting
J. Eckenrode,
PhD 53Background to Home
Researchrisk factors within the families. Home visiting offers promise, but requires
further study. The point of this review is to stimulate research and management interest in improving home visiting programs and making them costeffective. Home visiting has shown positive benefits (Eckenrode, Ganzel,
Henderson, et al., 2000) and remains a promising opportunity for decreasing
child maltreatment. It also has the potential for increasing the involvementof fathers in family and community programs and for reaching young mothers who might be socially isolated in remote military communities. With theincreasing frequency and length of overseas deployments such efforts will
be important in serving military families. We hope that home visiting will
receive increased research emphasis in the Army and continue to serve as a
keystone of the Army’s child maltreatment prevention efforts.
Key Points
The effectiveness of home visiting in preventing child maltreatment
is yet to be determined.
Home visiting had little impact on parental risks for childmaltreatment in the first three years of a child’s life. The same risk
factors are associated with child maltreatment regardless of home
visiting.
At the end of the three-year evaluation, the home-visited andcontrol groups did not differ significantly on either maternallyreported child abuse or substantiated reports of child maltreatment.
There was a modest impact in preventing child neglect.

References
Chaffin M. (2004) Is it time to rethink Healthy Start/Healthy Families?
Child Abuse & Neglect; 28:589–595.
Duggan AK, McFarlane E, Fuddy L, Burrell L, Higman SM, Windham
AK, & Sia C. (2004). Randomized trial of a statewide home visiting
program: Impact in preventing child abuse and neglect. Child Abuse &Neglect; 28:597–622.
Duggan AK, Fuddy L, Burrell L, Higman SM, McFarlane E, Windham AK, &Sia C (2004) Randomized trial of a statewide home visiting program: Impact in reducing parental risk factors. Child Abuse & Neglect; 28:623–643.

54 Family Violence Research, Assessment and Interventions

Eckenrode J, Ganzel B, Henderson, CR, Smith E, Olds D, Powers J, Cole R,
Kitzman H, & Sidora K (2000) Preventing child abuse and neglect witha program of nurse home visitation. Journal of the American Medical
Association; 284:1385–1391.
Kempe H (1976) Child Abuse and neglect: The family and Community.
Cambridge, MA: Ballinger Publishing Company.
Straus MA (1995) Manual for the Conflict Tactics Scales (CTS) and Test
Forms for the Revised Conflict Tactics Scales (CTS2). Durham, NH:
Family Research Laboratory, University of New Hampshire.
Straus MA, Hamby SL, Finkelhor D, Moore DW & Runyan D. (1998) Identification of child maltreatment with the Parent–Child conflict Tactics
Scales. Development and psychometric data for a national sample ofAmerican parents. Child Abuse & Neglect; 22, 249–270.
Windham AM, Rosenberg L, Fuddy L, McFarlane E, Sia C, & Duggan AK(2004) Risk of mother–reported child abuse in the first 3 years of life.
Child Abuse & Neglect; 28:645–667.

John J. Eckenrode, PhD 55

BACKGROUND OF RESEARCH AND INTERVIEW WITH
JOHN J. ECKENRODE, PHD

Home Visiting Revisited: One Spoke in the
Wheel, Not the Silver Bullet
By James E. McCarroll, Ph.D.
Joining Forces Joining Families Volume 8, Number 2, Spring 2005
The following interview with distinguished scholar andresearcher, John Eckenrode, PhD, of Cornell University, presents a provocative discussion of home visiting
expanding upon the previous review of home visiting
programs, Home Visiting: Research Review and Implications for Family Advocacy Programs.  
Dr. Eckenrode raises important questions abouthome visiting.  
■■ Should the program goal be prevention of child abuse or prevention ofchild neglect?
■■ Would it be more effective and engaging to reframe child abuse prevention as promotion of maternal and child health and development?
■■ What are the pros and cons of approaches that target parental risk factors
versus an empowerment strategy?
■■ What are the differences in programs that use nurses versus paraprofessional home visitors?
■■ How can we better utilize fathers and other family members to increase
the benefits of home visiting?
■■ What do we know about the cost-effectiveness of home visiting?  
Dr. McCarroll: The journal Child Abuse & Neglect recently published a seriesof research studies on the effects of the Hawaii Healthy Start Program (HSP)on home visiting. We reviewed those articles (Duggan, McFarlane, Fuddy, etal., 2004; Duggan, Fuddy, Burrell, et al., 2004; Windham, Rosenberg, Fuddy,
et al., 2004) and Mark Chaffin’s commentary on them (Chaffin, 2004) toinitiate dialogue and research ideas around the Army’s experiences with its
home visiting model. Please share your thoughts on those articles as well as
your views on home visiting as a means of preventing child maltreatment.
Dr. Eckenrode: The Duggan articles are consistent with what some otherresearch is showing, especially with regard to the particular home visiting
model that was tested in Hawaii. The evidence coming out of the parapro-

56 Family Violence Research, Assessment and Interventions

fessional home visiting models is mixed, at best, and negative at worst. But,
I thought the message was not entirely as discouraging as Dr. Chaffin’s commentary suggested. In the Duggan articles there were at least some modest
benefits of the program in terms of mothers’ self-reported neglect behavior.  
There was little or no evidence that the program was preventing physicalabuse, severe or minor. This is an important point because when we thinkof these programs we tend to think of the prevention of abuse, physical orsexual abuse, rather than neglect. In fact, most of the issues that the home
visitors are dealing with have to do with neglect given the population young
mothers and fathers with whom they typically work. Even in our Elmira trial(Olds, Eckenrode, Henderson, et al., 1997; Eckenrode, Ganzel, Henderson,
et al., 2000) when there was some evidence for long-term effects, we were
careful to say that what we were preventing was primarily neglect rather
than abuse. Chaffin touched on a number of important issues with regard
to the quality of the evidence and the need for better research and the stateof the art in terms of what the data show. In general, it was a timely and awell-written piece.
Dr. McCarroll: Is the primary prevention of child maltreatment still a reasonable goal of a home visiting program?
Dr. Eckenrode: It is. However most of the successful early intervention
and family support programs would be labeled as comprehensive programsand do not focus exclusively on child abuse and neglect. They tend to bea bit broader – family support, parental support, and early education programs that deal with a range of issues. The program begun by David Olds
in Elmira was not proposed to the community or to the parents initially asa child abuse and neglect prevention program. It focused more generally onmaternal and child health; child abuse and neglect were among the issues
or outcomes of that program. That is important. Some of these programs
have become known as child abuse and neglect prevention programs because of who has picked up on what issues and what advocacy efforts havetaken place. But, it is important to put it in the larger context, not only forthe field, but also in terms of running these programs and in identifying
families who will be in them. It is more effective when it is cast in termsof a program to promote maternal and child health and well-being anddevelopment of children, with child abuse and neglect being one of several
program goals.
Dr. McCarroll: Duggan and colleagues point out that the vast majority ofparents will not maltreat their children. Hence, having them participate inhome visiting programs is essentially a waste of resources, whereas targeting

John J. Eckenrode, PhD 57

already maltreating parents puts a different cast on it. Would you go for atargeted approach or a universal approach?
Dr. Eckenrode: The data are pretty clear at this point that these services
are probably not having a very big impact on families where the need is
not very high: the well-functioning, two parent, middle income families
with no identifiable risk factors such as substance abuse or mental healthproblems or domestic violence or those kinds of issues. While such families
may have some minor benefits from participation, it is unlikely that thosefamilies would benefit greatly or that they would remain in the programs
very long. Most of these programs have high attrition rates, and the attrition rate will be higher among families that do not feel they have the need.
Given how difficult it is to fund these programs at the level of communities,
even for the high-risk parents, it is unlikely that we would be able to justify
a universal approach. The situation may be different in the military where
there are different structures and different funding options and so forth, but
at least in the civilian community, I do not think we will see a push at thepolicy level for universal approaches because the data do not support it at
the moment.
Dr. McCarroll: Do you see benefits of targeted services toward such groups
as first time mothers and already maltreating parents?
Dr. Eckenrode: I am most familiar with the program that selected primarily first time mothers. The data are less strong in terms of the effectivenessof these programs with parents that have already had one or two children.
Some fair consideration should be given as to whether first-time parents are
an important sub-population who would be open to health messages, open
to change, and may have questions about the health of their children, andtherefore may be more amenable to those kinds of interventions. Plus, theytend to be higher risk, as teen parents are, for example. There is room for
more research on whether other populations of parents can benefit as much.
Regarding maltreating parents, I have not seen strong data indicating theeffectiveness of these programs for preventing recidivism of maltreatment
among already identified maltreating parents. I am not sure that I would
target a home visiting program on already maltreating parents, especially if
one were interested in prevention rather than remediation.
Dr. McCarroll: What has been your experience on the use of screening tools?
I know that the Duggan articles used the Kempe family checklist (Kempe,1976). The military has its own risk assessment instrument.
Dr. Eckenrode: I am not an expert on what particular measures can beused as screening tools. We targeted low income, single parent status, and58 Family Violence Research, Assessment and Interventions

age as risk factors. Other programs such as ours have taken a broader demographic approach and recruited mothers who have met certain demographic
criteria. There are other risk factors for maltreatment, as cited in some of theliterature such as in the Duggan papers and the Chaffin article and work by
Neil Guterman (2001) that point to the need to target and customize ourapproaches to parents who have risk factors that are known to be associatedwith child abuse and neglect, such as substance use, psychological problems
or the presence of domestic violence. It is precisely these kinds of risks thathome visitors, particularly paraprofessional home visitors, are not very welltrained to tackle. They are difficult problems to deal with and may require
some combination of approaches, home visiting and other kinds of therapeutic approaches for some of the more serious issues such as substanceabuse and mental health problems. You cannot really expect home visitors
in a modest intervention such as this to deal with very significant family
problems such as those.
Dr. McCarroll: Would you give us your thoughts on differences between programs that attempt to correct the risk factors that brought the family into theprogram in the first place, as Duggan et al. and Chaffin advocated, versus
those that use an empowerment model emphasizing parental strengths?
Dr. Eckenrode: It is not an either-or situation. I have a lot of respect for
the empowerment model and the work of my colleagues at Cornell, Urie
Bronfenbrenner (1979) and Mon Cochran (Cochrane, 1995; Forest, 2003)
who use and promote it. We have developed programs at Cornell that try tobuild on those insights in working with families and family support workers. But, there are certain, straightforward risk factors that are present infamilies. For example, if you start working with mothers pre-natally there
are some obvious risk factors impacting child development such as maternalsmoking or alcohol use. I do not think anyone would argue that focusing on
those risk factors in the young pregnant woman would be a mistake. Completely letting a mother engage in such behaviors that define her own goals
in a home visiting program would be a misguided effort. On the other hand,
there is a lot that can be learned from empowerment approaches in termsof how we work with families, how they are approached, the collaborative
efforts that are used in these programs with parents, respect for parents,
respect for diversity and training cultural competence of our visitors. These
are all very positive things and they speak more to the approach that is usedby the visitors than the content of what is being attempted. There needs to besome balance between this approach of targeting risk factors including what
we know from epidemiological literature about certain risks that are present for mothers and children in the population. Some families have more ofJohn J. Eckenrode, PhD 59

those risk factors, whether it is poverty or substance use or domestic violence, and we certainly cannot ignore those when it comes to these typesof prevention programs. But, it does raise some questions. How do you dothat while preserving the dignity of the enrolled family? How do you recruit
them as partners in the process? How do you build upon the supportiveelement of the home visitor-family relationship? The key to the success ofany of these programs is the quality of that relationship between the home
visitor and the mothers.
Dr. McCarroll: How would you assess the quality of the relationship between
the mother and the home visitor?
Dr. Eckenrode: There have been attempts to do that. Some of the more
recent work that David Olds and his group have been doing in Denver has
explicitly tried to measure the quality of that relationship between nurses
and mothers (Forest, 2003). Typically this is done through self-report measures of the mother as a part of the evaluation design. It asks them not only
about what happened, but also the qualitative aspects of that relationship.
Jon Korfmacher (Korfmacher, Kitzman, & Olds, 1998) looked at some ofthat when he worked in Denver with David Olds. But, there are other approaches. You can also probably get good, reliable data from looking at that
relationship from the mother’s point of view. But, you can also get assessments from the visitor’s point of view as well in terms of how well that relationship is going.
Dr. McCarroll: What have been the differences in outcomes using nurse
home visitors compared to paraprofessionals?
Dr. Eckenrode: There have probably been more evaluations of paraprofessional models than nurse models at this point. The Duggan studies
examined a paraprofessional model. The only trial that I know of that has
explicitly tried to compare randomly assigned families to a nurse or paraprofessional home visitor is David Olds’ Denver trial (Olds, Robinson, Pettitt, et al., 2004), which is now completed, and those kids are now in elementary school. Most of the paraprofessionals were from the community anddid not have a college degree. The data clearly show the superiority of thenurse home visiting condition across several child and maternal outcomes.
Typically, the pattern of results shows small gains for the paraprofessionalvisited families, which were not statistically different from the control groupfamilies, and larger gains for the nurse-visited families that were statistically different from the control group. The paraprofessional approach seems
to have very limited, modest effects. With large scale dissemination of theparaprofessional model, I would presume that there are some benefits forsome families, but across the board and across these studies we are just not

60 Family Violence Research, Assessment and Interventions

seeing very big effects at this point.
Dr. McCarroll: I wonder if that is due to the educational background of thenurses or whether the paraprofessionals are not getting adequate training
and supervision.
Dr. Eckenrode: It is kind of a mix. In David Olds’ trial in Denver theybasically got the same level of training and supervision (Olds, Robinson,
Pettitt, et al., 2004). So, it was not program implementation differences that
could explain that. When I hear David talk about it, it is a combination ofthings including their level of education and ability to respond to issues in a
family. There are also legitimacy issues and the sense of respect that people
accord nurses in the community. First time pregnant women may be more
open to the kind of relationship with a nurse and the kind of informationthat a nurse can provide because of questions around health issues. Nurses
may be in a better position to provide this kind of information. It is harder
for a paraprofessional to come into a family and achieve that same comfort
level around these kinds of issues. There are also programmatic issues. We
know there is more turnover among paraprofessional home visitors thanwith the nurses due to the inability, understandably, of many community
agencies to pay their paraprofessionals very well. We know that the continuity of that relationship over the time with the home visited parents is an
important program component that could be linked to success. So, there
are other structural reasons that might work against the effectiveness of theparaprofessional model.
Dr. McCarroll: Due to the wide dispersal of forces, the military is often only
able to use volunteers or paraprofessionals, and not nurses. Can you envision a mixed model for the military in which a nurse or an experienced
person acts as a supervisor of volunteers or paraprofessionals and alternates
visits with them?
Dr. Eckenrode: Yes. It is possible these kinds of hybrid models might besuccessful in some cases and contexts with some families. I do not think
we have the data, at least in the randomized trials, to know the answer tothat. Those are probably forthcoming as people experiment with different
combinations such as the level of education and level of supervision. We
may reach a day where there are data to support something like what you
describe. Whoever the visitors are, there are some program elements thatneed to be in place in terms of adequate training, supervision, caseloads, andlength of follow-up to ensure success. I certainly do not think you can go inwith a paraprofessional model even if they are supervised by higher level
people, do it for six weeks with a narrow focus on one or two issues, andJohn J. Eckenrode, PhD 61

expect to see much by way of long-term effects. I would rather see a morecomprehensive, long-term approach with a smaller number of families thana watered-down approach that tried to reach all the families and is unlikely
to be successful.
Dr. McCarroll: At what stage in a woman’s pregnancy would you start sucha program?
Dr. Eckenrode: That is a good question. As the pregnancy progresses,
mothers become more and more focused on it. But, you do not want to wait
too long into the third trimester to recruit women because if there are risky
health behaviors or nutrition problems, then you really need to get to themearlier. It is certainly better to recruit in the second trimester than the third.
Realistically, you just might not be able to pick up families much earlier
than that. I do not know what the standards are for pre-natal visits, but thatis probably a guideline that can be used as to when these programs should
start. Often these families are recruited through the pre-natal programs.
Dr. McCarroll: Also, in terms of developing models, the military may havean advantage over civilian communities in the opportunity to recruit fathers
into home visiting programs.
Dr. Eckenrode: I think there is a lot of interesting work that could bedone in terms of father involvement and how that might help keep mothersin the program longer. Such an approach might help to deal with some ofthese attrition issues. Father involvement could act as a multiplier reinforcing what the nurses are doing. We also know that family members can havea negative effect. If the young mother is living with family members that are
not on the same page as the nurses or other home visitors their effects can be
detrimental to the program’s effectiveness. But, the opposite is also true. Oneof the original goals of the program was having the involvement of a husband, a grandmother or a partner present during the pregnancy, at the birthof the child, and around the house enough to help with child care activities.
There is a lot of room for work and improvement there.
Dr. McCarroll: What information is available on program costs?
Dr. Eckenrode: There is a new study that has come out of Washington
State that examines the costs and benefits of several early intervention andfamily support programs. In terms of the nurse visiting program, the data
show that it is cost-effective over the long term, and that a Healthy Families
approach actually does not recover the costs of the program. The information is available on the web. The summary report is at www.wsipp.wa.gov/
rptfiles/04-07-3901.pdf. The technical appendix is at www.wsipp.wa.gov/

62 Family Violence Research, Assessment and Interventions

rptfiles/04-07-3901a.pdf and references at www.wsipp.wa.gov/rptfiles/ 0407-3901b.pdf. The Washington State project provides a more comprehensive view of outcomes than earlier cost-benefit studies allowed. A monetary value was put on education outcomes, substance abuse outcomes, teen
pregnancy outcomes, and child abuse and neglect outcomes, in addition tocriminal outcomes. We hope this effort produces a more complete accounting of policy options that can increase the efficiency with which taxpayer
dollars are spent.
Dr. McCarroll: Any final thoughts that I have not asked you about?
Dr. Eckenrode: An important point to make is that home visiting programs by themselves are kind of modest interventions requiring us to havemodest expectations and goals. They need to be seen in the context of thewhole web of services available to families and to children. I think the mosteffective long-term approaches will be those in which home visiting is apart of a network of services such as combining home visiting with otherhigh quality programs like center-based child care. The other challenge is
how to bridge between these programs once families leave the home visiting programs. How do you continue working with these families throughthe pre-school years until the children reach school age and beyond? As
stand alone programs, they are not likely to have great impact on families.
They really need to be thought of as one component of a more comprehensive approach to something like preventing child abuse and neglect, which
would include other kinds of approaches to already maltreating families,
community-based prevention efforts, and school-based prevention efforts.
Home visiting is one spoke in the wheel and it might be an important one
and an interesting one, but it is not the silver bullet that has come along thatis going to solve all these problems.
Dr. McCarroll: Thank you for this information. I am sure our readers willappreciate your thoughts on home visiting. We look forward to your input
in the future.
Dr. Eckenrode: You are welcome. My pleasure.

John J. Eckenrode, PhD 63

Key Points
Most of the issues that the home visitors are dealing with have to dowith neglect given the population young mothers and fathers withwhom they typically work.
These [home visiting] services are probably not having a very
big impact on families where the need is not very high: the wellfunctioning, two parent, middle income families with no identifiablerisk factors such as substance abuse or mental health problems ordomestic violence or those kinds of issues.  
Home visiting programs by themselves are modest interventions
requiring us to have modest expectations and goals. They need to be
seen in the context of the whole web of services available to families
and to children.

References
Bronfenbrenner, U. (1979) The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University
Press.
Chaffin M.. (2004) Is it time to rethink Healthy Start/Healthy Families?
Child Abuse & Neglect; 28:589–595.  
Cochran M. (1995) Empowerment and Family Support. Ithaca, NY: Cornell
Cooperative Extension.  
Duggan AK, McFarlane E, Fuddy L, Burrell L, Higman SM, Windham AK,& Sia C. (2004) Randomized trial of a statewide home visiting program:
Impact in preventing child abuse and neglect. Child Abuse & Neglect,
28:597–622.
Duggan AK, Fuddy L, Burrell L, Higman SM, McFarlane E, Windham AK,& Sia C. (2004) Randomized trial of a statewide home visiting program: Impact in reducing parental risk factors. Child Abuse & Neglect,
28:623–643.
Eckenrode J, Ganzel B, Henderson CR, Jr, Smith E, Olds DL, Powers J,
Cole R, Kitzman H, & Sidora K. (2000) Preventing child abuse andneglect with a program of nurse home visitation: The limiting effectsof domestic violence. Journal of the American Medical Association, 284,
1385–1391.

64 Family Violence Research, Assessment and Interventions

Forest C. (2003) Empowerment Skills for Family Workers. Cornell Family
Development Press and distributed by Cornell University Press, Ithaca,
NY
Guterman NB. (2001) Stopping Child Maltreatment Before it Starts. Thousand Oaks, CA: Sage Publications, Inc. 8. Bronfenbrenner, U. (1979)
The ecology of human development: Experiments by nature and design.
Cambridge, MA: Harvard University Press.
Kempe H (1976) Child Abuse and neglect: The family and Community.
Cambridge, MA: Ballinger Publishing Company.
Korfmacher J, Kitzman H, & Olds DL. (1998) Intervention processes aspredictors of outcomes in a preventive home–visitation program. Journal of Community Psychology, 26:49–64.
Olds DL, Eckenrode J, Henderson CR, Jr, Kitzman H, Powers J, Cole R,
Sidora K, Morris P, Pettitt LM, & Luckey D. (1997) Long–term effects
of home visitation on maternal life course and child abuse and neglect:
15–year follow–up of a randomized trial. Journal of the American Medical Association, 278:637–643.
Olds DL, Eckenrode J, Henderson CR, Jr, Kitzman H, Powers J, Cole R,
Sidora K, Morris P, Pettitt LM, & Luckey D. (1997) Long–term effects
of home visitation on maternal life course and child abuse and neglect:
15–year follow–up of a randomized trial. Journal of the American Medical Association, 278:637–643.
Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Ng RK, Isacks K,
Sheff K, & Henderson CR, Jr. (2004) Effects of home visits by paraprofessionals and by nurses: Age 4 follow–up results of a randomized trial.
Pediatrics, 114:1560–1568.
Windham AM, Rosenberg L, Fuddy L, McFarlane E, Sia C, & Duggan AK.
(2004) Risk of mother–reported child abuse in the first 3 years of life.
Child Abuse & Neglect, 28:645–667.

John J. Eckenrode, PhD 65

REVIEW OF RECENT RESEARCH OF JOHN J. ECKENRODE, PHD

Primary Prevention of Child Maltreatment
By James E. McCarroll
January 2010
Dr. Eckenrode’s latest publications (at the time of this writing) include an
overview of current knowledge of the primary prevention of child maltreatment (Eckenrode, In press). The following is a summary of the important
points of that chapter.
Primary prevention can occur at the level of the individual child, parent,
or family, or it can be directed toward a community or a society at large.
All effects of prevention are difficult to evaluate, particularly those that are
directed toward communities or societies. Eckenrode discussed two major
models of primary prevention: the developmental-ecological (Belsky, 1993)
and the public health model (Kellam & Langevin, 2003). The developmental-ecological model views multiple risk and protective factors operating at
the levels of individuals, families, and communities. This model suggests that
focus on single risk factors is unlikely to be successful unless combined withother interventions. The public health model is more familiar to the medical and epidemiological community as it organizes prevention in three levels: primary, secondary and tertiary. Eckenrode notes that recently the language of primary, secondary, and tertiary prevention has been replaced by
the more understandable terms universal, selective, and indicated (Mrazek& Haggerty, 1994; Kellam & Langevin, 2003). Universal replaces primaryand denotes interventions directed at whole populations; selective interventions replaces secondary prevention and denotes targeting interventions at
the population at increased risk; indicated interventions replaces tertiary
prevention and denotes the population at greatest risk for recurrence of acondition. An example of an indicated intervention is a program aimed atpreventing recurrence of maltreatment among parents with prior child protective services involvement.
Eckenrode summarizes the current state of knowledge of programs thathave shown efficacy in preventing abuse and neglect. A wide variety of programs currently exists, but the manner and results of evaluations vary. Studies using a design involving randomized assignment to intervention and tocomparison groups are given the highest priority. However, such a designis rarely possible so evaluations are conducted that still provide information, but have limitations (McCall & Green, 2004). The most consistent evidence of effectiveness comes from the Nurse Family Partnership (Olds, Hill,

66 Family Violence Research, Assessment and Interventions

Robinson, et al., 2000) home visitation programs. Research shows that home
visitation is more likely to prevent dysfunctional parenting and child maltreatment by focusing on high risk groups rather than attempting to serve auniversal need. Other examples of home visitation programs are presented
and the complex elements of conducting and evaluating home visiting programs for parents are discussed. Other areas in which primary prevention
programs have been instituted are localized in pre-schools and in schools
while others are broadly based public education and information programs.
Eckenrode devotes considerable effort to explain the need for researchon child maltreatment prevention as well as methodologies of how programs are evaluated. The reader is pointed to many sources of information
based on evaluation. These sources take the form of lists or registries that
identify effective programs. This discussion is valuable to the practitioner
and to the policy maker in describing the evidence on which rankings ofprograms are based.
Additional discussion is given to the phases of prevention research (efficacy, effectiveness, and dissemination) and the standards of evidence for
each. The increased rigor of methodology shows the development of the
field of prevention research and the need for increased scrutiny of evidence
at the level of practice and policy.
Finally, Eckenrode presents his views on the next steps in child maltreatment prevention research. Important among these is the need to link risk
and protective factors to maltreatment. He stresses that there is no substitutefor the measurement of maltreatment and that there are often multiple measures of maltreatment: official reports, self-reports of victims and parents ofabusive or neglectful behavior, observations of parent-child interaction andmedical records. The importance of measuring maltreatment is stressed because often only the purported risk factors for maltreatment are measured.
He calls for increased collaboration among the fields of research, practice,and policy. An example of this need is for knowledge about how mental
health, substance abuse, and partner violence affect child maltreatment.
While there has been much development of knowledge in the field of childmaltreatment prevention research, he advises caution on moving too quickly
from the design of interventions to the wide-scale application of programs
without the supporting technical assistance such as training, infrastructure,and continued monitoring and evaluation to support them in the field.
This chapter is a valuable resource for both practitioners and policy makers in that it summarizes the field of prevention research in general as well as
its application to child maltreatment prevention. It makes increasingly clear
the need for those who practice and who evaluate to have an understandingof research methods. Without understanding the need for multiple sources

John J. Eckenrode, PhD 67

and measures one is likely to expend enthusiasm and resources on programs
that have not met standards for implementation.
Key Points
Primary prevention of child maltreatment can occur at the level ofthe individual child, parent or family, or it can be directed toward a
community or a society at large.
Two major models of primary prevention are the developmentalecological and the public health model. The developmentalecological model views multiple risk and protective factors
operating at the levels of individuals, families, and communities.
The public health model organizes prevention in three levels:
universal, selective, and indicated.
There is a need for increased collaboration among the fields ofresearch, practice, and policy. An example is the need for knowledge
about how mental health, substance abuse, and partner violence
affect child maltreatment.

References
Belsky J. (1993). Etiology of child maltreatment: A developmental–ecological analysis. Psychological Bulletin, 114, 413–434.  
Eckenrode J. (In press). Primary prevention of child abuse and neglect. In J.
White, M. Koss, & A. Kazdin (Eds.), Violence Against Women and Children: Consensus, Critical Analysis, and Emergent Priorities. Washington,
D.C.: American Psychological Association.
Kellam S & Langevin D. (2003). A framework for understanding “evidence”
in prevention research and programs. Prevention Science; 4:137–153.
McCall RB & Green BL. (2004). Beyond the methodological gold standardsof behavioral research: Considerations for practice and policy. Society
for Research in Child Development, Social Policy Report; 18: 1–20.
Mrazek PJ & Haggerty RJ. (Eds.). (1994). Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, D.C.:
National Academy Press.
Olds DL, Hill P, Robinson J, Song N, & Little C. (2000). Update on home

68 Family Violence Research, Assessment and Interventions

visiting for pregnant women and parents of young children. Current
Problems in Pediatrics; 30:109–141.

John J. Eckenrode, PhD 69

SECOND INTERVIEW WITH JOHN J. ECKENRODE, PHD

Developments in Evidence-Based Home
Visiting Program to Prevent Child
Maltreatment
By James E. McCarroll
July 2009
Dr. McCarroll: Your previous interview was largely devoted to home visiting. Have there been new developments in that arena?
Dr. Eckenrode: I think the biggest development in the last six or eightmonths has been the interest by Congress in home visitation as a part ofthe proposed health care reform. Nurse home visitation programs have provided the best evidence. The debates now are around “What is the evidence
and who is to decide what is effective?”
Dr. McCarroll: A recent paper (MacMillan, Wathen, Barlow, et al., 2009)
describes many of those state programs. Can you summarize the current
state of the Nurse Parent Partnership program that you are evaluating?
Dr. Eckenrode: I am mostly connected with the Elmira study. We justcompleted data collection this year of the Elmira families. This was a 27 year
follow-up. We just finished data collection so we have not begun analyses
with that data yet. We have a paper that recently appeared in the Archives ofPediatrics and Adolescent Medicine (Eckenrode, Campa, Luckey, et al., 2010)
on the 19 year follow-up study. It shows that there is some continuing effectof home visiting on criminal justice involvement, in this case, particularly
for the girls. Data analysis on the 27-year follow-up will look at how these
27-year olds are doing developmentally as young adults.
Dr. McCarroll: MacMillan stressed the need for proceeding in logical steps
from research to the way people actually conduct their programs. Fidelity isimportant in moving from the laboratory to the field. How do you see home
visiting programs that are evidence-based moving through the implementation stages, from design to evaluation to the community where they areavailable to people?
Dr. Eckenrode: There are clearly challenges, especially when programs
are already ongoing. Some are very well-established and have a long trackrecord so it is hard to come in in midstream and advocate the step-by-step
approach needed to develop, evaluate, and disseminate them. But, on the

70 Family Violence Research, Assessment and Interventions

other hand, I think there is going to be a continuing push for accountability
and for increasingly rigorous evidence, which is usually obtained throughrandomized trials. One of the problems is that there is not enough funding available to conduct rigorous trials for the variety of programs serving
families and children. It is going to become harder and harder to advocate
for large scale expenditures of public dollars on programs that do not havethat kind of evidentiary base.
Dr. McCarroll: When you implement a rigorous program, what are the issues with regard to recruitment, training, and retention, particularly in rural areas or isolated areas?
Dr. Eckenrode: There are clearly resource issues including personnel
such as the availability of trained staff. Transportation in getting people out
to families or families into centers is another important issue. Those are very
real problems that require some creative solutions. You may have to regionalize and combine resources from a variety of places and obtain funding
streams in order to have the resources available to mount efforts in rural orsparsely populated areas. But, you can run into some of the same problems
in urban areas where there is a high concentration of poverty. An interestingdevelopment is the use of multidimensional programs such as child abuse
prevention programs using a variety of modalities. Some, like public service
announcements, are fairly low cost. A more intensive approach is to focus
specifically on higher risk families. This puts the imperative on targeting thefamilies that are most in need so that you use your resources most wisely. For
example, MacMillan talks about the Triple P program (Positive Parenting
Program) (Sanders, Pidgeon, Gravestock, et al., 2004; Prinz, Sanders, Shapiro, et al, in press). It is a multi-dimensional prevention program that uses
a variety of strategies. It is being tested in counties in the Carolinas that do
not have big urban centers, but there are a lot of rural and semi-rural communities. There are examples of more comprehensive, multi-dimensional
programs that do reach into those kinds of communities and look like they
are having some success. These emerging models might be more transferable than some of the ones that have been developed in more urban settingsrequiring a larger work force.
There are also a number of nurse home visitation programs that serve
rural populations as well. In the end, the idea is to maintain fidelity to theoriginal program models. The Elmira home visiting program was the firstnurse home visiting model. It was developed in a semi-rural, relatively small
town of about 30,000 people, but with a lot of rural areas around it.
Dr. McCarroll: They were also probably not high mobility though, which isJohn J. Eckenrode, PhD 71

one of the problems of the military.
Dr. Eckenrode: Absolutely. I think that is a unique challenge to the military where you may only be able to hold on to families for a relatively brief
period of time. On the other hand, you have monitoring and surveillancesystems that are probably better than on the civilian side of things. You
know where your people are going. In the civilian sector you often lose trackof people who move from state to state. But, there is still another challenge.
Some of the positive effect of these programs is due in part to the continuityof the relationship the families have with the home visitor rather than simply the content of what is being delivered. I do not know if there is an easyanswer to that one.
Dr. McCarroll: Have you evaluated the relationship-building aspect of the
Nurse Family Practitioner program?
Dr. Eckenrode: More attention is being paid to measuring what actually
goes on in the relationship between the home visitor and the parents. Thereare explicit attempts to get feedback from the parents about the quality ofthat relationship and get feedback from the nurses. There is also a clear attempt to select home visitors that have good relationship-building qualities.
Some of these qualities are hard to quantify, but there is clear recognition
that you want people who have both the credentials and the people skills toempathize and relate to these young mothers in an open and non-stigmatizing way. But, the data suggest that those are not a sufficient to make those
programs effective. You also need the training and the content knowledge.
Dr. McCarroll: One of the issues brought up by Duggan and colleagues inthe evaluations of the Hawaii Healthy Start home visiting program was thetension between the home visitors wanting to maintain a good relationship,
yet maintaining fidelity to the program (Duggan, McFarlane, Fuddy, et al.,
2004; Duggan, Fuddy, Burrell, et al., 2004; Windham, Rosenberg, Fuddy,
et al., 2004). Apparently, some home visitors felt that they had to make achoice between one or the other and most often they tended to fall in the
direction of keeping a good relationship rather than doing what they were
supposed to be doing with regard to corrections and surveillance.
Dr. Eckenrode: The nurses are given some latitude in terms of individual
visit-by-visit protocols depending on what they encounter with the family.
There is certainly some decision-making required on the part of the nurses.
Again, that is why you want some trained individuals who are used to doing
what is essentially clinical decision-making and not just following a standard manual or protocol word for word and feeling like they can not deviate
from it.

72 Family Violence Research, Assessment and Interventions

Dr. McCarroll: My reading of your work puts heavy emphasis on the qualifications of the nurses. Do you think people from other disciplines could beselected and trained to be adequately functional?
Dr. Eckenrode: That is probably likely. We do not have the data to backit up right now, but a number of different models are being tested. It would
be great if that would happen because it would expand the potential workforce of people who could be used as home visitors. But, we think there issomething special about the nurses given the population being served andthe issues that are salient to that population of young people. These are newparents and young pregnant mothers-to-be. A lot of the issues they are concerned with are health-related. I do not think such a program would be easily replicable with say a social worker or an early childhood educator. But, I
think we should encourage that kind of experimentation.
Dr. McCarroll: There are many more levels of nursing training now than there
used to be. They are going to play a larger and larger role in health care. Thatis probably the good side. The down side is that the level of training may belower. But, the lower level degree nurses may have some credibility by the factthat they have a nurse title and could be trained up to another level.
Dr. Eckenrode: That is right. Any kind of large scale dissemination ofnurse home visiting will require a multi-pronged approach to addressing theinfrastructure at the local level to support such programs. Hopefully, there
will be some incentives to increase the nursing work force and to retrain
people who are working in other settings or are only working part time or
are out of nursing for one reason or another to do this kind of work.
Dr. McCarroll: Are there differences in home visiting programs regionally?
For example, if you find that people do things differently in South Carolina
than they do in Oregon? How much latitude do you think a program canhave given that you still have a requirement for fidelity?
Dr. Eckenrode: I am not the expert on the dissemination side and do
not have a real close up view of how the programs are running in terms of
those local or regional adaptations. Clearly, when you have ethnic and racial
and language differences, you need to adapt the program to be sensitive tothose differences in parenting practices or social customs. But, it is a fineline between adaptation and maintaining fidelity. If you stray too far fromthe model, you risk the danger of watering it down and changing it to suchan extent that it is no longer effective. That is why I think that any significant
adaptations to a model should also be done within the culture of experimentation and testing and not just left up to a local providers to decide how to
and when to adapt a program.  

John J. Eckenrode, PhD 73

Health Families America right from the beginning did not want to havea single manualized program that everybody had to follow, but wanted toleave it up to local communities to adapt a certain set of broad principles tomeet their local needs. The Nurse Family Partnership is a much more manualized program where specific elements need to be in place before they will
support the program. So, time will tell the extent to which you can change
and adapt these programs to meet local conditions.  
I do not think that children’s or parents’ needs change all that much fromone region to another. For example, the need for strong attachment bonds
is not different in Alaska or South Carolina. What changes are the regional
service structures that have been put in place to support the programs. The
need to work within those structures might be different from region to region, but I do not think a protocol around encouraging mothers to be moresecurely attached to their infants is going to change from region to region
or really much from culture to culture or even when you go internationally.
There are some relatively basic, universal issues and the same is true with reducing risks during pregnancy. Getting mothers to stop smoking is the same
issue in the south as in the north as in the east as in the west. What changes
are the service delivery systems in those regions.
Dr. McCarroll: In the programs that you see coming forth, do you thinkhome visitors will still be based on high risk or be required to perform alarger set of functions?
Dr. Eckenrode: I think that some of the organizations that are looking
at this are coming down on the side of more targeted interventions for highrisk families. There are still people out there advocating for universal approaches, but it is a tough sell. The evidence from many programs seems
to indicate fairly clearly that you get the most benefit from the higher riskfamilies who are most in need. The lower risk families that are more intact
are less stressed and those families just do not have as much need for thesekinds of services. They tend not to be as engaged if the family does not perceive the need. It is hard to retain them in such programs.
Dr. McCarroll: How do you select those families if they do not want the program, do not feel they need it, or do not want it involved in their life? Whatwould be your list of high risk people in addition to young unmarried mothers?
Dr. Eckenrode: Young parents are particularly at risk. Certainly the unmarried, single mothers, socio-economically stressed families, families where
there is instability in terms of caretakers or in terms of residential mobility,
which would obviously be relevant to the military. If you put these things

74 Family Violence Research, Assessment and Interventions

together it is usually a combination of age and marital status and stability
and income. Those together carry a lot of the weight. Then you could lookat other family stressors such as illnesses and things of that kind that could
also compromise a parent’s ability to provide sensitive care to their children.
Examples of these are maternal depression, substance use, and the presenceof domestic violence. I think these are all red flags in a sense in terms of thepotential need for some support to those young parents. The Nurse Family Partnership has tended to look at these demographic risks: age, marital
status, and socioeconomic status. Other programs have broadened that list
some to include stresses within the family, but I think from a policy perspective, it is hard to have a broad and comprehensive assessment. It is a little easier from a policy perspective to plan services at the community level aroundthe broader demographic groups. Those carry a lot of weight and I think themore specific family stresses often flow from low income and young age.
Dr. McCarroll: The military also faces the problem of an increasing numberof families that have children with disabilities. Another developing problem
that is hitting the country is families of injured service members. We do notreally know the effects these have on child rearing practices.
Dr. Eckenrode: In terms of disabilities, some of the programs have beendeveloped out of the concerns of parents of children with behavioral problems or disabilities. The Triple P program really started in Australia not as achild abuse and neglect prevention program, but as a program to promote
effective parenting of children who were difficult to parent and children withlearning disabilities, behavioral problems, and other kinds of handicapping
conditions. That program really sprang out of those concerns, trying to assist parents in providing sensitive and supportive parenting in those contexts
and not rely on more coercive forms of parenting to get kids to behave or to
do certain things and not do other things. Some of those models might beparticularly good ones to look at because they came out of that tradition.
Dr. McCarroll: The people who read our newsletter want to know, “Whatcan I do today? What can I do to change my work tomorrow?” How do you
answer that kind of question without sending them a paper to read?
Dr. Eckenrode: It depends on their level. A number of things have tohappen from a policy level to make these things work. There has to be somecommitment from the top to invest in proven programs or, even more difficult, to shift money away from programs that already exist to proven programs. That is a difficult shift in the policy arena.
There is also a need to create specialized knowledge within organizations to keep them abreast of what is happening. New information comes onJohn J. Eckenrode, PhD 75

board so fast that it is worth spending at least some money to create the kindof specialized staff or knowledge to keep abreast of it. But, it is not just about
funding programs, but is also about the quality control and fidelity issues.
The first thing I would do is find out what is going on and what is happening on the ground and see if what is going on is based in evidence. We needto create the knowledge base needed to keep on top of what is happening
in the outside world. Once you decide to implement a program, then build
in quality controls to make sure that it is being done with fidelity and with
continuous quality improvement.
Dr. McCarroll: Thank you for your insights on the state of home visitationand on the important policy issues of implementing such programs.
Dr. Eckenrode: You are welcome.
Key Points
We targeted low income, single parent status, and age as risk factors.
Other risk factors for child maltreatment are family stressors that
could compromise a parent’s ability to provide sensitive care to theirchildren such as illnesses, maternal depression, substance use, andthe presence of domestic violence. I think these are all red flags ina sense in terms of the potential need for some support to thoseyoung parents.
High risk families include young unmarried mothers, socioeconomically stressed families, families where there is instability interms of caretakers or in terms of residential mobility, which could
be relevant to the military.
There are still people advocating for universal approaches for home
visiting, but it is a tough sell. The evidence from many programs
indicates clearly that you get the most benefit from visiting thehigher risk families who are most in need.

76 Family Violence Research, Assessment and Interventions

References
Duggan AK, Fuddy L, Burrell L, Higman SM, McFarlane E, Windham AK,& Sia C. (2004) Randomized trial of a statewide home visiting program: Impact in reducing parental risk factors. Child Abuse & Neglect;
28:623–643.  
Duggan AK, McFarlane E, Fuddy L, Burrell L, Higman SM, Windham AK,& Sia C. (2004) Randomized trial of a statewide home visiting program:
Impact in preventing child abuse and neglect. Child Abuse & Neglect;
28:597–622.
Eckenrode JJ, Campa M, Luckey DW, Henderson CR, Cole R, Kitzman H,
Anson E, Sidora–Arcoleo, K, Powers J, & Eckenrode JJ. (2010). Long–
term effects of prenatal and infancy nurse home visitation on the life
course of youths. Archives of Pediatric and Adolescent Medicine; 164:
9–15.
MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, &Taussig. (2009). Interventions to prevent child maltreatment and associated impairment. The Lancet; 373:250–266.
Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population–
based prevention of child maltreatment: the US Triple P system population trial. Prevention Science (in press).
Sanders MR, Pidgeon AM, Gravestock F, Connors MD, Brown S, Young
RW. (2004). Does parental attributional retraining and anger management enhance the effects of the Triple P—Positive Parenting Programwith parents at risk of child maltreatment? Behavior Therapy; 35:
513–35
Windham AM, Rosenberg L, Fuddy L, McFarlane E, Sia C, & Duggan AK.
(2004). Risk of mother–reported child abuse in the first 3 years of life.
Child Abuse & Neglect; 28:645–667.

BACKGROUND OF RESEARCH OF BRUCE D. PERRY, MD

The Effects of Violence on the Brain of theDeveloping ChildBy James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 3, January 2008

Dr. Perry presented the inaugural lecture in the McCain Lecture Series(www.lfcc.on.ca) in London, Ontario, Canada, on his work on the effectsof family violence on children. The lecture describes optimal as well as disrupted child brain development, andprovides practi­cal advice on strategies to shape optimal
devel­opment for children.
Dr. Perry explains that early life experience determines
how a child’s genetic potential is expressed. The development of the brain is “use-dependent” meaning that brainsdevelop according to the stimuli they encounter. Be­cause
each child’s experience is different, each brain adapts uniquely. Optimal development is achieved when the child experiences con­sistent, predictable,enriched, and stimulating interaction in attentive and nurturing relation­
ships. Brain development is also susceptible to negative influences. Children
who do not have a stable and nurturing environment are subject to damage to their developing brain. Prolonged, chronic stress leads to maladaptive
neural systems, which may be adaptive for the child’s survival in the shortterm, but problem­atic for later intellectual, emotional, and social development.
Dr. Perry’s lecture addresses points for parents, service providers, andcommunity leaders to foster improved child and family development andfunctioning. He emphasizes key scientific principles paired with practicalsuggestions that can be implemented widely in public education programs:■■ Promote education about brain development. While FAP personnel are
not neuroscientists, they can help educate the public about key principles
of brain development to help par­ents understand the long-term impor-78 Family Violence Research, Assessment and Interventions

tance and implications of their actions.

■■ Respect the gifts of early childhood. High quality early childhood caresettings should provide enriching, safe, predictable, and nurturing environments. During early child­hood, the brain is developing most rapidly.
This phase presents the best opportunity to foster optimal brain development.
■■ Address relational poverty in our modern world. In today’s world of smaller fami­lies and frequent deployments for military families, there are fewer opportunities for the development of connections between people. Dr.
Perry’s message is to increase the oppor­tunities for children to interact
with others: have family meals, play games, increase con­tact with extended families and neighbors, and limit watching television.
■■ Foster health developmental strengths. Certain skills and attitudes help
children meet the challenges of life and may inoculate them against theadverse effects of violence. Dr. Perry presents six core strengths for children, which he calls “a vaccine against violence”. The child who develops
these core strengths will be resourceful, successful in social situa­tions,resilient, and may recover more quickly from stressors and traumatic
incidents. [See box, Six Core Strengths for Children]
Six Core Strengths for Children: Helpful for parents, caregivers, andhealthcare providers■■ Attachment: ability to form and maintain healthy emotional relation-

ships■■ Self-regulation: capacity to contain impulses, notice and control urges aswell as feelings such as frustration■■ Affiliation: being able to join and contribute to a group■■ Attunement: being aware of others, recognizing their needs, interests,
strengths, and values■■ Tolerance: understanding and accepting differences in others■■ Respect: valuing differences and appreciating worth in yourself and others

Bruce D. Perry, MD 79

Key Points
The development of the brain is “use-dependent” meaning thatbrains develop according to the stimuli they encounter. Because
each child’s experience is different, each brain adapts uniquely.

Reference
Perry BD. Maltreatment and the developing child: How early childhood experience shapes child and culture. The Margaret McCain Lecture Series,
September 23, 2004. www.lfcc.on.ca

80 Family Violence Research, Assessment and Interventions

The Role of Genetics in Children’s Brain
Development
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 3, January 2008

Promoting greater understanding of the brain and its critical relationshipto child devel­opment will help the Army Family Advocacy Program (FAP)
develop innovative prevention and treatment processes. In his interview, Dr.
Perry discusses the basic needs of children and the consequences for thechild’s developing brain if these needs are not met. Generally, the environment of childhood interacts with the child’s genetic endow­ment to produce
healthy development. When there is chronic abuse or neglect, lasting damage may result. Dr. Perry’s experience in the clinic and the laboratory aroundchroni­cally neglected children reinforces the need for children’s stable emotional attachments, touch from primary adult caregivers, and spontane­ous
interaction with peers. He describes how developments in modern technology can un­dermine the strength of the family and the de­velopment of peer
relationships that promote the growth of cognitive and caring potentials inthe developing brains of children.
Prior to birth and during childhood, important processes of brain development nec­essary for adult cognition occur. The develop­ment of the brain
proceeds in steps:■■ The development of nerve cells,■■ Movement of the cells to their proper place in the brain,■■ The expression of the function of each type of cell,■■ Loss of cells that are redundant or are not used,■■ Development of nerve cells so they can connect with different parts ofthe brain,■■ Development of cell-to-cell communication,■■ Development of structural supports for nerve cells, and■■ Improvement of efficiency of neural trans­mission.
These steps are dependent upon genetic and environmental interaction
for their proper development. Understanding the neuroscientific implications of early childhood brain development lends a greater appreciation ofchildren’s needs. During early childhood, when the greatest changes occur,
the caregiver has the opportu­nity to create an environment for the child tomaximize the expression of genetic potential.

Bruce D. Perry, MD 81

Key points
Promoting greater understanding of the brain and its critical
relationship to child development will help the Army Family
Advocacy Program (FAP) develop innovative prevention andtreatment processes.
Generally, the environment of childhood interacts with the child’s
genetic endowment to produce healthy development.
Understanding the neuroscientific implications of early childhood
brain development lends a greater appreciation of children’s needs.
During early childhood, when the greatest changes occur, thecaregiver has the opportu­nity to create an environment for the childto maximize the expression of genetic potential.

Reference
Perry BD. (2002). Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture. Brainand Mind; 3: 79–100.

82 Family Violence Research, Assessment and Interventions

INTERVIEW WITH BRUCE D. PERRY, MD

Healthy Families, Healthy Communities
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 3, January 2008
Dr. McCarroll: in addition to your clinical and research work, you have been
involved with the Army’s Family Advocacy Program (FAP) for many years
teaching in the Family Advocacy staff Training program.
Dr. Perry: Most of my FAP teaching is focused on understanding the normal stress response, its implications for people exposed to traumatic events
like combat, and how chronic and prolonged stress can impact families thathave a deployed parent. I cannot think of any system where understanding
stress and the consequences of stress are more important than the military.
We think about military stress in terms of exposure to combat and traumaticstress, but there are other stressful components for the military family. In
the last three or four years the rate of deployment and the stressors on children, spouses, and other family members of the military have been high.
Increasingly, our focus has been on intervention strategies and activities that
increase resilience of the military and on those things that make the militarycommunity more vulnerable, especially during deployments.
Dr. McCarroll: Where does one draw the line between psychological stressand psychological trauma?
Dr. Perry: That is an important question for the field of mental health.
Two people can have the same experience, but for one person the level ofstress is so high that it is traumatic and for the other person it is not. From aneurobiological perspective, events become traumatic when stress response
systems are activated in such an extreme way that they go from being adaptive to being maladaptive.
Dr. McCarroll: How would one recognize the change?
Dr Perry: You look for physiological changes such as changes in sleep
patterns, ir­ritability, mood and energy levels. When those things happen,
you need to step back and say, “My life is too complicated. There is too muchstress going on. I am wearing out my body.” The stress response system affects the brain, the immune system, the heart, the lungs, the skin, and thegut. People who are under chronic duress end up getting physically run down
and are much more likely to get colds, have a hard time recovering from aninfection or have cardiac problems. Their underlying genetic tenden­cies orBruce D. Perry, MD 83

vulnerabilities will be unmasked by this chronic stress.
One of the challenges is to create systems in education, health care andhuman services that are responsive to these issues. For example, chil­dren
may attend a school where there are only a few military children. These children may have difficulty concentrating, and be tired from lack of sleep because of worries about their Dad or Mom. They may look like they have academic problems or an Attention Deficit Disorder. These children are often
misunderstood by the public education system. Their problems go unnoticed because adults who play significant roles in their lives are not traumainformed or military-sensitive.
Dr. McCarroll: Can some of these problems be prevented? if so, what generalprinciples of prevention do you recommend?
Dr. Perry: One of the most important fac­tors in prevention is group cohesion. If you feel you are part of a supportive community you can sustain
a tremendous amount of duress. If all the families left behind when soldiers
deploy support and assist each other, that support can be a tremendous help.
The people who are most isolated and the most vulnerable are the militaryfamilies living in the wider community. There may not be another militaryfamily living on their block that is experiencing deployment or goes to theirchurch or whose child goes to their child’s school.
One lesson we have learned about preven­tion and dealing with traumaticstress is that relationships matter. Your social network is tremendously important. The more you are isolated and physically or emotionally separated
from the rest of the military community, the more vulnerable you become.
Dr. McCarroll: So, your advice to isolated families would be to increase theirsocial support?
Dr. Perry: Yes. Tap into your extended fam­ily, into your community, yourneighbors, or whatever social network you have. That will help sustain you,and is probably the most important principle. Other important fac­tors are
information and education. The more you know about an expected set of
events, the more you will be able to deal with them. Information is power.
You can tell people what to expect and the anticipated time course. You cantell them, “You are not crazy. Most people experience these things. If it gets
worse or it is so prolonged that you cannot manage it, here are some resources. These are the people you can talk to and this is the person who may
be able to help you.” We find that the combina­tion of information and accessto resources can be very helpful.
Dr. McCarroll: If you have a child or adolescent with behavior problems that

84 Family Violence Research, Assessment and Interventions

emerged during a deployment, where do you start?
Dr. Perry: Most people know that a child’s main support system is hisor her parents. You can have a child overwhelmed by a trauma that also
impacts the parent, e.g., the father was killed or wounded in combat. The
mother would also be overwhelmed and her ability to help the child would
be compromised. Consequently, we need to pay attention to the emotional
needs of the parent. That is an important place to start. If the mother’s needs
can be met, she can become stronger and better able to meet the needs ofher child(ren). The child’s needs must be met also. If you meet the needs ofthe parent and the needs of the child, you will be more effective than justtargeting your interventions to the child. The act of intervening and giving
support to the parent and the child can prevent a negative cycle from feeding on itself.
One should also question the health of the community. “Is this a community where there is a support group? Is this a community where there is an
isolated National Guard family? Has a family been in this community longenough to make friends?” Your inter­vention would be to provide a combination of social work, conventional psychiatric or psychological interventions,and the sharing of information about resources. If the family is connected toa healthy community, minor interventions can be extremely helpful.
Dr. McCarroll: How do you work with parents to make them trauma-informed? To what extent can you bring together neurobiological structuresand functions with behaviors, needs, and treatments, and do you think itenhances understanding these issues?
Dr. Perry: We do quite a bit of that, and we use materials that we havewritten for families including slides and mini-lectures. We also have layteachers. If a parent or a child is killed in a car accident, we will have a client
we worked with five years ago who also lost a child help us with that parent.
This approach is very helpful because sometimes our typical jargon does nottranslate well. The information is communicated better by someone whoshares the same perspective as the person with whom we are working.
Dr. McCarroll: Our Army statistics reveal that the rates of child neglect haveincreased since the war started. This has been attributed to lack of (parental) supervision, unkempt homes, and mothers with depression. Have you
encountered this?
Dr. Perry: Our colleagues report this. If you look at the waxing and waning of child abuse and neglect complaints, it is very much tied to communitycohe­sion, economics, and mobility. When­ever there is a downturn in factorsthat would stabilize a community, there is an increase in neglect and abuse.

Bruce D. Perry, MD 85

Dr. McCarroll: Treatments and prevention might extend beyond the issuesof community cohesion. How do you help people who enter a system and do
not share the same priorities (i.e., cleanliness in one’s home and attentive
parenting)?
Dr Perry: Teaching people about parenting is a huge chal­lenge. We used
to live as big extended families in which you experienced child-rearing practices. You learned a lot about children because you were around them. Today’s families are much more mobile and smaller. It is not unusual for someone to be an only child or have one sibling and grow up in a system in which
there is no mechanism for effectively transfer­ring child-rearing practices.
People are talking about the need to get some of these practices into public
education because we are not teaching them in families any more.
Dr. McCarroll: How does one remediate those families?
Dr. Perry: You can identify high-risk family situations and provide nonpunitive education and support services for these families. They would benefit from home visitation models. However, these programs are often inefficient because they are poorly targeted.
Dr. McCarroll: Thank you for your contributions to the military communityand for this interview.
Dr. Perry: Thank you for the opportunity.
Key Points
Events become traumatic when stress response systems are activatedin such an extreme way that they go from being adaptive to being
maladaptive.
One of the most important factors in the prevention of stress is tomaintain group cohesion. If you feel you are part of a supportive
community, then you can sustain greater adversity.
If you meet the needs of the parent as well as the needs of the child,
you are much more effective than if you just target interventions tothe child.
When there is a downturn in factors that would stabilize a community,
there is often an increase in neglect and abuse.

86 Family Violence Research, Assessment and Interventions

REVIEW OF RECENT RESEARCH OF BRUCE D. PERRY, MD

The Neurosequential Model of Therapy
By James E. McCarroll, PhD
May 2009
Dr. Perry has continued his research on the relationship of neuroscience
to child maltreatment. A recent textbook chapter expands this exploration
to the development of psychopathology (Perry, 2008). Child maltreatment
increases the risk for many disorders. The subject of Dr. Perry’s chapter is“Why.” The following is taken from that chapter.
Maltreatment can be comprised of a combination of neglectful and traumatizing experiences. Maltreatment and trauma affect the developing brain
through multiple, often overlapping mechanisms.  Trauma impacts the stressresponse systems and neglect, through an absence of experiences required
to express genetic components in developing neural systems, has other complex effects on the developing brain. Trauma may cause post-traumatic stressdisorder and neglect may cause an attachment disorder. In addition, trauma
or neglect may cause an alteration in neural systems based on an underlying genetic vulnerability. Finally, symptoms or other disturbances caused
by maltreatment may disrupt ongoing developmental pathways through degrading cognitive and emotional functioning.
Dr. Perry spells out the principles of neurodevelopment as a basis forunderstanding the developing brain. His review is very helpful to the nonneuroscientist for increasing knowledge of how development is impacted
by maltreatment, but also for explaining these effects to parents or otherinterested parties. The following is a brief summary of topic areas. Please see
Dr. Perry’s publication (2008) for details.
Basic brain neurodevelopment — Development proceeds in a sequence
beginning in utero. The earlier a trauma or neglect occurs, the more chance
there is for disturbance of development. The following is the sequence ofdevelopment:■■ Neurogenesis — Cell birth occurs largely in utero. This can be severely
affected by mother’s drinking as well as other insults.
■■ Migration — Neurons move to settle in the places where they will establish a permanent function such as to the brainstem or the cortex. Cell
migration can be affected by genetic or environmental factors.
■■ Differentiation — Neurons mature into unique structures producing
neurotransmitters such as serotonin. Neurochemical, hormonal, or stressresponse changes can affect the way cells transmit information.

Bruce D. Perry, MD 87■■ Apoptosis — Cell death. More neurons are present in the developing

brain than are needed. Some neurons will connect with others and somewill not. Neurons with little environmental stimulation may not survive.
This loss will affect brain development.
■■ Arborization — Neurons continue to differentiate. They will send out
fiber-like receptive processes that connect with other cells. This increases
the complexity of brain function by creating networks of cells to receiveand process information.
■■ Synaptogenesis — This occurs through chains of neurons connecting(called synapses) with other neurons. This development permits flexibility of brain organization and function, which underlies all brain activity.
■■ Synaptic sculpting — The connections between neurons (the synapses) continue to evolve through the brain processes already developed.
This process is driven by neurotransmission, which occurs in responseto stimulation, a “use it or lose it” phenomenon. This process continues
throughout life and is the basis of complex brain activity such as learningand memory, emotion, and higher level cognitive functioning.
■■ Myelination — This is the development of a covering of cells on the neurons that permits faster functioning. As myelination continues throughout adolescence and young adulthood, complex brain processes become
more efficient.
As can be imagined, trauma and neglect can affect any or all of the above
processes making for less efficient and functional brain development. As
clearly noted above, brain development is sequential and the product of both
genetics (nature) and the environment (nurture).
Dr. Perry’s chapter includes detailed descriptions of the developmental
impact of trauma and neglect on the brain with examples at various childages and stages of neurodevelopment. There is also detailed description ofbrain structures and how they are affected by maltreatment. Some familiarity with these structures and their functions will give the practitioner a goodidea of how the brain functions and how disturbances of neurodevelopment
hinder it.
One purpose of Dr. Perry’s exposition of the processes of neurodevelopment is to acquaint the reader with the complexity of the effects of maltreatment. He calls maltreatment “the Great Imposter.” By this he means thatmaltreatment can mimic many psychiatric conditions. There is a practical
implication of this viewpoint. Current descriptions of psychopathology inthe psychiatric diagnostic system, the DSM-IV (American Psychiatric Association, 1994) do not consider the effects of maltreatment as a mechanismthat underlies psychopathology. Abuse of children and adults and child ne-

88 Family Violence Research, Assessment and Interventions

glect are V codes, a focus of clinical attention rather than diagnostic categories. Because of this lack of consideration of maltreatment as a cause ofa disorder, treatment plans may pursue only symptoms while ignoring thecause, maltreatment.
Dr. Perry also presented his neurodevelopmental model of brain development in the publication Reclaiming Youth (www.reclaimingyouth.com)(Perry & Hambrick, 2008). Reclaiming Youth International (RYI) is an organization dedicated to helping adults better serve children and youth whoare in emotional pain from conflict in the family, school, community, orwith self. In this article, Dr. Perry outlines developmental challenges that
contribute to risk and resiliency. Developmental challenges are not only
maltreatment-related, but consist also of threat, humiliation, deprivation,chaos, and violence. These problems continue and beg for changes to address these challenges. For example, it is unlikely that weekly therapy for one
hour can reverse or even seriously impact the alterations in brain function
or behavior caused by developmental trauma or neglect.
The neurosequential model of therapy (NMT) is not a specific technique,but rather an approach to clinical work. It matches the timing of specifictherapeutic techniques to the stages of brain development and neural networks mediating the neuropsychiatric problem. It consists of child assessment, identification and articulation of the primary problems to be addressed, identification of key strengths, and the application of interventions,which could be educational, enrichment, or therapeutic, to help families andprofessionals meet the needs of the child. A brief description of these steps
follows.
■■ Assessment — Given the knowledge of brain development and effects ofinsults at specific times, the assessment consists of a detailed child history from conception through the present. The nature, timing, and severityof challenges is reviewed and an estimates of developmental effects are
created. A second component of this assessment is a review of relational
history of the child. This assessment targets attachments and related vulnerabilities and strengths based on the child’s history of relationships.
■■ Functional review — An interdisciplinary team conducts an assessmentof current functioning including speech and language, social skills, selfregulation, and other functions. This assessment forms a baseline fromwhich the staff and parents can chart the child’s progress.
■■ Recommendations — The NMT process yields a map of where to go witha sequence of interventions based on the problems identified. This process will attempt to replicate the normal sequential process of neurodevelopment. Treatment starts with the most basic brain area involved andmoves up to higher levels of functioning. For example, a therapeutic pro-

Bruce D. Perry, MD 89

gram for brainstem development (the lowest level of brain organization)
could include breathing, yoga, music, and therapeutic massage. This canlead to self-regulation skills. Once this stage has been addressed and improvement has been shown, work can move on to higher functions suchas play therapy and relational skills. Finally, verbal and insight-oriented
therapy and cognitive-behavioral strategies can be given to improve cortical functioning.
Because brains function in a “use it or lose it” mode, patterned repetitive activity is therapeutic. The brain is organized hierarchically and so istherapy, which consists of positive nurturing interactions with trustworthy
peers, teachers, and caregivers.
Dr. Perry’s final article included in this review is devoted to the application of neurodevelopmental principles and procedures to maltreated children (Perry, 2009). His goal is to provide knowledge that will allow clinicians
to incorporate these principles into practice and policy. Perry reminds us that
there are millions of maltreated children in the protective services, mental
health, juvenile justice, and educational systems in need of services. As previously noted, treating the trauma is often not enough. The NMT model ofsequential brain development is a guide to timing positive therapeutic experiences to restore functioning and build the capability for growth. Becauseof the sensitivity of the developing brain, he emphasizes early and aggressiveintervention that can be implemented for young mothers and fathers to promote infant mental health and development.
Throughout his work and his publications, Dr. Perry has emphasizedpractice based on neurodevelopmental principles applied in an age and development-appropriate fashion. Finally, he observes that parents often haveexperienced the same traumas as their children. It is possible to generate a“map” for adults in the child’s relational network. This plan can identify thestrengths and vulnerabilities of the adults and allow both the child and parents to engage in mutually beneficial activities that can help both improvetheir lives.

90 Family Violence Research, Assessment and Interventions

Key Points
Maltreatment can be comprised of a combination of neglectful andtraumatizing experiences. Both affect the developing brain throughmultiple, often overlapping mechanisms.  
Trauma or neglect may cause an alteration in neural systems basedon an underlying genetic vulnerability.
Maltreatment is “the Great Imposter.” It can mimic many psychiatricconditions.
The neurosequential model matches the timing of specifictherapeutic techniques to the stages of brain development.

References
American Psychiatric Association. (1994). Diagnostic and Statistical
Manual. Washington, DC: American Psychiatric Association.
Perry BD. (2008). A neurodevelopmental perspective on the role of abusein psychopathology. In T. P. Beauchaine and SP Hinshow (Eds.), Textbook of Child and Adolescent Psychopathology. New York: John Wiley &Sons, 93–128.
Perry BD. (2009). Examining child maltreatment through a neurodevelopmental lens. Journal of Loss and Trauma. 14: 240–255
Perry BD & Hambrick EP. (2008). The neurosequential model of therapeutics. Reclaiming Children and Youth; 17: 38–43.

Bruce D. Perry, MD 91

SECOND INTERVIEW WITH BRUCE D. PERRY, MD

Effects of Military Deployment on Children
By James E. McCarroll, PhD
May 2009
Dr. McCarroll: I appreciate the opportunity to talk to you again. Much of
our last interview was on the stress of continued military deployment onfamilies. Let me just continue with that theme. Since we published that interview in January 2008, have you had any more people coming to yourChild Trauma Academy (CTA) who are military and whose stories would
help to shed some light on these issues?
Dr. Perry: We have had a number of families where the stress of continued deployment has impacted them, particularly how the children arefunctioning. We have provided some guidance and input to schools about
how to be sensitive to these children and not label them. If you are not imbedded in a military community, the rest of the world does not appreciatethese issues very well because we are all swept up in our own lives. If you are
the only child in the classroom whose parent has been deployed multiple
times and you are worried about how they are doing, that influences theway you are behaving, sleeping, and acting in class. The probability that theteacher is going to be aware of this is pretty low. In a few of these kids whoare struggling the teacher uses the normal formulation: “This is a child withlearning problems, this is a child with attention deficit; this is a child who isjust a bad kid.” We have tried to spend as much time as possible reminding
the educators and the other people who live and work with these childrenthat their changes in behavior and functioning are not at all unexpectedconsidering the ongoing duress that these kids are under and that the parent
who is still at home is also overwhelmed and distressed. So their ability to be
comforting and organizing for these children is some times compromised.
The group that we have seen the biggest problem with has been the children
who are living outside the military community, where there is not an awareness of the challenges that they are undergoing.
Dr. McCarroll: Can you categorize the kids in terms of what you see themost?
Dr. Perry: Most of what we see is an adjustment response. In some cases,
you could give them a diagnosis of attention deficit hyperactivity disorder(ADHD) since that diagnostic category really does not have any necessary
exclusionary criteria. If you strictly apply the criteria, a lot of these kids will

92 Family Violence Research, Assessment and Interventions

have attention problems that would meet that threshold. But, I think thatgiving them that label and then assuming that they are like other attentiondisordered kids is a mistake. We can try to help people be aware of the factthat these are more anxiety-related issues. When you can be reassuring andgive these children opportunities to talk about their concerns and fears, their
behavior will improve.
Dr. McCarroll: Do you think that the community of teachers and others who
have contact with children who are not on a military post are any moreaware of these kinds stresses than they were earlier in the war?
Dr. Perry: No. If anything it is less because it was more in the minds ofpeople when it was more prominent in the news. To some degree the decrease in violence in Iraq and the shift in focus to Afghanistan has caused
them to be less focused on it. It may be that when a child’s parent is deployed
now they may be at less risk because there is less violence, but the reality forthe child is the same.
Dr. McCarroll: At the CTA you see children who are referred by a variety ofsources as well as walk-ins. What kinds of symptoms are they showing?
Dr. Perry: Our organization has partnerships with a number of clinicalprograms across the world. We have direct contacts with clients who arereferred to us because they are having some sort of emotional or behavioral
problems, and we also have this big network in which we are taking advantage of the eyes and ears of many, many, many clinicians in other settings.
Some are in school settings, some of our partners are juvenile justice settings,
some are in conventional mental health, and some are in child protective
settings. Through direct referral and hearing these things from our partners
we learn a little bit about what is going on with some of these families.
Dr. McCarroll: In addition to ADHD and anxiety what else are you seeing
in military kids?
Dr. Perry: In some of the older children we see things that would be
more along the lines of what you could consider oppositional defiance thatis more an externalizing behavioral problem.
Dr. McCarroll: Of what age group are you speaking?
Dr. Perry: Thirteen, fourteen, fifteen years old. These children sometimes
have been moved multiple times and are trying to fit into a peer group. Thisis a particularly challenging time for any child and for any family that hasa child that age. We see teenagers who have really been struggling with thelack of having a father around and are using unhealthy ways to act out there

Bruce D. Perry, MD 93

issues. That leads to things like defiance in the classroom and, at some times,
vandalism. We have heard about these kids from some of the schools wework with. Very often they will talk about these children in the context of
their problems and it is only when we take a history that we find out that
this is a family where there is a parent who has been deployed three times.
“Well, do you think that may have something to do with it?” And they go,“Oh yeah, well, maybe.”
Dr. McCarroll: Your neurodevelopmental model moves the intervention
though stages of brain development. Does that model tend to apply to thiskind of child or do you take another strategy with them?
Dr. Perry: Most of these children were pretty well regulated before allthis happened. They were on-task in school and did not have any major
developmental changes. When they developed adjustment symptoms oranxiety symptoms or even what we might call vicarious posttraumatic stressdisorder (PTSD) symptoms, they responded pretty well to cognitive interventions. These kids respond to talking. But, a lot of them are so dysregulated and so anxious that we couple the cognitive work with somatosensory
activities that can help them be quieter internally. Some respond really well
to motor activities, like the physical activity of sports, while some others
respond very well to things like music. Some of them like to use their hands
and are very creative. A combination of somatosensory activity and conventional cognitive approaches are used to help these kids.
Dr. McCarroll: At about what age would you use the cognitive approach?
Dr. Perry: If we have a child who is five or six, who is relatively well organized and does not have any previous developmental insults that would
make them overly sensitive, then we can talk with them pretty easily. You
obviously would have to use an age-appropriate activity and to approach itslightly differently than you would someone who is older, but these kids do
respond well to certain kinds of cognitive engagement.
Dr. McCarroll: Over what time frame does that take place?
Dr. Perry: We will usually work with them for six months or more. However, we have heard that there are children who have had relatively limited
periods of time like two weeks to two months. The feedback that we get isthat even a few weeks of some adult engaging them, giving them information, trying to be supportive and reassuring, helps these children. At least
they are functioning in the classroom or they are functioning in the home inregards to sleep or behavior.

94 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Is that an inpatient program with therapy every day?
Dr. Perry: No. Most of the kids with whom we work are in a typical community setting. Once or twice a week we will have some sort of therapeutic
activity. We try to include the parent and other adults that live and workwith the child in the process. They see us and they hear the language we use
and the tone of voice. We try to provide the cognitive anchors for these kids
and then we ask the parents to essentially mimic what they have seen us do.
Part of our work is to create essentially a co-therapist in the parent, or theteacher, or another therapist who may be also working with the child.
Dr. McCarroll: Can you comment on what you see as resilience factors thatare internal to the child? What do you see as their major building blocks?
Dr. Perry: There are a of couple areas. One that is very underestimatedis that the children who have a set of values or a belief system that has been
incorporated into their child rearing end up being much more resilient. Ifthey are able to draw upon their world view, their faith, their sense that whatmom’s doing or what dad’s doing is right, they have better outcomes. The
belief system is really important. There is also a very powerful positive social
element to being part of a community of faith. Those children have relational anchors such as an extended family, a grandparent, or a teacher who
takes special interest in them and gives them a little extra time. Those social
anchors appear to play a big role in resilience in the present, in children who
may not have a strong social network currently. If they have had that in thepast, they are relatively more resilient than children who did not.
Dr. McCarroll: What resources do you find that people use in the community when they go for help?
Dr. Perry: A lot of people tend to underestimate the available resourcesin the community. We find that people who go out into the community andtry to connect in healthy ways to neighbors, to a community of faith, toafter school programs, or to resources that are not conventionally thoughtof as “mental health” that those people do much better. If they get the childinvolved in sports, if they get the child into an after school program, if thechild has a mentor, those children do better then those children who do nottake advantage of those resource. We think that as part of the staffing process. What we do during consultation is explicitly try to catalog what we callthe therapeutic web. We try to help this family get connected to the YMCA,
to their neighbors. We are actually very aggressive about that. Since the lasttime you and I talked, we have developed a couple of metrics to look at relational connections. What we find is that in spite of all of the other things
that we might recommend, if you have a high social engagement score, youBruce D. Perry, MD 95

only need to act on a couple of the things that we suggest to have a goodoutcome. If you have a low relational connection score, even if you act on
everything we recommend, your outcomes are not as good. This therapeutic web appears to be really important actually to get them though some ofthese challenging times.
Dr. McCarroll: The therapeutic web is really a catchy phrase. Has the concept of therapeutic web and its metrics been published?
Dr. Perry: We actually just finished a book about this topic which will
be published in April of 2010 and have several journal articles that are introducing some of these concepts. The therapeutic web is essentially a term
used when trying to help people understand the importance of being safe
and connected. The idea is that all these lines, like the web of a spider web,are lines of healthy interaction that come from the people around you. They
have an impact on the way you are externally regulated, which influences
the basic neurophysiology of your stress response. If you are in the presenceof familiar people you will receive non-verbal cues of acceptance, of reward,of comfort, and that changes the stress response physiology of your brain. It
puts you in an internal state where you are more open to acquisition of new
cognitive content so it is easier to learn new cognitive material. It also puts
you in a position where you are more receptive, more accurately perceive
social cues, and more able to learn social information. If you are surroundedby people who are safe and familiar, you will feel safer and your physiology
will be better regulated. The concept of having a very scant therapeutic web
means that you essentially have to depend upon your own internal resources
to regulate yourself. If you are not great at self-regulation, you are going tohave a higher probability of being poorly regulated. This means that if you
are threatened you will stay in that higher arousal state for a longer periodof time. Also, if you have trauma-related changes in your brain and you areexposed to an evocative cue, you will spend a longer time in the high arousal
state. It will take you longer to come back down to normal. There is a lot of
the research about physical and mental health and vulnerability to substanceabuse and other behaviors. It turns out that people who have lots of stable,
healthy relationships are physiologically healthier. They have better mental
health outcomes and better academic outcomes. We think that these things
are all interrelated. Over the next ten or fifteen years this is going to turn out
to be a very important area of investigation and ultimately will form the way
we do education and mental health work.
We have had preliminary presentation of some of these metrics, but thefull elaboration of this model has not been published completely. The application of this approach in different settings is somewhat different. For

96 Family Violence Research, Assessment and Interventions

example, in the therapeutic preschool it looks different than the way you
would do it in a residential treatment center. We have several sites that are
now looking at outcomes after having used this approach. Hopefully, overthe next couple years more and more things will be published.
Dr. McCarroll: Can you comment briefly on how you conceived of the metrics?
Dr. Perry: One of the hardest things that we have tried to figure out isthe metrics. We are not very good at measuring these relational elements.
We have come up with some very simple questions about the perception of
the quality of relational interaction and its frequency. What we have comeup with is a very simple descriptive anchor. We will look at the presence,
quality, and frequency of a maternal interaction, of male role models, andthe interaction with father, friends, extended family, school, and so forth.
We came up with a kind of a crude number, but I am sure there are moresophisticated ways to look at that.
Dr. McCarroll: Do you use a number of informants such as the child, theparent, the teacher?
Dr. Perry: That is exactly right. We did a couple of very interesting andvery simple things that turned out to be pretty powerful. We would havepeople who came in for an appointment write down the number of people
they had had a conversation with in a week and in the last day. People who
wrote down one name had very scant relational connections, people who
wrote down four of five people were pretty moderate, and there were somepeople who wrote eight, nine, ten, twelve people. Simple things like that turnout to be pretty interesting although there are all kinds of methodologicalflaws when depending on that alone. We have actually been trying to figureout how to look at this in a way that gives us a some what accurate sense of
these relational characteristics.
Dr. McCarroll: Are there advantages and disadvantages to saying that achild has a diagnosable disorder such as an adjustment disorder, ADHD, oran anxiety disorder?
Dr. Perry: There are people who think ADHD is kind of like getting
pneumonia, that you have it, and it is a singular thing. ADHD is essentiallya description. We think that educators, foster parents, and other people tend
to categorize children based on these labels. We avoid giving a label that has
some kind of pejorative connotation. That is a broader issue in all of mental
health. The public does not have a very sophisticated appreciation of neuropsychiatric problems. There is still lot of stigma. We do not want people toBruce D. Perry, MD 97

do a short cut into a simple linear problem-solving approach where they saythat you have this diagnosis, called ADHD, and this is the treatment, called
Ritalin. When that happens, people will just avoid really understanding why
this child is struggling.
Dr. McCarroll: Labels tend to stick don’t they?
Dr. Perry: Yes.
Dr. McCarroll: I liked your phrase in one of your articles, the great imposter,
does that apply to this situation too?
Dr. Perry: Very much so. Say the child goes though a challenging time,
like deployment of the parent. If the child copes with it by withdrawing it
can look like major depression. There may be depressive elements, but it isprobably not the same as a major depression. If you are a child who handles
it in a different way, you may look like a child who has ADHD. For example,
we had a child who looked like he had an obsessive-compulsive disorder(OCD). He was just at that age of development where he was already a little
obsessive. When his father went away he became superstitious and had allthese little rituals. It is like calling a baseball player OCD. They have theseweird little rituals around batting, but that does not meant that they have
OCD. That is how this boy presented. He had to do certain things before hewent to bed. He wanted to do certain things because he had a magical thinking that it would protect his father. But it was not OCD; it was just a form ofprimitive thinking.
Dr. McCarroll: So neuro-developmental missteps are “the great imposter?”
The great imposter mimics psychiatric disorders.
Dr. Perry: Yep, yep.
Dr. McCarroll: Your approaches are very sophisticated. You talked aboutmodeling for parents and other providers. Is there a need, in your view, toramp up training for providers? Your CTA offers a lot of courses, either online or in person. What is your position on how to get these concepts to thefield and to what depth?
Dr. Perry: That is actually a really good question. It is a big challenge forour group and a challenge for our field in general. When we try to introduce any innovation, there is a process of translating emerging findings into
common practices. That takes a long time. In some cases, there are somecolleagues of mine who looked at this process in the field of neurology. They
established with a whole series of scientific studies, a certain set of practices
that would lead to better out comes following stroke. It was well established98 Family Violence Research, Assessment and Interventions

and well published, and they looked at how long it was before these established and well-researched, finds turned into common practice in clinicalneurology. It was thirty years.
Part of the challenge in our field is educating our peers when we find out
something new, a new effective therapeutic technique for example, or moresophisticated ways of looking at children and trying to solve some of these
problems. The process of getting these approaches into our education process, takes a long time. One of the other challenges for our field is that, is that
it is a lot easer to disseminate simple approaches than more complex ones.
We all like simple things and systems have an easier time making simple, incremental, change that has a protocol than they do making a more complex,
all-encompassing change. So, part of our challenge with the approach that
we are using is that it is really not a specific technique. It is a much more aconceptual approach. Operationally, it can be somewhat different depending on the field in which it is applied: in education, in a residential treatment
setting, in a conventional mental health clinic, or in a foster home. The way
it is functionally put into action is different in different settings, but the core
concepts are similar.
Our challenge is that we are trying to teach this and disseminate thisinformation. We are battling the tendency in some groups to look for thesimple answer. We want to have one-size-fits-all. That has been a problem
in mental health for a long time. For example, if we find one group has had
trauma and we find that a trauma-focused cognitive behavioral group really
works, then we run out the door and say “All right. Let’s teach this to everyone with trauma.” You just can not do this. That approach might be great forhalf the people, but there are probably groups that are not going to respondas well as others, certain ages probably will also not respond, and there areprobably certain types of trauma probably will not respond as well as others.
Part of our challenge in mental health is that we are dealing with incredibly
complex, multidimensional issues. We tend to still take pretty simple, liner
problem-solving approaches that work great maybe sometimes, but a lot oftimes they are not effective for everyone.
Dr. McCarroll: I would like to ask you about the gaps you see between yourfield and the fields that interest you, perhaps fields that have not traditionally worked together. It seems a very important aspect of your work andtraining is how you try to reach different groups to tie them together.
Dr. Perry: Exactly.
Dr. McCarroll: Where do you think are the biggest gaps? Who are the people
that you would like to get your information to?

Bruce D. Perry, MD 99

Dr. Perry: Educators have a tremendous opportunity to understand andhelp children who are impacted by these issues. They tend to spend moretime with children than any of us. In any given classroom you are goingto have a child whose in whose household there has been some domestic
violence. There is a probability that if you have twenty kids you are going tohave three or four of them who have been victims of some kind of maltreatment. If you have a classroom of twenty-five kids over a year you are goingto have a high probability that a family member is going to die during thattime. There is traumatic loss, death, child maltreatment, a parent who has
been deployed, and others. It is really hard to be an educator and not run
into children who are affected by trauma.
Dr. McCarroll: A lot of life is telescoped into the classroom.
Dr. Perry: Exactly. We, as a mental health community, owe educators a
lot of time, understanding, patience, and attention.
Dr. McCarroll: How do you reach that community?
Dr. Perry: It is hard. Educators are under a tremendous amount of pressure to accomplish these cognitive landmarks, bench marks that they arepushed to achieve. They feel tremendous pressure already and their time islimited. When you come in and say, “Listen. There is more that you need tolearn.” The last thing they want to do is go to another in-service about something they think is not relevant. Rather than telling them what we thinkthey need to learn, we try to form a relationship with the school and provide
whatever service they seek. They will say “I have a kid that needs help withsuch and such” and we will say “Ok. We will start working with the child.”
Once you get to know the teacher or the people in the school and you help
them a little bit then you have the opportunity to educate them about why
you think a child acted this way and what may be helpful in the classroom.
Little by little you are able to help them learn by working with them.
Dr. McCarroll: In the same way you model for parents in the clinic.
Dr. Perry: Exactly, exactly. It is a very hard thing when you come in as anexpert and tell people something they should know. There are always people
in a group who will be receptive, but if you do not meet somebody where
they are and walk side by side with them for a little while, you are not going
to be able to communicate as effectively. We always try to do our teachingin the context of actual clinical work. A major teaching method we have is acase-based staffing process. We will take a child and a clinician, a school, or
the system with which they are struggling. In the context of staffing the childin a structured way, we help the adults think in a way that is developmentally

100 Family Violence Research, Assessment and Interventions

sensitive. We explain exactly why we would make a certain recommendation. At the same time we are helping them solve a problem we are teachingthem about the concepts that help us solve the problem.
Dr. McCarroll: Is that based largely on the neurosequential model of therapeutics?
Dr. Perry: It is. We tend to take the neurodevelopmental perspective andthen pull in lots of other research. In any given staffing we may end up withtherapeutic recommendations that range all the way from music and movement, to cognitive behavioral therapy, to an inside-oriented analytic perspective. It really depends on where they are developmentally.
Dr. McCarroll: What is the difference between age-appropriate and developmentally-appropriate work with kids. How do you distinguish between
those?
Dr. Perry: That is a really good question and is one of the big challenges.
For example, if you have a two-year old and they have some sort of fundamental deregulation that originates from abnormalities in the lower parts ofthe brain, we know that fundamental somatosensory activities are going tohelp that: things like holding them, rocking them, and even some forms oftherapeutic massage. When you take a two-year old in your lap and you rockthem, that is age-acceptable. They think that is ok. But, if you have a sixteen
year old who has the same type of deregulation you could not put them inyour lap and rock them. They would find it odd and it would be awkward
and uncomfortable. What we try to do is find an age-acceptable way to provide patterned repetitive somatosensory activity. You might take this sixteen
year old child, put hip hop on, give them their ear phones and have themdance. You might have to do some thing like go running with them, or you
might have them swim or do yoga where there is repetitive rhythmic breathing that they can focus on. We try to find and age-acceptable and developmentally appropriate activity.
Dr. McCarroll: Some of the behaviors that you are describing are arousing
and others are calming. How do you decide which ones to use and which
ones would be helpful and which ones might not be helpful?
Dr. Perry: One of the keys is taking the histories about these children.
We ask the caregiver or the teacher about the things that the child gravitates
toward. You almost always find that kids do an activity that they have foundto be self-regulating. They may rock or when they are doing their homework
they may hum. They may really love sports or they may really love music.
You take something that they already like and you structure and modify itBruce D. Perry, MD 101

so it is more effectively patterned and used in ways that are more structured
and regulated. When you get a good history you can make plausible estimates about what would be regulating and what is likely to be escalating.
Dr. McCarroll: What do you say when someonr says they had a bad childhood and they turned out all right?
Dr. Perry: Well, it is a funny thing because whenever you meet thosepeople or talk to with them they will tell you how much pain they had. Just
because they can have a job, just because they can do some things that are
well within the norm does not mean that they were not impacted by thosedevelopmental insults. One area where they very often have unknown consequences of developmental trauma is in their physical health. The workby Rob Anda and Vince Fellitti on the adverse childhood experiences andphysical health outcomes documents that the greater the allosteric load
during development the greater your risk is for early morbidity and mortality (see for example, Felitti, Anda, Nordenberg, et al., 1998). Also, it is
not always the mental health issues that are the outcomes of developmental
trauma. It may be that in one person it is more manifest in social areas, inanother person in cognitive areas, another person in physiological health. It
really has to do with your own genetic makeup and other factors within yourdevelopment that may have either buffered or made you more vulnerable insome domain.
Dr. McCarroll: You can think of examples where people might receive help as
an adult such as joining the military and having a good career or finding agood spouse or a good mentor, minister or anything like that. Is that usually
the way these people are helped?
Dr. Perry: Exactly. In fact, this is much of what is in the new book that
we have written. What we find is that there are many examples of incredibly
wonderful productive people who had really rough starts. There are individuals and or organizations who can help some of these folks overcome
these developmental traumas and, in some cases. Sometimes, they can get toa place of strength and wisdom that you can not get to unless you have been
through traumatic experience. That does not mean that there was not a cost.
I think that what people need to appreciate is that trauma need not destroy
somebody. But, anybody who has been through trauma will tell you, “Listen.
It changed me it had an impact on me. There was a tremendous amountof pain. I may be fine now, but I got fine because of this person or this opportunity.” It is an interesting thing that you almost always find that healing
happens when there is offsetting kindness to the earlier unkindness.
Dr. McCarroll: That is a beautiful thought. I like that.

102 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Speaking of children with a rough start, what do you believe
is occurring neurologically with autistic children?
Dr. Perry: That is a really good question. There is some new evidence
about the inability or inefficiency of the creation of synapses in certain partsof the brain in children who have autism. That makes sense considering thenumber of repetitions required for these kids to sort of make a change developmentally. I am not sure. It may be from some genetic vulnerability due tothe inefficiency or lack of a certain protein involved in efficient synaptogenesis, but it appears that they require two to three times as many repetitions tocreate a synaptic connection in some parts of the brain as a child who does
not have autism. That mechanism would account for some of the sensory
integration problems that these kids have. In order to make an association
between sight and sound, between smell and touch, between all of theseincoming sensory inputs, if that takes more repetitions you can see where
they develop a kind of a social blindness and also an exquisite sensitivity tochanges in the environment. When you change the environment for you
and me, our brains can rapidly shift, but if you already have inefficiencies inthe synaptic association between primary and sensory input, shifts would
be more overwhelming and in some cases very dramatic for kids that haveautism. You can do something just as simple as move a book on their bookcase and they will literally unravel. I think there is something unusual about
the way their brain is organizing at key times both in utero and in the extrautero period.
Dr. McCarroll: Do you think that there is any similarity between kids withsome form of autism and any other disorders?
Dr. Perry: There are people who study this who consider autism as aspectrum disorder. It goes all the way from high functioning autism to low
functioning autism. I think there is probably some physiological relatedness
across that spectrum. There is also a whole different group of kids who canpresent like autism, but who have been severely neglected. Their developmental insults are more obvious. That is what you would expect from somebody who did not hear very much, was not held very much, and was not interacted with socially. But, with kids who have no developmental trauma or
neglect to speak of there still is this continuum that appears to exist. I thinkthat it is a combination of genetic vulnerability and some developmental
insult. I think that over time we are going to find more about environmental
toxins that are potentially related to the increases in autism that has takenplace over the last twenty years.

Bruce D. Perry, MD 103

Dr. McCarroll: This has been fascinating. I have enjoyed it and thank you
for the time.
Dr. Perry: It was my pleasure and I appreciate the opportunity to talk andshare our work.
Key Points
If you are the only child in the classroom whose parent has been
deployed multiple times and you are worried about how they are
doing, that influences the way you are behaving, sleeping, and acting
in class.
Some resilience factors of children are having a set of values or abelief system, and relational anchors such as an extended family,
a grandparent, or a teacher who takes special interest in them andgives them a little extra time.
The therapeutic web is a term that helps people understand theimportance of being safe and connected. Like a spider web, there arelines of healthy interaction that come from the people around you.
Having a very scant therapeutic web means that you essentially haveto depend upon your own internal resources to regulate yourself.

Reference
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards
V, et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse
Childhood Experiences (ACE) Study. American Journal of Preventive
Medicine; 14:245–258.

104 Family Violence Research, Assessment and Interventions

REVIEW OF RECENT RESEARCH OF HOWARD DUBOWITZ, MD

Meeting Children’s Basic Needs:
A Conceptual Model of Child Neglect
By James E. McCarroll, PhD, and Robert J. Ursano, MD
Joining Forces Joining Families Volume 10, Issue 1, March 2007
Much of Dr. Dubowitz’s work has focused on child neglect, a complex social
problem. Child neglect accounts for the largest number of cases and highest
rates of any kind of maltreatment in the U.S. civiliansociety and in the Army. Recent data also indicatethat child neglect in the U.S. Army has risen during
recent deployments.
Child neglect has been difficult to define, bothin research and in practice. Some communities havemore concern for physical aspects of child care whileothers may focus more on psychological issues.
However, there is overall general agreement on the circumstances that areharmful to children (Dubowitz, Klockner Starr, & Black, 1998). Part of the
discussion of child neglect is whether to categorize subtypes and, if so, how.
In a study of the relationships of three major subtypes of neglect (physical,
psychological, and environmental), Dubowitz, Pitts, and Black (2004) foundmodest correlations among the neglect subtypes indicating some degree ofoverlap, while still suggesting somewhat unique factors in each.
A recent conceptual model of child neglect at ages 4–6 (Dubowitz et al.,2005) identified 12 children’s needs, and conceptualized neglect as occurring when these basic needs are not adequately met. This study related childneeds to longitudinal measures of child maltreatment. Three basic needs
were derived: emotional support/affection, protection from family conflict,and protection from community violence. The model then assessed whether
these three constructs were related to children’s adjustment at age 8. Low
perceived support from the mother was associated with child behavior problems. Exposure to family conflict and children’s sense of experiencing little

106 Family Violence Research, Assessment and Interventions

early affection were associated with both child behavior problems and withsocial problems. The investigators concluded that conceptualizing neglect as
the failure to meet children’s needs could help build our understanding ofchild neglect.
An important part of Dr. Dubowitz’s work is educating health care professionals on family maltreatment. Two articles on child neglect provide veryclear and useful language and approaches for providers of health care. The
first (Dubowitz, Giardino & Gustavson, 2000) describes manifestations ofchild neglect, provides principles for assessment and management of neglect
and suggests that caregivers focus on children’s basic needs rather than on
the omissions of parenting. The second article (Dubowitz, 2002) describes
the importance of preventing child abuse and neglect, identifies risk andprotective factors for child maltreatment, and provides guidance on screening, brief assessment, and initial management of child maltreatment.
One of the important issues that Dr. Dubowitz has emphasized in his research and teaching is the association between father involvement and childneglect. In a 2000 study, Dubowitz and colleagues found that the mere presence of a father did not significantly influence the degree of neglect of thechild, but the nature of his involvement did. Fathers who felt more effective
as parents were less likely to neglect their children. Less neglect was associated with fathers’ longer duration of involvement, more involvement withhousehold tasks, and less involvement in child care (Dubowitz, Black, Kerr,
Starr, & Harrington, 2000). The investigators thought that the sense of parenting efficacy might represent parenting skills and suggested that caregivers could play a valuable role in enhancing the involvement and parenting
skills of fathers.
In a very recent article, Dr. Dubowitz (Dubowitz, 2006) commented on
two studies on child neglect (Coohey, 2006; Pittman & Buckley, 2006), reviewed the significant research on fathers and child maltreatment, and described the current need to understand the roles of fathers in child rearing and child maltreatment. Coohey found several predictors of recidivism
among fathers who abused their children: (1) father unemployed, (2) not thebiological father of all the children in the family, (3) denying responsibility
for his behavior, (4) having previously maltreated a younger child, and (5)seriously injured a child. Dubowitz noted that an important clinical implication of Coohey’s work was getting fathers to acknowledge their own responsibility, which has implications for both prevention and intervention.
Dr. Dubowitz noted that Pittman and Buckley’s study of 2,841 offenders
treated in the U.S. Air Force Family Advocacy Program found many similarities and few differences between mothers and fathers of neglected children.
The mothers reported more distress and more problems outside the family,

Howard Dubowitz, MD 107

while fathers reported more rigid expectations of children and less familycohesion. Taking into account such differences may help tailor treatment interventions to address specific problems that differ for mothers and fathers.
Finally, Dr. Dubowitz has performed community research on the effectiveness of strategies to prevent child neglect. The program, Family Connections, was a demonstration project of a prevention strategy assessed in 154
families who received the intervention for 3 months or 9 months (DePanfilis& Dubowitz, 2005). The outcomes of the program were protective factors(parenting attitudes, parenting sense of competence, family functioning, andsocial support), key risk factors for neglect (caregiver depressive symptoms,
parenting stress, and everyday stress), child safety (physical and psychological care of the child), and child behavior (caregiver reports of child internalizing and externalizing behavior). Internalizing behavior included somatic
complaints and withdrawn, anxious, or depressive behavior. Externalizing
behavior was measured as delinquency or aggressiveness. The intervention
aimed to improve protective factors, diminish risk factors, and thereby improve child safety and behavior. Interestingly, the 9 month program had few
advantages over the 3 month program. This finding reinforces the need forresearch on the optimal length of intervention for community-based programs.
There are many implications of Dr. Dubowitz’s work for the Army Family Advocacy Program as well as suggestions for further research. Among the
research and program development opportunities within the Army community are to: (1) determine the types and prevalence of subtypes of neglect; (2)clarify the degree of overlap of neglect subtypes with other types of neglect
and with other types of child maltreatment, and domestic violence; (3) develop neglect prevention programs targeting the subtypes of neglect and thehighest risk families; and (4) understand the meaning and implications ofchildren’s experiences of neglect and risk for harm.
Dr. Dubowitz’s work in the field of child neglect can help educate andinform the Army community. In the current context of rapid, long, and repeated military deployments, it is often hard for parents to balance all theneeds of the active duty member(s) and the children. Further understandingof child neglect in our own community can protect our nation’s children andstrengthen the Army family.

108 Family Violence Research, Assessment and Interventions

Key Points
Three basic needs of children are for emotional support andaffection, protection from family conflict, and from community
violence.
Programs emphasizing parenting efficacy could play a valuable rolein enhancing the involvement and parenting skills of fathers.
Dr. Dubowitz suggests that caregivers focus on children’s basic
needs rather than omissions of parenting.
Research Possibilities Involving Neglect■■ Prevalence of subtypes.
■■ Targeting neglect prevention programs to the most prevalent subtypes.
■■ Degree of overlap of subtypes and other forms of child maltreatment.
■■ Child neglect and domestic violence.
■■ The meaning of children’s experiences of neglect and the risk ofharm.

References:
Coohey C. (2006). Physically abusive fathers and risk assessment. Child
Abuse & Neglect; 30: 467–480.
DePanfilis D. & Dubowitz H. (2005). Family Connections: A program forpreventing child neglect. Child Maltreatment; 10: 108–123.
Dubowitz H. (2002). Preventing child neglect and physical abuse: A rolefor pediatricians. Pediatrics in Review; 23: 191–196.
Dubowitz H. (2006). Where’s Dad? A need to understand father’s role inchild maltreatment. Child Abuse & Neglect; 30: 461–465.
Dubowitz H, Black MM, Kerr MA, Starr RH, & Harrington D. (2000).
Fathers and child neglect. Archives of Pediatric and Adolescent Medicine;154: 135–141.
Dubowitz H, Giardino A, & Gustavson E. (2000). Child neglect: Guidancefor pediatricians. Pediatrics in Review; 21: 111–116.
Dubowitz H, Klockner A, Starr RH, & Black M. (1998). Community andprofessional definitions of child neglect. Child Maltreatment; 3: 235–243.

Howard Dubowitz, MD 109

Dubowitz H, Newton RR, Litrownik AJ, Lewis T, Briggs EC, Thompson R,
English D, Lee L, & Freerick MM. (2005). Examination of a conceptualmodel of child neglect. Child Maltreatment; 10: 173–189.
Dubowitz H, Pitts SC, & Black MM. (2004). Measurement of three major
subtypes of child neglect. Child Maltreatment; 9: 344–356.
Pittman JF & Buckley RR (2006). Comparing maltreating fathers andmothers in terms of personal distress, interpersonal functioning andperceptions of family climate. Child Abuse & Neglect; 30: 481–496.

110 Family Violence Research, Assessment and Interventions

INTERVIEW WITH HOWARD DUBOWITZ, MD

Conceptualization and Measurement ofChild Neglect
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 1, March 2007
Dr. McCarroll: Based on your international experiences, training, and practice, what do we know about child maltreatment across cultures?
Dr. Dubowitz: To the best of my knowledge all cultures have a taboo
against child sexual abuse, although cross-cultural differences do exist. For
example, a majority of countries do not have prohibitions against childpornogra­phy. Physical abuse issues are a little trickier. Even within the stateof Maryland there are dif­ferences. For example, some people may equate any
hitting of a young child as abuse while others accept spanking as appropriate
in some circumstances.
Dr. McCarroll: Tell us a little about your Center.
Dr. Dubowitz: Our Center is within the Department of Pediatrics at
the University of Maryland Medical School. We have four main activities:
clinical programs, clinical research, teaching, and advocacy. Our goal is toencour­age the development of policies that will help children and families
within the city, the state, and nationally.
Dr. McCarroll: In your teaching and research do you address the intersection of child and adult maltreatment?
Dr. Dubowitz: I generally do raise it as an issue. I think this is an important intersection. One of the projects that we are completing is focused on
routine screening for domestic violence by pediatricians.. There are studies
showing that parents, usually mothers, will report domestic violence to pediatric and other medical staff when asked. Dr.
Dr. McCarroll: What is the best way to screen for child or adult maltreatment?
Dr. Dubowitz: I recommend using a screen­ing instrument. Screening
cannot and must not be limited to visual examination. So much gets missed
when you depend only on gross exami­nation, such as the woman with theblack eye. Abuse is a problem that is often well masked.
Dr. McCarroll: Would you say the same thing about child abuse? Would youHoward Dubowitz, MD 111

rely on a screening instrument as opposed to a visual examination or verbal
report?
Dr. Dubowitz: I think the difficult ques­tion is what instrument to use. If
there were something practical it would be quite attrac­tive. However, thishas been elusive. As part of a project called SEEC — a safe environment forevery child — we included two questions that seem to be important. They
were part of a one-page questionnaire that parents completed while waiting
for the child’s appointment. (1) “Have you been concerned that your child
may have been sexually abused?” and (2) “Have you felt the need to hit yourchild?” These questions have shown some predictive value. The big problem
is that of response bias in the direc­tion of social desirability and how does
one circumvent it. [Editor’s note: Social desirability is presenting oneself inan overly favorable light.] In a current study that we are conducting with
about 85–90 pediatricians in private practice, we are targeting risk factors
such as depression, substance abuse, domestic violence and paren­tal stressas the four big contributors to child abuse and neglect.
Dr. McCarroll: Your earlier papers emphasize the ecological model as developed by Brofenbrenner (1979) and Belsky (1980). Do you still teach this asa way of conceptualizing how children are affected by their world? [Editor’snote: The ecological model is a theory emphasizing the multiple interacting
factors that contribute to child abuse and neglect.]
Dr. Dubowitz: Yes, it is a major focus. It is important for professionals,
when these cases evoke feelings of pain, anger, and dismay, to recognize thatneglectful parents are not simply evil people. Where these models can behelp­ful is to caution us not to excuse the behavior, but to understand that
there are underpinnings to some of these problems. I often will suggest that
pediatricians think of abuse and neglect as symptoms. That seems to help
take some of the edge off of angry feelings and helps us realize the importance of the family, cultural, and community issues that contribute to thesituation.
Dr. McCarroll: It sounds like this approach could be helpful to parents aswell as to physicians.
Dr. Dubowitz: I am always careful when presenting the model to not letparents off the hook. It is walking a bit of a tightrope. I do say that parents
have the primary responsibility to protect and nurture their children. The
cliché that it takes a village is, however, actually kind of true.
Dr. McCarroll: The high rates of neglect in the U.S. civilian community andthe Army are of concern. In many publications one reads about subtypes ofneglect, but most jurisdictions do not publish data on subtypes. What is the112 Family Violence Research, Assessment and Interventions

value of categorizing neglect into subtypes? Would this help to target interventions?
Dr. Dubowitz: Again, there is quite a bit of variation across states. Veryoften, states have two, three or four subtypes. One of them is often calledfailure to provide. This includes the physical aspects of childcare such as
food and housing, clothing, and, sometimes, health care. The second main
subtype that is often used is lapses in supervision. Some also have education­
al neglect, but generally it is the physical aspects of children exposed to hazards and concerns about supervision that states are most con­cerned about.
Dr. McCarroll: Do you think the subtypes are primarily for researchers? Are
clinicians interested in using such categorization?
Dr. Dubowitz: I think that this is not a question just for researchers. These
different subtypes are, in fact, different. To lump togeth­er, for example, thechild who has inadequate nutrition with a child who is abandoned does notmake much sense. The circumstances are quite different. One could argue
that for the individual clinician, even having subtypes is too crude. I say thisas a clinician. For example, the criminal law on abandonment in one state
requires that about 15 or 20 different contex­tual variables need to be taken
into account. In the instance of a child left alone, contextual variables might
be the age of the child, the time of day, how long is the child left alone, arethe utilities functioning in the house, is there food in the house, does thechild know how to reach a parent? In cases of failure to thrive, contextual
variables also make a huge difference. Clini­cians, even sometimes withouteven using the terminology, recognize this variability and try to probe thespecific circumstances. By doing so they are paying attention to the differences across and even within subtypes.
From an administrative standpoint, I can see how, for example, childprotective services might lump these different categories into fail­ure to provide. For researchers as well there is a need to clarify the meaning of thesedifferent experiences for children. Also, there is substan­tial overlap between
the subtypes. In the LONGSCAN, for example, with 1,300–1,400 children,in a subsample of chil­dren who have experienced lapses in super­vision, it
gets pretty tricky because many of these children have experienced othertypes of neglect or other forms of maltreatment as well. [Editor’s note: See
Dr. Dubowitz’s biography for a reference to the LONGSCAN.] But I should
also give another perspective. There are differences and subtypes of neglect,
but ultimately these are symptoms of parents having difficulty meeting theirchildren’s basic needs. From a conceptual standpoint does it really matter?
If one looks at the underlying parental, family, and community dynamics
that are underpinning these manifestations, are they likely to be so differ-

Howard Dubowitz, MD 113

ent? Therein lies a concep­tual argument for lumping rather than divid­ing.
So, I think the answer is that it depends specifically on the question. If it is amatter of broader public policy then some of these differ­ences might seem
unnecessarily nuanced. On the other hand, if it’s trying to understand thespecifics around the feeding of young children then the issue of that specificsubtype might be quite important.
Dr. McCarroll: You mentioned in one of your articles that various risk factors such as substance abuse, depression, non-biological parents, and others,
have low predictive value for neglect.
Dr. Dubowitz: I hope I have not been dis­missive of risk factors because
we need a variety of strategies. Even if a particular risk factor has a low predictive value, I think when you start combining them the predictive power
gets bet­ter. This gets back to definitional issues. Both domestic violence andmaternal depression are strong risk factors for child abuse. If one is looking
at only parental age, then the connection is weaker.
Dr. McCarroll: What are the underpinnings of risk factors? Is this the question of what lies behind the parents’ failure to adequately take into accounttheir children’s needs?
Dr. Dubowitz: For a long time it has been convenient to point and wag afinger at a guilty parent, but I think one might take a broader epidemiological view, a public health perspective saying, “Wait a moment.” You know, if
we are in a society that says on the one hand says we love children and at thesame time one in four girls and maybe one in ten boys are sexually abused,
I think it behooves us to take this broader perspective of what are the contributors that are underpinning these facts.
I have stubbornly held on to the view that most parents most of the time
would like for things to be good for their children. So the big question as we try
and put a dent in this problem is to better understand what gets in the way of,hope­fully, good intentions.
Dr. McCarroll: Thank you for your thoughts.
Dr. Dubowitz: You are welcome.

114 Family Violence Research, Assessment and Interventions

Key Points
Four major risk factors for child abuse and neglect are depression,
substance abuse, domestic violence, and parental stress.
Parents, most of the time, would like for life to be good for theirchildren. The big question is to understand what gets in the way ofgood intentions.

Howard Dubowitz, MD 115

REVIEW OF RECENT RESEARCH OF HOWARD DUBOWITZ, MD		

Project SEEK — A Safe Environment for
Every Kid
By James E. McCarroll
January 2010
Dr. Dubowitz and colleagues have undertaken studies in their clinics to improve child safety and health (Dubowitz, Feigelman, Lane, & Kim, 2008).
The Safe Environment for Every Kid (SEEK) project aims to prevent childmaltreatment through the development of screening procedures in pediatricprimary care clinics for major risk factors associated with abuse and neglect.
In this research, they have used screening questionnaires to identify parents with psychosocial problems and compared those screening questions
to standard instruments used to detect risk factors for child maltreatment.
The Parent Screening Questionnaire (PSQ), a 20-item questionnaire to becompleted by the parent waiting for a checkup of their child (under 6 yearsof age), was developed to briefly screen parents for the targeted risk factors:
maternal depression, corporal punishment, family substance abuse, and intimate partner violence and major stress (Fiegelman, Dubowitz, Lane et al.,(2007).
A subset of parents participating in the study evaluation were asked tocomplete questionnaire measures that served as “gold” standards against
which to compare the screening questions. [Editor’s note: The term gold
standard denotes the highest possible level of value. A gold standard test
is not infallible, just the best that is known. Unfortunately, applicable gold
standards in medical practice are rare.] Four papers based on the first SEEK
study reported testing the PSQ against standard measures related to the risk
factors. The first sample was largely urban, low-income, and black. Most
were single mothers with an average age of 25 years. Two-thirds were highschool graduates or less and the children had an average age of 5 months.
The average household composition was two children and two adults. Medicaid was the insurance for 90% of the families.
In the first paper, the investigators estimated the prevalence of depression of mothers (Dubowitz, Feigelman, Lane, et al., 2007) seeking care for
their children in a primary care pediatric clinic. Parents’ scores on two depression screening questions from the PSQ were compared to the Beck Depression Inventory II (BDI II, the gold standard for identifying depression
in this study (Beck, Steer, Ball, et al., 1996). The two PSQ questions were:116 Family Violence Research, Assessment and Interventions“Lately, do you feel down, depressed, or hopeless?” and “During the pastmonth, have you felt very little interest or pleasure in the things you used toenjoy?” Twelve percent of the mothers met the criteria for at least moderate
depression on the BDI II. Twenty-two percent met the BDI II criteria for
mild depression. The two PSQ questions individually yielded similar rates,
19% and 17%, respectively. The sensitivity of the two questions was 74% andwas considered satisfactory, although not as high as the investigators had
hoped. [Editor’s note: Sensitivity is a measure of the ability of a screening
test to accurately identify persons with the problem in question, in this case,depression as measured by the BDI II.]
The authors discussed some implications of screening for depression
in a primary pediatric care clinic. One issue was that depression is often
masked and that people may not be aware of it or willing to seek treatment
for it. Their discussion could be of value to primary care doctors, nurses,
and others who may screen for depression outside a mental health clinic.
The authors concluded that the prevalence of depression in this populationof mothers of young children was quite high, as found in other studies. They
also concluded that the two item depression screening questions of the PSQ
had adequate statistical properties (stability and reliability) for accurate
identification of parents who may be at least moderately depressed and who
might benefit from further evaluation.
In screening for harsh punishment by parents, the PSQ was comparedto the Conflict Tactics Scale, Parent-Child (CTSPC), a standard measure ofparent-child conflict (Feigelman, Dubowitz, Lane, et al., 2009). Two items
from the PSQ were associated with discipline: “Do you often feel your childis difficult to take care of?” and “Do you sometimes find you need to hit/spank your child?” The frequencies of “Yes” responses to the two screening
items were low. Five percent of parents with infants and 11% of those witholder children responded positively to the question of whether the child wasdifficult to care for. Three percent of parents with infants and 26% of parentsof older children responded positively to the second question, the need tohit the child. The CTSPC included both physical assault and psychological aggression items. Minor physical assault on the CTSPC ranged between
1-10%. Six caregivers endorsed items that were considered severe physicalassault. Twenty-one percent of parents reported psychological aggression(e.g., yelled, screamed, swore or cursed at the child). The authors concluded
that the prevalence of corporal punishment in this sample was high, butsimilar to that reported in several national studies. The ability of the PSQ
to detect harsh punishment was moderate (57%), but it performed betterfor older children. However, there are many reasons why the results of thisstudy were not more favorable in being able to detect corporal punishment

Howard Dubowitz, MD 117

of children. The frequencies of corporal punishment are very likely underestimates and questions asked of parents on the PSQ and the CTSPC were notexactly the same. However, the authors concluded that primary providers
could use the PSQ in several ways. Any family endorsing either of the twoitems could benefit from counseling in the pediatric office. Physical assault
against infants is especially serious. Such harsh disciplinary practices call for
helping parents find better alternatives.
Parental substance abuse was screened by the use of two questions on the
PSQ: “In the past year have you or your partner had a problem with drugs or
alcohol?” and “In the past year, have you or your partner felt the need to cut
back on drinking or drug use?” The comparison standard measure used wasa modified version of the Composite International Diagnostic Inventory(CIDI) including the sections for alcohol and drug use (World Health Organization, 1993). The CIDI prevalence for alcohol abuse was 13.9%, 3.2%
for drug abuse, and 15.7% for either. The screening questions had a sensitivity of 10-13%, depending on which question was used. The investigatorsconcluded that the screen identified relatively few of the substance-abusing
parents, but that whose would otherwise have gone unidentified.
A fourth paper reported on screening for intimate partner violence(Dubowitz, Prescott, Feigelman et al., 2008). The purpose was to estimate
the prevalence of intimate partner violence (IPV) and to determine theeffectiveness of a brief screening instrument for detecting IPV. The three
screening questions were: “Have you ever been in a relationship in which
you were hurt or threatened by a partner?” and “In the past year, have you
been afraid of a partner?” and “In the past year, have you thought of getting
a court order for protection?” A total of 12% answered positive to at least
one of the PSQ screening questions. These responses were compared to the
Revised Conflict Tactics Scale (CTS2) (Straus, Hamby, Boney-McCoy et al.,1996). On the CTS2, responses varied from 9% reporting a physical injury
to 76% reporting psychological aggression. The sensitivity was 29%.
The authors noted that it would have been better if the sensitivity of the
PSQ questions had been better, but there were several possible reasons why
it was low. IPV is a very sensitive subject, but identifying those who arewilling to admit the problem and seek help may be a benefit to them andto their children. Although one hopes that screening will identify as manyfolks with the problem as possible, it is likely that those who do not disclose
the problem in a clinic setting are unlikely to engage in treatment. It is also
probable that for many sharing such sensitive information, and in a setting
where they are unaccustomed to discussing their problems, is a slow andperhaps lengthy process. Dr. Dubowitz hopes that in the SEEK model, avaluable message is communicated (“We care about you, too!”) and perhaps

118 Family Violence Research, Assessment and Interventions

a seed is sown. Parents may eventually recognize that this is a setting where
they can obtain help.
The overall result of the SEEK project resulted in lower rates of childmaltreatment in terms of fewer child protective services reports, fewer instances of possible medical neglect documented as treatment non-adherence, delayed immunizations, and less harsh punishment reported by parents (Dubowitz, Feigelman, Lane, & Kim, 2009).
In general, these papers examining the SEEK Parent Screening Questionnaire showed many positive results. Screening for risk factors for child maltreatment and family disruption can be accomplished in primary pediatriccare. Without such screening, risk factors would likely be unrecognized inall but the most severely affected families. Screening for sensitive information is difficult and requires rapport between the screener (in this case, thepediatrician) and the parent. The investigators have shown that this exists inprimary pediatric care. Recognition of the problem for which screening is
conducted also serves an educational function in which the pediatrician andchild’s caregiver can talk about the risk factors that could affect the parents
and their child(ren). It also provides the opportunity for the parent to consider further evaluation regarding an identified problem. While the percentages on sensitivity may be confusing to the reader, there are several overall
points that can be made. Even though the sensitivity may be low, it is worthwhile to identify even small numbers of parents who need help with the risk
factors identified — if this leads to them being helped.
There are many ways to administer screening questions. Several of thosemethods were used in this study: face-to-face, by computer, and paper andpencil. Each has its advantages and disadvantages (Kim, Dubowitz, HudsonMartin, & Lane, 2008). An important advantage of the parent responding to
the PSQ while waiting for their child to be seen is the efficiency saving time,a serious concern in a busy pediatric practice. Recruitment and retention of
study participants was said to be challenging (Dubowitz, Feigelman, Lane,& Kim, 2008). Some did not return to complete the study protocol. The unwillingness of the participants to admit certain problems is likely to produce
underestimates of the true prevalence of the events; this is to be expected.
The study showed that screening for problems in an attempt to provide safer
environments for children can result in helping parents and pediatricians
identify risk factors and suggest ways of addressing these problems. Most
importantly, the studies have shown the SEEK model of enhanced pediatricprimary care to be a promising approach for preventing child maltreatment.
Hopefully, it will also promote children’s health, development and safety.

Howard Dubowitz, MD 119

Key Points
Screening for risk factors for child maltreatment and family
disruption can be accomplished in primary pediatric care. Without
such screening, risk factors would likely be unrecognized in all but
the most severely affected families.
The SEEK project resulted in fewer child protective services
reports, fewer instances of possible medical neglect documented astreatment non-adherence, delayed immunizations, and less harshpunishment reported by parents.
Screening also serves an educational function in which thepediatrician and child’s caregiver can talk about the risk factors that
could affect the parents and their children.

References
Beck AT, Steer RA, Ball R, & Ranieri W. (1996). Comparison of Beck
Depression Inventories IA and II in psychiatry outpatients. Journal of
Personality Assessment; 67:558–597.
Dubowitz H, Feigelman S, Lane W, Prescott L, Blackman K, Grube L,
Meyer W, & Tracy JK. (2007). Screening for depression in an urban
pediatric primary care clinic. Pediatrics; 119:435–443.
Dubowitz H, Feigelman S, Lane W, & Kim J. (2009). Pediatric primary careto help prevent child maltreatment: The Safe Environment for Every
Kid (SEEK) Model. Pediatrics; 123:868–864.
Dubowitz H, Prescott L, Feigelman S, Lane W, & Kim J. (2008). Screening
for intimate partner violence in a pediatric primary care clinic. Pediatrics; 119: 435–443.
Feigelman S, Dubowitz H, Lane W, Prescott L, Meyer W, Tracy JK, & Kim
J. (2009). Screening for harsh punishment in a pediatric primary careclinic. Child Abuse & Neglect; 33: 269–277.
Kim J, Dubowitz HD, Hudson–Martin E, & Lane W. (2008). Comparisonof 3 data collection methods for gathering sensitive and less sensitive
information. Ambulatory Pediatrics; 8: 255–260.
Lane W, Dubowitz H, Feigelman S, Kim J, Prescott L, Meyer W, & Tracy
JK. (2007). Screening for parental substance abuse in pediatric primarycare. Ambulatory Pediatrics; 7: 458–462.

120 Family Violence Research, Assessment and Interventions

Straus MA, Hamby SL, Boney–McCoy S, &Sugarman DB. (1996). The
Revised Conflict Tactics Scales (CTS2): Development and preliminary
psychometric data. Journal of Family Issues; 17: 283–316.
World Health Organization. (1993). Composite International Diagnostic
Interview, Version 2.1. Geneva: World Health Organization. Available
at: http://www.hcp.edu/wmhcidi/index.php.

Howard Dubowitz, MD 121

SECOND INTERVIEW WITH HOWARD DUBOWITZ, MD

A Safe Environment for Every Kid:
The SEEK Study
By James E. McCarroll, PhD
January 2010
Dr. McCarroll: In your last newsletter interview you talked about your Safe
Environment for Every Kid (SEEK) project in which you studied screening by pediatricians in private practice for risk factors such as depression,
substance abuse, domestic violence and harsh punishment. Where has thatproject gone from that point?
Dr. Dubowitz: It has gone quite a ways (Dubowitz, Feigelman, Lane, &Kim, 2009). It is built on an earlier study where we had applied the same preventive model in a West Baltimore University-related clinic. Being a pediatrician, I have been especially interested in prevention. Most American kids
get regular check ups, particularly in the first three years of life. Infants andtoddlers are usually seen every two or three or so months. These checkups
present a terrific opportunity for physicians and sometimes nurses to knowwhat is cooking in the kid’s home and family environment. For some time,
pediatrics has acknowledged that it is not enough to narrowly focus on justthe child. If mom is depressed or the parents are using drugs or there is violence, that can have an enormous impact on children’s health, development,
and safety. So, we have been testing a model of modifying pediatric primarycare to consider screening for some of these major risk factors that we know
are pretty prevalent and strongly associated with both child abuse and neglect. Aside from preventing child abuse and neglect, the hope has been thatby identifying and addressing these problems, like mom’s depression, that
we can improve children’s health and development. So, this project has abroader frame than preventing abuse and neglect. It shifts the paradigm toone of promoting children’s health and development.
Dr. McCarroll: How did you target your screening?
Dr. Dubowitz: We set up a randomized trial in a clinic serving about
9,000 kids and where pediatric residents had their half-day a week “continuity clinic.” We randomly divided the clinic days: two days were intervention
clinics and two were control clinics. Within the interventions clinics, every
parent bringing in a kid under six years of age for a checkup was supposed
to receive the Parent Screening Questionnaire to complete while waiting for122 Family Violence Research, Assessment and Interventions

their child to be seen.. That is a very important point because we know clinically if one is going to screen only when there is evidence of violence or signsof depression, one is going to miss an enormous amount. These are problems that are often well masked. In the brief intro to the screen, we say, “We
are asking everyone these questions.” We indirectly convey “It is not becauseof the way you look or because we think you are acting as though you arehigh on drugs, but these are common problems facing lots of families andso we are asking everyone.” Aside from this clinical intervention, all of thesefamilies were eligible to participate in the evaluation of SEEK; a subset wererecruited.
Dr. McCarroll: How does the clinician establish enough rapport to ask thesequestions?
Dr. Dubowitz: The whole effort occurs in the context of a relationship.
Generally speaking, pediatricians and parents have nice relationships. Parents usually like their kid’s pediatrician. It is very much for that reason that
we saw this as a terrific opportunity. This may begin prenatally, but thenthere are these repeated visits over time in which, hopefully, a relationshipand rapport are established, which should help someone disclose difficult,sensitive information. We are very careful to strike an empathic tone. On
our screening questionnaire, we tell the parent that we are concerned thatchildren be in safe environments. We are also conveniently building on
something that has been long established in pediatrics - an interest in kids’safety. Usually, safety has been discussed in terms of bike helmets and smoke
alarms and the like. It is stretching that paradigm a little bit to think aboutother risks that might compromise children’s safety, health, and development; it is building on the concern about a child’s environment.
Dr. McCarroll: One of the issues you spoke of in the last interview is the impact of children witnessing domestic violence. I wondered how you inquired
about domestic violence with patients.
Dr. Dubowitz: That has been interesting because there is no clarity on
the best way to ask about it. Depression has been researched best, domestic
violence very little. So, we have worked with different questions. We finallydecided to ask the following: “Have you ever been in a relationship in which
you were physically hurt or threatened by a partner?” “In the past year, haveyou been afraid of a partner?” “In the past year, have you thought of getting a court order for protection?” We have analyzed how different screening questions perform against the Conflict Tactics Scale (CTS), a measureof how intimate partners resolve conflict (Straus , Hamby , Boney-McCoy,&Sugarman, 1996). We found relatively low sensitivity, but quite good, asHoward Dubowitz, MD 123

you would expect, specificity. [Editor’s note: Sensitivity means the abilityof a test or screening instrument to detect the outcome variable when it ispresent, e.g., in this case, domestic violence. Specificity is the opposite: theability of a test to indicate that, in fact, the outcome for which screening is
conducting is not present. In this study, the screening instrument was very
good at determining when there was no domestic violence, but not so goodat detecting its presence.]
Dr. McCarroll: Do you think it comes as a surprise to parents that parents’difficulties can affect their kids or do they think that the kids are in some way
immune from that?
Dr. Dubowitz: I can answer that a little indirectly. We were concernedthat parents might resent our approach and think we were just being nosy.
But, at least anecdotally, we did not find that to be a problem. The first study
probably involved three or so thousand families and the second study more
like four or five thousand. Our experience has been positive. We hypothesized that parents might even appreciate being asked these questions. In
the first and second studies, we had measures of parental satisfaction with
their kid’s pediatrician hypothesizing that this interest in how they were doing would add to parents’ satisfaction. In the first study, in a very high risk
population, we found some evidence that parents actually did appreciate it.
In the second study, which was a rather high functioning middle class suburban population for the most part, we found that it really did not makemuch difference. We did not find a problem or a benefit.
Dr. McCarroll: It may be that those in the lower income and lower socioeconomic group were happy that somebody anywhere was concerned about
them.
Dr. Dubowitz: I think so because I know it is appreciated when a clinician communicates to these parents, mostly moms, “I care about you; youare important, too.” I am guessing that it is something they do not often
hear.
We are just finishing the second study. We have answered some of thepreliminary impressions. As in the first study, it appears that we were able
to reduce child abuse. We measured child abuse and neglect three ways: byparental self-report, by review of the kid’s medical records, and by child protective services reports. In the first study, all three measures favored the intervention group. We were excited about that. In the second study, mothersin the intervention group reported less psychological aggression and minor
physical assaults toward their children. There were, however, very few CPS
reports and problems documented in the children’s medical records and no124 Family Violence Research, Assessment and Interventions

significant differences between the groups.
There are important questions about identifying intimate partner violence. Even though you would like a screen that is very sensitive and picks
up most folks who are affected, is it still better than nothing to identify one
in five or even one in ten? Some would argue that it is. The problem is thatneither we nor anyone else has clearly shown that identifying these folks
in health care settings really leads to improved situations. There is a recent
paper by MacMillan (MacMillan, Wathen, Janieson, et al., 2009) where theyquite clearly argue, as does the US Preventive Services Task Force (2004),
that short of showing that there is a benefit, we do not have a solid basis forscreening for that problem. In pediatrics there are now perhaps half a dozen
papers including our own showing that women will disclose this information. Sometimes, the rates are reasonably high, perhaps about 20%, but weare still stuck in not demonstrating that that leads to help for them or for thechild. We looked at how many of them got services; the numbers were small.
There can be a complicated journey from identifying a problem, to the person acknowledging it, to then receiving help and being helped.
Dr. McCarroll: One of the issues I have addressed in these re-interviews is to
ask what gaps occur in your work that you would like to see filled. I believe
you have just identified a major one: the ability to get people into treatment
and have an effective treatment for things that you identify and know are
dangerous.
Dr. Dubowitz: Absolutely. I think how to encourage folks, how to motivate them to get the help we think they need is such a big issue. In the secondof the SEEK studies we included motivational interviewing in our trainingof about 100 pediatricians and pediatric nurse clinicians. It was probably
not enough, but it is a skill that I think would be great if folks were better at
it. But, even then, this is such a big challenge. I talked to a psychologist last
week about our findings and she asked “How long is the follow-up period?”
I said “Well, in the second study, 12 months.” And she said, “Well, that may
not be long enough.” You know, someone hears that they have a problem andideally, you would want to follow them for two or three or more years. [Editor’s note: See Hettema, Steele, & Miller (2005) for a review of motivational
interviewing.]
Dr. McCarroll: Thank you for your interview. We will be watching for moreof your exciting work on children and family maltreatment.
Dr. Dubowitz: You are welcome. And, thank you for your interest.

Howard Dubowitz, MD 125

Key Points
There has been little clarity about how to ask parents about theoccurrence of domestic violence.
In our parent screening questionnaire, we asked three questions:■■ “Have you ever been in a relationship in which you were physicallyhurt or threatened by a partner?”■■ “In the past year, have you been afraid of a partner?”■■ “In the past year, have you thought of getting a court order forprotection?”

References
Dubowitz H, Feigelman S, Lane W, & Kim J. (2009). Pediatric primary careto help prevent child maltreatment: The Safe Environment for Every
Kid (SEEK) Model. Pediatrics; 123: 868–864.
Hettema J, Steele J, & Miller WR. (2005). Motivational interviewing. Annual Review of Clinical Psychology; 1: 91–111.
MacMillan HL, Wathen CN, Janieson E, Boyle M, McNutt L, Worster A,
Lent B, & Webb M. (2009). Screening for intimate partner violence inhealth care settings. Journal of the American Medical Association; 302:
493–501.
Straus MA, Hamby SL, Boney–McCoy S, &Sugarman DB. (1996). The
Revised Conflict Tactics Scales (CTS2): Development and preliminary
psychometric data. Journal of Family Issues; 17: 283–316.
US Preventive Services Task Force. (2004). Screening for family and intimate partner violence: recommendation statement. Annals of Internal
Medicine; 140: 382–386.

126 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF DESMOND K. RUNYAN, MD,
DRPH, AND THE LONGSCAN PROJECT

Highlights of Recent LONGSCAN Project
Findings
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 11, Issue 3, March 2010
The long-term effects of the maltreatment of children are among the most
persistent and difficult questions to answer in the child maltreatment arena.
With the Longitudinal Study of Child Abuse and Neglect(LONGSCAN), Dr. Runyan and colleagues have undertaken a series of studies to answer these questions. In 1990,
the Office of Child Abuse and Neglect (then the National
Center on Child Abuse and Neglect) committed funds
for the LONGSCAN (Runyan & Litrownik, 2003). This
project is a consortium of five independent prospective
studies designed to examine the long-term consequencesof child abuse and neglect (Runyan Curtis, Hunter, et al.,1998). The five sites are widely distributed across the United States: Eastern,Southern, Midwest, Southwest, and Northwest.
Children enrolled in the study were recruited at four years of age or
younger. The samples include maltreated and non-maltreated children, children at high risk of maltreatment, and children placed in foster care. The
goal of LONGSCAN is to follow the approximately 1,300 children and theirfamilies until the children become young adults. Maltreatment data are collected from multiple sources. Children and their caregivers have been regularly assessed at approximately 2-year intervals using face-to-face interviews
and standardized instruments, some of which were created for this study.
Yearly telephone interviews are also conducted on a subset of the study population incorporating factors at the child, parent, family, neighborhood, andlarger community levels. Data collected at each interval include exposure
to maltreatment, age-specific potential risk and protective factors, and age-128 Family Violence Research, Assessment and Interventions

appropriate outcomes such as the domains of mental health, behavior, social
functioning, school, and employment.
Ecological-developmental theory (Belsky, 1980; Bronfenbrenner, 1977)
has been the basis for the selection of research questions, measurement, andanalyses. This theory is based on the knowledge that children’s response tomaltreatment and intervention varies by age, developmental level, and thecontext of the maltreatment. In addition to ecological-developmental theory, a social-developmental model (Catalano & Hawkins, 1996) is a complementary framework for the investigations. This model hypothesizes that interactions with others mediate the influences of individual and social factors
on outcomes.
The findings of LONGSCAN will provide a scientific basis for policymaking, program planning, and targeting service delivery by increasing ourunderstanding of the following:■■ The child, family, and community factors which increase the risk formaltreatment in its different forms;■■ The differential consequences of maltreatment, depending upon its timing, duration, severity, and nature, and upon the child’s age and culturalenvironment;■■ The child, family, and community factors (e.g., chronic exposure to violence, parental substance abuse) that increase the harm (measured byage-appropriate negative outcomes) caused by different forms of maltreatment;■■ The factors that increase the probability of positive child outcomes despite maltreatment and other adverse life circumstances;■■ The strengths and weaknesses of various societal interventions such as
child welfare programs, foster care, mental health services, parentingclasses, etc. Some of the sites are involved in intervention research andevaluation of services, expediting the integration of research findings
into policy and practice.
The LONGSCAN investigators and others who have used the datasets
have produced a large volume of publications. Many of these are available on
the LONGSCAN website. [Editor’s note: See websites of interest.] Two recent
publications focus on the importance of early childhood maltreatment, one
on later aggression (Kotch, Lewis, Hussey, et al., 2008) and on adolescentsexual behavior (Black, Oberlander, Lewis, et al., 2009). Early childhood
neglect (birth to age 2 years) predicted child aggression scores at ages 4, 6,
and 8 years (Kotch, Lewis, Hussey, et al., 2008). Boys had higher aggression
scores than girls, younger children had higher scores than older children,and more caregiver depressive symptoms were associated with higher ag-

Desmond K. Runyan, MD, DrPH 129

gression scores. Surprisingly, early abuse, later abuse and later neglect did
not predict later aggression at later ages beyond 8. The authors noted thatthe effects of juvenile violence are a serious concern, and on a worldwide
basis. The authors have shown that neglect may have profound and longlasting effects on the child, especially if it occurs early in development.
The relationship of childhood maltreatment to adolescent sexual
behavior is an important public health question. Analyses of the LONGSCAN found that all types of childhood maltreatment predicted adolescentengagement in sexual intercourse (Black, Oberlander, Lewis, et al., 2009).
Emotional distress, as measured by the Trauma Symptom Checklist (Briere,
1996), mediated the relationship between maltreatment and sexual intercourse at age 14, but not at age 16. The authors concluded that maltreatedchildren are at risk for early sexual behavior, but by age 16, other factors account for it.
Many publications from the LONGSCAN include descriptions of
the relationship of maltreatment to various health and social outcomes.
Other studies include the risks for child maltreatment in different environments, ethical issues, costs and other economic issues, parenting and caretaking, development, foster care, prevention, type of maltreatment, longterm outcomes and many others. This very comprehensive effort to collectlongitudinal data across a variety of domains will provide child maltreatment researchers with much material for analysis and study over many years
to come.
Key Points
Ecological-developmental theory is based on the knowledge thatchildren’s response to maltreatment and intervention varies by age,developmental level, and the context of the maltreatment.
The goal of LONGSCAN is to follow approximately 1,300 children
and their families until the children become young adults
Early childhood neglect (birth to age 2 years) predicted childaggression scores at ages 4, 6, and 8 years
All types of childhood maltreatment predicted adolescentengagement in sexual intercourse.

130 Family Violence Research, Assessment and Interventions

References
Belsky J. (1980). Child maltreatment: An ecological analysis. American
Psychologist; 35:320–335.
Black MM, Oberlander SE, Lewis T, et al. (2009). Sexual intercourse among
adolescents maltreated before age 12: A prospective investigation. Pediatrics; 124:941–949.
Briere, J. (1996). Trauma Symptom Checklist for Children: Professional
Manual. Odessa, FL: Psychological Assessment Resources, Inc.
Bronfenbrenner U. (1977). Toward an experimental psychology of humandevelopment. American Psychologist; 32:513–531.
Catalano RF & Hawkins JD. (1996). The social development model: A
theory of antisocial behavior. In Delinquency and Crime: Current Theories, JD Hawkins (Ed.). New York, NY: Cambridge University Press, pp.
149–197.
Kotch, Lewis, Hussey, et al. (2008). Importance of early neglect for childhood aggression. Pediatrics; 121:725–731.
Runyan DK, Curtis PA, Hunter WM, Black MM, Kotch JB, Bangdiwala S,
Dubowitz H, Eng­lish D, Everson MD & Landsverk J. (1998). LONGSCAN: A consortium for longitudinal studies of maltreatment and thelife course of children. Aggression and Violent Behavior; 3:275–285.
Runyan DK & Litrownik AJ. (2003). Introduction to special issue: LONGSCAN and family violence. Journal of Family Violence; 18:1–4.
LONGSCAN principal investigators
The following are the LONGSCAN principal investigators and the focus ofstudies at each of the five sites.
■■ Howard Dubowitz, MD, is Professor of Pediatrics and Director of theCenter for Families at the University of Maryland School of Medicine,
Baltimore. His site focuses on a cohort of children drawn from three
Baltimore pediatric clinics serving children with non-organic failure
to thrive, children of drug-abusing or HIV-positive mothers, and lowincome, inner-city children. Site-specific objectives of this study are thedevelopmental impact of chronic neglect, the mediating influence ofhome interventions, and the importance of fathers in children’s adaptive,
academic, and social development.
■■ Diana English, PhD, is the Director of Research for the Child Welfare
Research Group at the School of Social Work, University of Washington,
and the Director of Research and Development for the Child Welfare
League of America. Her site focuses on a cohort study of children (ages
1-4), consecutively classified as moderate risk by Child Protective Ser-Desmond K. Runyan, MD, DrPH 131

vices offices in Seattle. This study will yield data about the risk assessment
process and allow an examination of the impact of social service andmental health interventions.
■■ Jonathan Kotch, MD, MPH, is Professor in the Department of Maternaland Child Health, School of Public Health at the University of North
Carolina at Chapel Hill. His site focuses on infants identified as high riskby the state public health department’s infant tracking program. These
children constitute a birth cohort, recruited not for maltreatment history, but identified because of extreme poverty, young maternal age,
single parenthood, and low birth weight. A control group of unreported
children matched for gender, race, social class, and family composition is
also included in the research. Of special interest to this study is the extent
to which family stress and social support predict child maltreatment andsubsequent child outcomes such as school failure, adolescent pregnancy,
substance abuse, and criminal or violent behaviors.
■■ Alan Litrownik, PhD, is Professor of Psychology at San Diego State University. His site focuses on a cohort study of maltreated children who
were placed in foster care in the first 18 months of life and followed until
age 4. This study will examine kinship vs. non-family foster care, the consequences of re-unification, and the utilization and impact of health careand mental health services.
■■ Richard Thompson, PhD, is the Director of Research for the Juvenile Protective Association in Chicago, IL, and Assistant Professor at the University of Illinois at Chicago. His site focuses on comparing the life courseof infants whose families are receiving comprehensive services after a report of child maltreatment to infants of similarly-reported families who
have only received follow-up by the state welfare agency and to a control
group up of matched infants. This cohort is drawn from among the mostviolent neighborhoods in Chicago and will examine the differential impact of experiences of child abuse or neglect versus witnessing violencefrom the time of infancy.

132 Family Violence Research, Assessment and Interventions

INTERVIEW WITH DESMOND K. RUNYAN, MD, DRPH

The LONGSCAN Project
By James E. McCarroll
February 2010
Dr. McCarroll: You are one of the principal investigators of the LONGSCAN(Runyan & Litrownik, 2003). This landmark study is badly needed. What
have been the major topics of interest to your group?
Dr Runyan: First, we have looked at the antecedents and consequencesof abuse over time. Secondly, we have been involved in developing a set of
statistical growth modeling procedures to look at trajectories of the effects
of maltreatment. Are the children who were abused early the same kids that
continue to be abused? Does most of the risk happen to a smaller group of
kids? Are there kids who have a lot of maltreatment early and then nothinglater on and another group of kids who were doing pretty well early on andthen get maltreated later? A third set of questions is related to fathers and therole they play. A fourth set is focused on social capital. An example is related
to the impact of kids’ psychological development and later school completion and work history.
Dr. McCarroll: How did you arrive at your classifications of the types ofmaltreatment?
Dr Runyan: We re-coded all the Department of Social Services (DSS)
records using the system we developed for LONGSCAN, the Modified Maltreatment Classification System (MMCS), as opposed to taking DSS codes
because there was a fair amount of disagreement.
Dr. McCarroll: In your classification of maltreatment, what did you find in
the DSS records on the histories of maltreatment?
Dr Runyan: That is one of the issues we are wrestling with. The May 2005
edition of Child Abuse and Neglect [Volume 29, Number 5] was devoted
to the LONGSCAN and included measurement issues. So much of the literature just lumps abused kids together and compares them to non-abused
kids. We have DSS records of all different kinds of things over time for eachof them, but also at age 12, 14, 16, and 18 we have asked the kids about theirown experiences. It turns out that for many of the kids who told us they
were sexually abused, the authorities had no idea they had been sexually
abused. The other group that is a little harder to understand is the group ofkids where social services said they were sexually abused, but the kids said,Desmond K. Runyan, MD, DrPH 133

no, they were not. So, there is that lack of concordance. Overall, the concordance figures look pretty high because most kids were not sexually abused
and neither they nor DSS said so (Runyan, Cox, Dubowitz, et al., 2005). It
is really intriguing to think about the kids who were abused and were nottelling anybody about it or only told us about it.
Dr. McCarroll: The Army only codes sexual abuse as severe. Are you making
finer distinctions of sexual abuse?
Dr Runyan: That is an interesting question. A lot of people have published
about how sexual abuse is the most destructive of the different forms of abuse.
That is not what we found. So much of the impact of sexual abuse is determined not by the sexual abuse itself, but by the response of the people aroundthem, particularly the mother. It gets hard to sort out and decide, “Well, thisis worse than this.” For some kids, being fondled or having to cope with an
exhibitionist is incredibly tough for them. The traditional response is adulthorror at child sexual involvement, which I share, but at the same time, what I
think is salient and horrific about sexual abuse may not be shared by the kids
who are the victims when we are trying to look at outcomes.
Dr. McCarroll: That is terribly complex. Is this true in any other type ofmaltreatment?
Dr Runyan: I am currently looking at the kids’ mental health functioningat different ages to see which of the forms of exposure to violence or maltreatment is most salient in terms of its impact on later depression, anxiety,or aggression. For example, Jonathan Kotch (Kotch, Lewis, Hussey, et al.,2008) has published a paper showing that neglect in the first two years oflife is related to aggression at ages 4, 6, and 8. (See Review of LONGSCAN
Research and Building Bridges to Research for more information about thisstudy.) Our data has also shown that aggression at earlier ages is not associated with subsequent adolescent or adult aggression, but aggression at age 8
is predictive of older child and adult aggression.
At age 8, it looks like witnessing domestic violence is far more destructive
for kids’ mental health than either sexual abuse or physical abuse; there wasno relationship between neglect and depression and anxiety. When we repeated the same analysis with the kids at age 12, psychological maltreatment
was the most destructive for the kids. In a sense, all abuse is psychologicalmaltreatment. When an eight year old kid or younger is exposed to domestic
violence, I think that is actually a form of psychological maltreatment. The
person who protects you from the world and is your rock is not safe herself.
There is a lot more work to be done on refining the definition and measurement of psychological abuse, but it does seem to be promising.

134 Family Violence Research, Assessment and Interventions

Dr. McCarroll: How did you categorize neglect?
Dr Runyan: Our system has two categories of neglect: failure to provide
and failure to supervise. But, even those two categories may not capture allthat we want. At this point we are not actually seeing a lot of adverse impact
from neglect but, the lack of precision of measuring is part of the complexity. We are looking at parental monitoring and trying to measure family
functioning, such as unreasonable parental expectations, in an attempt tofind ways to improve the definition of neglect.
Dr. McCarroll: One needs to think about the nuances of childhood and adultmaltreatment.
Dr Runyan: That is right. When we looked at measurement we ended up
sorting out severity, type and the chronicity. Did it happen lifelong or was it
episodic? Was it at one point? Did it happen early in life or later in life? All
those seemed to lead to different outcomes.
Dr. McCarroll: What kinds of outcome data are you collecting?
Dr Runyan: We collect data in an annual telephone interview with theparents about their contact with social services in the last year. We also ask
the parent whether the child has been hospitalized or has been seeing thedoctor or other professionals for mental health or special education services.
We have completed data collection to age 14 and are not quite done with age
16. We have about 900 14-year olds, 760 16-year olds and 400 18-year olds
so far.
Dr. McCarroll: What new data will you present? Is anything being collected
at ages 16 and 18 that has not previously appeared?
Dr Runyan: We have gone back and asked about employment and work,school completion, and, at ages 16 and 18, asking the kids for their own selfreports about their maltreatment. The report that will be really useful is atage 18 when we do not have to tell them that we have to share information
with social services.
Dr. McCarroll: One of the results that might come out of this is some sense ofa life trajectory based particularly on early abuse.
Dr Runyan: That is a topic that we are interested in describing. A lot of
people think that kids who are maltreated are going to have a bad outcome.
We want to address risk. Right now it looks like about 35% of our kids escape pretty unscathed. About a similar percentage do not escape and are
pretty severely affected. The other 30% do not look red hot either. We are
excited about looking at the 35% that look really pretty good on all our mea-Desmond K. Runyan, MD, DrPH 135

sures. Were those kids looking pretty good all the way along? Are there kidsthat looked bad earlier and then that looked better? We are trying to follow
those pathways.
Dr. McCarroll: You also have non-maltreated kids, too?
Dr Runyan: Right. However, over the course of the study many of thosenon-maltreated kids have been maltreated. So, out of the original cohort of
1,354 kids, we have 188 kids who have never had any maltreatment reports.
Dr. McCarroll: What do you think has quick applicability to the maltreatment field? Has anybody picked up on any of your findings to either change
their policy or procedures or statutes?
Dr Runyan: I think what is most applicable is the impact of fathers. Even
the kids who live in “single families without fathers” have father figures.
There is some real applicability to social services, to think more carefully
about that. If you just ask the simple demographic question, “Is there a father in the home?” the answer is “No”. When you ask the kids if they havesomebody who is like a father, all the kids name somebody. Howard Dubowitz (2006) has published a number of papers on fathers.
Dr. McCarroll: Have any findings from LONGSCAN surprised you?
Dr Runyan: The first big surprise to me is how little impact we could findfor neglect. I was also surprised by the strength of the impact of domestic
violence exposure. Our data suggest that it is important for the kids’ ownneeds that we address that. We really cannot afford to operate separatelyfrom the folks who worry about domestic violence. We really need to beworking with them.
Dr. McCarroll: Thank you for your work and your leadership on the LONGSCAN study. It will be an important database for researchers and practitioners for years to come.
Dr Runyan: You are welcome.

136 Family Violence Research, Assessment and Interventions

Key Points
I am currently looking at the kids’ mental health functioning atdifferent ages to see which of the forms of exposure to violenceor maltreatment is most salient in terms of its impact on later
depression, anxiety, or aggression.
Even the kids who live in “single families without fathers” havefather figures. If you just ask, “Is there a father in the home?” theanswer is “No”. When you ask the kids if they have somebody who islike a father, all the kids name somebody.
Our data suggest that it is important for the kids’ own needs that we
address the impact of domestic violence exposure. We cannot afford
to operate separately from the folks who worry about domestic
violence. We really need to be working with them.

References
Dubowitz H. (2006). Where’s Dad? A need to understand father’s role inchild maltreatment. Child Abuse & Neglect; 30:461–465.
Runyan DK, Cox CE, Dubowitz, H, Newton RR, Upadhyaya M, Kotch JB,
Leeb RT, Everson MD & Knight ED. (2005). Describing maltreatment:
Do child protective service reports and research definitions agree?
Child Abuse & Neglect; 29:461–477.
Runyan DK & Litrownik AJ. (2003). Introduction to special issue: LONGSCAN and family violence. Journal of Family Violence; 18:1–4.

SECTION INTRODUCTION

Domestic Violence
The contributors to this section cover a wide variety of domestic violence
topics. Lee Badger and Mary Ann Forgey have separate interviews and research, but both are related to the assessment of domestic violence, particularly in a military environment. Among Dr. Forgey’s research interests is theeffect of domestic violence on military women. Dr. Badger has studied theuse of standardized clients in medical research and applied her knowledge
with Dr. Forgey to develop an evidence–based domestic violence assessment
curriculum for the Army.
Jacqueline Campbell is an international authority on the assessment of
dangerousness, particularly the risk of homicide, for female domestic violence victims. She also studies the effects of domestic violence on women’s
health in civilian and military environments.
Kevin Hamberger has devoted much of his research to developing typologies of domestic violence offenders. His work has been important inlearning about the role of anger in male offenders and the role that anger
plays in personality disorders, particularly those offenders with borderline
personality organization and borderline personality disorder.
Kathleen Kendall–Tackett has studied the effects of domestic violence on
women’s health. She has worked extensively in women’s health on topics thatare not traditional. For example, she recently completed a study on the relationship between breastfeeding, fatigue, sleep deprivation, depression, andtrauma history in new mothers.
Suzanne Swan is one of the few researchers to tackle the topic of women’s violence. This research has focused on the context of women’s violence
related to their victimization by their male partners, their experiences ofchildhood trauma, depression, anxiety, posttraumatic stress symptoms, andsubstance use. She has recently started a program to prevent dating violence
on a university campus.
Daniel O’Leary has also tackled a difficult topic, that of adult psychologi-

138 Family Violence Research, Assessment and Interventions

cal abuse (or psychological aggression). This type of maltreatment has beendifficult to define, but its effects are thought to be as harmful or more harmful in some circumstances that physical violence. His research has addressed
the context of psychological abuse and its relation to verbal arguments andphysical abuse.

INTERVIEW WITH LEE W. BADGER, PHD, MSW

Using Standardized Clients for Problem
Assessment
By John H. Newby, PhD
Joining Forces Joining Families Vol. 10, No. 2, August 2007
Dr. Badger discusses the use of standardized clients (SCs) to improve clinical competence. SCs are used in both training and testing environments.
The testing environments can range from examining students at various levels of training to “high stakes” evaluations such as admission to advanced training programs
in medicine and for licensure. Measures of student andstandardized client performance have been developed,
but there is little consensus on the merit of these measures due to the complexity of the concepts, costs, anddifferent clinical situations. The psychometric issues
required in using SCs are the same as in the development of other tests.
Among these are reliability, validity, scoring, cut-off points, and standard
setting. However, the picture becomes more complicated when using SCs
because one may measure both the SC and the trainee or examinee.
Dr. Newby: What led you to study standardized clients (SCs)?
Dr. Badger: When I became a member of the faculty of a medical school,
I saw SCs enacting an astonishing range of roles with multiple signs, symptoms, and behaviors. I also saw the possibility of their use in research. My
first project was an investigation of physicians’ assessment skills in the recognition and management of depression in primary care settings (Badger,
deGruy, Plant, et al., 1994; Badger, Plant, deGruy, et al., 1994). In this study,a panel of six SCs, each with a different presentation and level of depression, were presented to about 50 primary care physicians. Although detection was related to a greater amount of information gathered, inquiry about
the DSMIII-R symptoms was generally low, and in no case was sufficient140 Family Violence Research, Assessment and Interventions

information acquired to make a formal DSM-III-R diagnosis of depression.
The findings suggested that the detection of depression by primary care
physicians was low. I was later approached by a group at Dartmouth Medical School to participate in a study that used undisclosed SCs to study therecognition and management of depression in primary care. Most recently,
with a colleague at a school of social work in a study funded by the Fund for
the Advancement of Post Secondary Education in the U.S. Department of
Education, I applied SC methodology to the teaching of social work practiceto MSW students.
Dr. Newby: What do we know about the reliability and validity of SCs?
Dr. Badger: The reliability and validity of SCs are dependent on the accuracy of the case scenarios (validity) and the consistency with which the SC
enacts the scenario (reliability). The case scenario is the scripted narrative
to be enacted. The signs and symptoms must be consistent with each otherand with the disorder or problem that is being portrayed. The only way toensure this internal validity is to select real cases. If the narrative is basedon a real case, it cannot be argued that the signs and symptoms are incompatible or that the narrative has conflicting components. Reliability is also
performance-related. The SC should enact the role as scripted every time inexactly the same way.
Dr. Newby: How do you train SCs?
Dr. Badger: The training of SCs is very straightforward. Coaching generally involves three people: the coach (or researcher or teacher) who is incharge of the project, the SC, and the clinician who nominated the actual
case for use as an SC role. Only the clinician knows the actual behavior, tone,
and affect of the client that is to be portrayed.
Dr. Newby: Are there specific steps to structure case scenarios and prepareSCs for portraying their roles?
Dr. Badger: The most important thing is to be absolutely clear about the
purpose of the simulation. You have to decide whether you want to illustrate
a case of the greatest prevalence, if you want to portray a case that is atypical, or if you want to illustrate specific risk factors. After you are absolutely
clear about the research or educational objectives and what kind of case youwant to develop, you will ask clinicians to nominate cases. The next step isto develop the SC narrative from the agency or medical record, including all
facts relative to the assessment and treatment. The narrative should containa detailed social history, psychiatric and medical history, current symptoms,
physical signs and anything that might be relevant to the assessment andLee W. Badger, MSW, PhD 141

to your educational or research purpose. Finally, use the narrative to write
the SC script. It should contain a list of positive and negative cues, all extracted from the narrative, to provide the SC with guidelines for responding
to questions. Other than the opening statement, SC roles are usually notverbatim scripted. If there are parts you want to script verbatim, these must
be carefully crafted to sound true to the role. You want the SC to be naturalin making comments. You do not want to over-script them.
Dr. Newby: What are your thoughts about using professional versus nonprofessional actors?
Dr. Badger: I am very much in favor of using individuals who are notprofessional actors. I have used actors in the past and, while they are very
good at learning the roles, most actors are trained to project from a stage.
When you put them in a situation that would be equivalent to a therapist
making an assessment, they overact. They do not seem natural; they appear to be acting. I have used professional actors on a couple of occasions
for student evaluation, but I was not satisfied with them. I have used wellover 40 ordinary community people in one project or another and they are
remarkable in terms of how well they can take on a role and play anotherperson for a day.
Dr. Newby: What are the differences between role-play scenarios or otherexperiential instructional techniques, and using SCs?
Dr. Badger: Role-play is a very old tradition. It has been used with somesuccess for students in developing and rehearsing their skills in the presumed
safety of the classroom. However, in contrast to SC methodology, role-playreally lacks authenticity and internal validity and has additional educational
disadvantages. There are lots of methods of using role-play, but usually students enact roles about which they know little or nothing. Very often they do
not have any of the background or experience to understand situations fromthe client’s perspective. Even worse, they may disclose personal informationthat they might later regret.
Dr. Newby: Would you comment on your current Army Family Advocacy
Research with Dr. Mary Ann Forgey, who is also from the Graduate Schoolof Social Service at Fordham University?
Dr. Badger: The purpose of our study is to develop and evaluate the effectiveness of a training curriculum in evidence-based spouse abuse assessment and intervention planning using SC training and evaluation methodology. The effectiveness of the curriculum will be judged by the extent towhich the training program leads to the accurate identification of violence142 Family Violence Research, Assessment and Interventions

patterns, risk factors, and the development of assessment-driven differential
intervention plans.
Dr. Newby: How will that research improve assessments?
Dr. Badger: SCs will be useful because we want to make assessment andintervention curricula that are evidence-based. We searched the literatureand identified risk factors and the patterns and types of abuse. We can now
present SC cases that will best illustrate the empirically supported risk factors, consequences, and patterns of abuse. Through the use of SCs, we will beable to control what we present to trainees in a way that we could not using
either role-play or real clients. Our purpose is to make this curriculum portable so that it can be used at any installation that would like to benefit from
it. At this point we will pilot test it at Fort Bragg. During the late summer of
2007, we will recruit, coach and train our SCs before testing the effectivenessof our curriculum.
Dr. Newby: Other important aspects?
Dr. Badger: SCs can simulate client-clinician interaction with a high degree of realism. SCs eliminate the threat to students or trainees of unintended personal disclosures that happen when they are asked to enact therapist
and client roles. SCs can be incorporated into a wide range of curricularareas, such as assessment of mental health issues, services to children, andintimate partner violence. Very importantly, SCs offer the researcher or the
instructor control over the appearance, behavior, and content of teachingcases. SCs can ensure diversity among racial, ethnic, age, gender, religious,
sexual orientation, and socio-economic groups, and have a level of control
that you cannot possibly have in using role-play only. Another advantage
of using SCs is that when the simulation is over you can ask them about
their sense of the interaction and get their feedback. It gives the therapist in
training an enormous advantage to get all of this feedback. The use of SCs ishighly acceptable to students and trainees as a teaching tool.
Dr. Newby: Thank you Dr. Badger. We look forward to your research involving the use of SC in the assessment and planning of interventions for interpersonal violence that occurs in the Army.
Dr. Badger: You are welcome.

Lee W. Badger, MSW, PhD 143

Key Points
Standardized clients can be used in both training and testing
environments to improve clinical competence.
The reliability and validity of standardized clients are dependent
on the accuracy of the case scenarios (validity) and the consistency
with which the standardized client enacts the scenario (reliability).
You have to decide whether you want to illustrate a case of thegreatest prevalence, if you want to portray a case that is atypical, or
if you want to illustrate specific risk factors.

References
Badger LW, deGruy FV, Plant MA, Hartman J, Anderson R, Ficken R,
Gaskins S, Leeper J, Maxwell A, Rand E, Templeton B.(1994a). Psychosocial interest, medical interviews, and the recognition of depression.
Archives of Family Medicine; 3: 899–907.
Badger LW, Plant MA, deGruy FV, Anderson R, Ficken R, Gaskins S, Hartman J, Leeper J, Maxwell A, Rand E, Tietze P. (1994b). Patient presentation, interview content, and the detection of depression by primary care
physicians. Psychosomatic Medicine; 56: 128–135.

144 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF MARY ANN FORGEY, PHD

Knowledge into Action: Brief Review of
Research of Mary Ann Forgey, PhD
By John H. Newby, PhD
Joining Forces Joining Families, Volume 9, Issue 2, April 2006
How is research-based knowledge of intimate partner violence being usedby practitioners to facilitate the assessment process? Dr. Forgey seeks to answer this question by exploring the extent to which childwelfare social workers are using research-based knowledge about intimate partner violence in their risk assessment process. Using a focus group format, she plans to
ask child welfare practitioners in a large metropolitan
area 1) what they find critical to assess in intimate partner violence, 2) why they assess this specific content, 3)
how they collect their information, and 4) the role that
this information plays in their assessment, formulation, and intervention
processes.
Her interest in exploring how research knowledge is integrated into
practice also has an international focus. As a recipient of a Fulbright ScholarAward that took her to Dublin, Ireland, Dr. Forgey explored the extent towhich Irish social workers integrate domestic violence research into theirassessment process. She plans to compare data collected from U.S. child welfare workers with the data she collected in Ireland. The cross-national comparison will identify the similarities and differences between the two countries regarding the use of research knowledge in the assessment process, andthe supports and obstacles that were encountered. The comparative analysis
will further enhance the development of creative training strategies and assessment tools to strengthen practitioners’ ability to implement evidencedbased assessment in intimate partner violence.
Dr. Forgey stresses two important points. First, it is critical that we begin
to look at how practitioners integrate research knowledge into intimate part-146 Family Violence Research, Assessment and Interventions

ner violence interventions. Second, there is a need to better understand what
research-based knowledge is not being used and why. Her research is designed
to shed light on both of these issues.

Mary Ann Forgey, PhD 147

INTERVIEW WITH MARY ANN FORGEY, PHD

Domestic Violence: Understanding thePatterns, Consequences, and Risk Factors
By John H. Newby, PhD
Joining Forces Joining Families, Volume 9, Issue 2, April 2006
Dr. Newby: How did you get interested in domestic violence research in the
military?
Dr. Forgey: While the family advocacy program coordinator in Wiesbaden, Germany, in the 1980’s, I saw a range of domestic violence which
made me question the idea that it was a unitary phenomenon. That practice experience sparked my interest in research on the patterns of violence
within the Army. I believe research that identifies the patterns of violence
can depict a more accurate picture of what is happening and, therefore, ismore helpful for practitioners in planning services. Different patterns callfor different responses.
Dr. Newby: Much has been written about incorporating evidence-based
information into domestic violence interventions. What is evidence-based
practice?
Dr. Forgey: The current notion of evidence-based practice has focused
mostly on the practitioner’s use of intervention approaches that have empirical evidence of effectiveness. There has been a lot of debate about what
constitutes empirical evidence. Some individuals interpret empirical evidence narrowly and only consider the evidence of effectiveness emanatingfrom formal research studies. Others have a broader definition of empiricalevidence and include evidence from actual practice. This is often referred toas practice wisdom, expert opinion or authoritative knowledge. I do not believe we can rely on formal research evidence alone. We need to incorporate
practice wisdom, the systematic observations that practitioners make about
approaches that they see as effective.
Dr. Newby: How is evidence-based practice distinguished from evidencebased assessment?
Dr. Forgey: Evidence-based assessment is really one aspect of evidencebased practice. Evidence-based practice involves all phases of practice including engagement, assessment, contracting, and intervention. We need tofocus on the assessment phase of practice by making sure that areas explored148 Family Violence Research, Assessment and Interventions

during the assessment process are informed by up-to-date research and that
our interpretations of the data collected are also informed by this research.
Dr. Newby: From your experience, how is domestic violence research being
incorporated into assessments and interventions?
Dr. Forgey: The tool most frequently used to help the practitioner incorporate domestic violence research into assessments and interventions
is a protocol. A protocol provides guidance about what information to explore and often includes some standardized instruments. However, too often
protocols are not practitioner-friendly. To practitioners, a protocol can feel
more like a noose than a helpful guide. Protocols, for the most part, have
paid attention to what information to gather, but not to the process by which
it is gathered. Getting reliable information from clients is not just about theright questions, but also about how and when they are asked. This is why
practitioners need to be more involved in the development of protocols.
Dr. Newby: What are some of the contextual factors that should be considered in the assessment and treatment of domestic violence?
Dr. Forgey: There are three main areas of exploration necessary to understand the context of violence: (1) the pattern of violence, (2) the physicaland psychological consequences of the violence, and (3) the multi-level risk
factors involved. The pattern of violence includes such factors as type, level,
frequency, motivation, meaning and direction. Direction refers to whether
the violence is unilateral or bi-directional and whether the bi-directional
violence is asymmetrical or symmetrical. We also have to explore the physical and psychological consequences for each partner. The other areas of exploration are the multi-level risk factors: the individual, the family, and thesocio-cultural risk factors for domestic violence that have been identified
through research. For example, is there substance abuse involved? Is therea righteous attitude about violence on the part of the perpetrator? Is there
head injury? Is there a history of violence in the family of origin? Do one orboth partners have rigid sex role attitudes? Are there cultural supports or
impediments for the violence? Are there stressors such as unemployment
involved? Are there informal or formal support systems in each of the partner’s lives? Exploring these areas requires openness to the various causal
theories of domestic violence.
Dr. Newby: Are you describing the particular process that you use for linking
assessment data to improved domestic violence interventions?
Dr. Forgey: Exactly. This type of assessment in which you are using research on patterns, consequences, and risk factors to inform the areas youMary Ann Forgey, PhD 149

explore will yield important information about what type of interventions
would be most helpful. Unfortunately, the assessment process is often bypassed or the information gathered is ignored. There is often just one modelof batterer intervention available in many communities and only the interventions available are provided. We need to plan interventions based on theassessment that we have conducted.
Dr. Newby: Would it be helpful to have a theoretical or conceptual framework within which to base assessment and interventions?
Dr. Forgey: We need to be open to many theoretical perspectives when
we are trying to gather information for assessment, and when we try to interpret this information to understand a particular case situation. There areat least five theoretical perspectives about the causes of domestic violence.
The feminist perspective focuses specifically on male-to-female violence
and contends that factors that support male dominance in society are at theroot of the problem. Feminists see the empowerment of women through theprovision of resources such as housing, jobs, and strong legal sanctions forviolent behavior such as arrests, incarcerations, and orders of protection as
the most effective strategies to address male-to-female violence.
The social-cultural perspective recognizes both male and female violenceand explains domestic violence as a result of broader structural issues withinsociety that cause stress. Patriarchy, poverty, racism, societal isolation, andsocietal acceptance of violence are among these structural issues. Strategies
to address these issues are advocated by this perspective.
Intra-individual theories look at personal characteristics that could help
explain the violence. Substance abuse, personality disorders, and psychopathology have been put forth as causal or risk factors for violence. Intervention strategies try to address those specific dysfunctions.
Social learning theory contends that violence is a learned behavior and istransmitted from generation-to-generation. Intervention strategies focus on
unlearning the violent response and learning non-violent responses. Clientslearn ways to combat violence-producing cognitions by substituting newones and behavioral skills related to communication, stress management,
and help seeking.
Finally, family systems theory sees a couple’s inability to deal with relationship issues as the root of the problem. According to this perspective theescalation of relationship conflict often culminates in a violent response fromone or both partners. So preventing the escalation of conflict by changing thecouple’s interaction pattern is the major intervention from this perspective.
During the data-gathering phase of assessment, we need to be open to exploring the variables associated with each of these theoretical perspectives.

150 Family Violence Research, Assessment and Interventions

Dr. Newby: What was the context or patterns of violence found in your recently completed study of violence against Army women married to civilian
husbands?
Dr. Forgey: We found that 60% of all the violence reported was both bidirectional and of equivalent severity. However, when we looked at the other
40%, the enlisted female was much more likely to be the victim of unilateral
violence (Forgey & Badger, 2006). They were also four times more likely to
be victimized by minor unilateral violence, and three times more likely to be
subjected to severe violence and injury as a result of unilateral violence frommale partners. They were two times more likely to experience asymmetrical bi-directional violence. This means that the violence perpetrated againstthem was at a higher level than that which they perpetrated. One of the mostsignificant findings was that the enlisted females in the bi-directional severe
violence groups reported a significantly higher level of depression and hadsignificantly higher rates of child sexual abuse histories. We need more research in the area of bi-directional violence.
Dr. Newby: Are you planning further research on domestic violence in the
Army?
Dr. Forgey: I would like to examine the extent to which practitioners areusing intimate partner violence research on patterns, consequences, and risk
factors to inform their assessments and to develop tools and training methods to better support practitioners in the knowledge-to-practice transfer. I
would also like to pilot a training method using standardized clients to see
if this would help practitioners understand and apply research on intimate
partner violence to the assessment process.
Dr. Newby: Thank you, Dr. Forgey, for this interview.
Dr. Forgey: You are welcome.

Mary Ann Forgey, PhD 151

Key Points
Getting reliable information from clients is not just about the rightquestions, but also about how and when they are asked.
There are three main areas of exploration necessary to understand thecontext of violence:■■ The pattern of violence,■■ The physical and psychological consequences of the violence, and■■ The multi-level risk factors involved.  
Exploring the patterns, consequences, and risk factors for domestic
violence requires openness to the various causal theories ofdomestic violence. If we too rigidly adhere to one theory overanother, we may not be open to exploring all the patterns, theconsequences, or the risk factors that do not support our particulartheory.

References
Forgey MA & Badger L. (2006). Patterns of intimate partner violence
among married women in the military: Type, level, directionality andconsequences. Journal of Family Violence; 21: 369–380.
Additional References							[Editors note: The references provided are classic articles and books for thetheories discussed by Dr. Forgey and are not meant to represent current
academic positions on these theories.]
Giles–Sims J. (1983). Wife Battering: A Systems Theory Approach. New York:
Guilford.
Hamberger LK & Hastings JE. (1991). Personality correlates of men whobatter and nonviolent men: Some continuities and discontinuities. Journal of Family Violence, 6:131–147.  
O’Leary KD. (1988). Physical aggression between spouses: A social learning theory perspective. In VB Hasselt, RL Morrison, AS Bellack, & M
Hersen.(Eds.). In Handbook of family violence. New York: Plenum Press.
Straus MA, Gelles RJ, & Steinmetz S. (1986). Societal change and change
in family violence from 1975–1985 as revealed by two national surveys.

152 Family Violence Research, Assessment and Interventions

Journal of Marriage and the Family, 48:465–479.
Yllo K & Bograd ML. (1988). Feminist Perspectives on Wife Abuse. Newbury Park, CA: Sage Publications

INTERVIEW WITH MARY ANN FORGEY, PHD, AND LEE BADGER,
PHD, MSWThe Development and Evaluation of
an Evidence-Based Domestic Violence
Assessment Procedure for the Army
By James E. McCarroll, PhD
February 11, 2010
Drs. Forgey and Badger conducted a project to develop improved assessment
procedures for Army social workers responsible for domestic violence assessment interviews. The project, entitled The Development and Evaluationof a Training Curriculum in Evidence
Based Spouse Abuse Assessment, wasconducted from October 2006 to December 2008. The following description of the project and its phases isthe editor’s abbreviated version of theexecutive summary of the researcher’s final report (Forgey & Badger, 2008).
The rationale for the project was based on the assumption that US soldiers returning from Iraq and Afghanistan are dealing with a myriad ofhealth, mental health and substance abuse issues that put them at high risk
for a range of relationship problems, including intimate partner violence(IPV). Increased understanding about how to assess and intervene in IPVamong returning soldiers and their families is critical. In response to thisneed, this study first developed an IPV evidence-based assessment protocol
and training curriculum for Army social workers and subsequently evaluated both using standardized client and evaluation methodologies.
The study involved five phases:■■ Development of an expert panel to consult on current IPV and researchissues.

154 Family Violence Research, Assessment and Interventions■■ Revision of current Army spouse abuse procedures based on a review of

the research literature.
■■ Development of the training curriculum and training evaluation tools
using standardized client methodology.
■■ Implementation and evaluation of the pilot training curriculum.
■■ Analysis of curriculum effectiveness, revisions to the training curriculum and dissemination planning.
PHASE 1: Development of an Expert Panel
The expert panel consisted of persons from both the Army and fromacademic institutions with a strong history of IPV research and/or practice.
The expert panel consulted on all phases of the study. A total of five meetings
were held with the expert panel during the course of the study.
Phase 2: Revision of current Army spouse abuse procedures based on areview of the research literature.
An extensive literature review was conducted on patterns of IPV, risk
factors and consequences in both civilian and military populations in orderto develop an evidence-based assessment protocol. Based on the literature
review and a review of the Army’s current IPV assessment form, the expert
panel recommended essential content to explore in an IPV assessment. The
expert panel also recommended specific standardized measures to use within the assessment process. The result of this process was the development offour IPV assessment forms (Intake, Review of Pre-Interview Information,
Structured Interview, and Formulation) and an Interview Process Guide.
PHASE 3: Development of the training curriculum and training
evaluation tools using standardized client methodology.
Following the development of the IPV assessment protocol, the study
moved into the third phase: the development of a pilot curriculum to trainsocial workers in the implementation of the evidence-based assessment protocol. The pilot curriculum consisted of four components: a didactic component, experiential component, and pre-test and post-test components for
curriculum evaluation. Tools to evaluate the effectiveness of the training, an
IPV knowledge test, and an interview content and process checklist werealso developed during this phase.
The didactic component of the pilot curriculum focused on what to explore in the assessment of IPV, the empirical basis for this exploration, andhow to best explore this content using evidence-based assessment methods
and interviewing skills. The literature review conducted during Phase 2 informed the content presented within the didactic component. A DVD of aMary Ann Forgey, PhD, and Lee W. Badger, MSW, PhD 155

demonstration IPV assessment interview was also produced for use during
part of the didactic component. In the demonstration DVD, the Principal
Investigator conducted sequential interviews with a standardized client wifeand husband pair using the new evidence-based assessment protocol.
The experiential component of the pilot curriculum was designed to provide an opportunity for the participants to practice conducting evidencebased assessments with standardized clients. These standardized clients enacted client roles based on real case material from Army records. Four casescenarios, involving a total of eight husband and wife client roles, were developed from archived Army case records that fit typical Army IPV clients,
in demographics, violence type, and risk factors.
PHASE 4: Implementation and evaluation of the pilot training
curriculum
During this phase of the study, the pilot curriculum was implemented
by social workers from an social work clinic at an Army installation. Eightvolunteer social workers received the pilot curriculum from the investigators over a three day training period. Three days prior to the social worker
training, eight standardized clients received intensive training in the enactment of their client roles.
PHASE 5: Analysis of curriculum effectiveness, revisions to the training
curriculum, and dissemination planning.
The effectiveness of the pilot curriculum was measured by analyzing differences in participants’ pre-training and post-training IPV knowledge andIPV assessment interviews. A knowledge test, made up of twenty true-false
and multiple choice questions based upon the empirical IPV literature, wasadministered at pre-test (before the training) and at post-test (immediately
following the training). Questions addressed IPV patterns, risk factors, consequences, and the assessment process. Following each of the twenty questions, there was a rating scale to indicate how confident the social worker
was in her answers.
Knowledge test results indicated that the participants’ knowledge about
IPV patterns, risk factors and assessment methods increased from pre- topost-test. A paired t-test comparing the pre-test and posttest scores, despite
the small sample, showed a close to significant increase from pre-test to
post-test on the correct answers (t=2.25, p=.059) and a significant increasein the confidence scores (t=4.64, p=.002).
The videotaped interviews were analyzed using a qualitative researchdata analysis software system. An assessment interview checklist was developed for the purpose of creating a code list and attaching scores, or ratings,

156 Family Violence Research, Assessment and Interventions

to the videotaped assessment interviews. Per-item codes for the various content areas within the assessment interview (Presenting Incident, History of
IPV, and Background Content Areas) were created. In addition, per-item
process codes were created for four interview segments (opening process,presenting incident process, background information process, and closing
process). Once the interview was coded, two independent raters observed
all interview segments pertaining to the particular content or process item.
The raters were blind to the pre- or post-test status of the interview being
observed. The ratings were of three types, measured along a three point scale(0, 1, 2) for each item: quantity rating (the amount of exploration), quality
rating (the thoroughness of the exploration of the information) and criticalcontent rating (the thoroughness of exploration of content areas critical toa thorough understanding of the particular case). Interviewing skills wererated in terms of quality, that is, how well they were used.
Analysis of the rating results of the pre-test and post-test assessment interviews indicated that at post-test the participants’ exploration of the majority of evidence-based risk factors for intimate partner violence increased
in both quantity and quality. The quality ratings for all of the interviewing
process skills showed an increase at post-test. Content and skill areas that
did not improve at post-test were also highlighted as part of the analysis.
Based on these results, revisions were made to the Assessment Handbook, Trainer Manual, Participant Manual and Case Manual. Revisions
aimed to strengthen IPV assessment knowledge and interviewing skills that
had not improved at posttest. A major curriculum revision involved the expansion of the curriculum from a 3-day to a 5-day model. This expansion
will allow more time for the participants to review and analyze their videotaped interviews in relation to the content explored and the interviewing
skills used. Key teaching points for each case scenario were also developed
for the trainers so that they could more systematically integrate the researchknowledge from the didactic component into this review process.
Due to the evidence of the pilot curriculum’s effectiveness, the expert
panel recommended dissemination of the revised 5-day training curriculum
to all Army Family Advocacy Program social workers by the Army. Plans forthis training are in progress.

Mary Ann Forgey, PhD, and Lee W. Badger, MSW, PhD 157

Key Points
US soldiers returning from Iraq and Afghanistan are dealing witha myriad of health, mental health and substance abuse issues that
put them at high risk for a range of relationship problems, including
intimate partner violence (IPV).
Drs. Forgey and Badger conducted a project for the Army todevelop improved assessment procedures for Army social workers
responsible for domestic violence assessment interviews.

Reference
Forgey MA & Badger LM. (2008). The development and evaluation of a training curriculum in evidence based intimate partner violence assessment.
Project executive summary. Unpublished document.

158 Family Violence Research, Assessment and Interventions

INTERVIEW WITH MARY ANN FORGEY, PHD, AND
LEE W. BADGER, PHD, MSW

Research Procedures in the Development
and Evaluation of an Evidence-Based
Domestic Violence Assessment for the Army
By James E. McCarroll
Interview conducted 11 February 2010
Dr. McCarroll: In your previous interviews in the Joining Forces Joining
Families Newsletter, you described concepts that you used in your researchon the development and evaluation of the training curriculum in evidencebased intimate partner violence (IPV) assessment that you recently completed. [Editor’s note: See Dr. Forgey’s interview on evidence-based domestic
violence research and Dr. Badger’s interview on the use of standardized clients in education and research programs.] I would like to hear your thoughts
on highlights of your recent research.
Dr. Badger: You hear a lot about evidence-based practice being applauded by many disciplines, but I think it is important that people know how to
go about actually developing it, which we did in our project.
Dr. Forgey: Also, what is different about this project is that it is an example of evidence-based practice by an organization, rather than the individual
practitioner. In this instance, the Army developed an evidence-based assessment protocol for use by its practitioners. It was really an organizational
effort.
Dr. Badger: This approach makes logical sense, rather than having eachpractitioner working as an island and applying the evidence solely to his/her
own micro-practice.
Dr. Forgey: What is also somewhat unique about this project is that it had
input from an expert panel made up of both researchers and practitioners.
Dr. McCarroll: Let’s talk about your trials and triumphs in each phase of
the project.
Dr. Forgey: A critical element was the development of the expert panel
to begin the work, the first phase. The next phase was the review of the literature, and, based upon that review, revising what the Army was currently
doing with regard to domestic violence assessment. The third phase was thedevelopment of the assessment protocol and the training curriculum, thelatter using standardized client methodology. In the fourth phase, we imple-

Mary Ann Forgey, PhD, and Lee W. Badger, MSW, PhD 159

mented the curriculum. Phase five consisted of the analysis of the effectiveness of that curriculum.
Dr. McCarroll: We can discuss each one of them. One sees many literature reviews. People might say, “Haven’t people already done this?” How did
you do it and what did you learned by your approach?
Dr. Forgey: There were wonderful reviews in 2001 of the risk factors formale-to-female and female-to-male violence including physical, sexual, andpsychological abuse (Schumacher, Slep, & Heyman, 2001; Black, Heyman,& Slep, 2001; Schumacher, Feldbau-Kohn, Slep, & Heyman, 2001).We built
our literature review on their work and then focused on the IPV risk factors,
that have been identified since that time, with a particular focus on military
related risk factors.
Dr. McCarroll: What did you pursue subsequent to those reviews?
Dr. Forgey: Some of most important risk factors identified subsequent to
the 2001 reviews included traumatic brain injury and posttraumatic stressdisorder. We also explored the literature on deployment and its relation todomestic violence. We really concentrated on the military-specific literatureand military-specific risk factors for our protocol.
Dr. Badger: The literature review had several chapters. In addition to thecontent that needed to be explored in an assessment, we also needed to lookat information on structured versus unstructured interview techniques, assessment of lethality, and how standardized instruments are used. All thesewere researched factors that ultimately went into the decisions about the
optimum interviewing process.
Dr. Forgey: We divided the literature review into two major parts. One
was to answer the question of “What does a social worker need to explore?”
The second question was “How do you go about asking about domestic violence and its risk factors?” This second question brought us into the literatureon the standardized measures that exist for the different risk factors and how
useful they might be in an assessment interview. It also helped us answer thequestion of how best to assess the level of risk, the level of danger. One ofthe debates that we had was to what extent should standardized measures
be used? Should the social worker just administer the actual standardized
measure during the interview or should the inquiry about a particular risk
factor take place in a different way?
Dr. McCarroll: How did you solve that problem?
Dr. Forgey: We made the standardized measures that exist for the various risk factors (e.g. PTSD, TBI, substance use, depression) available to the160 Family Violence Research, Assessment and Interventionssocial workers in a supplemental guide to the protocol. But we left it to theirclinical judgment as to when to use the actual instrument in the interview.
For example, it was clear during the interview that the service member was
experiencing some symptoms of PTSD, the social worker may at that point
decide to administer that particular standardized measure.
Dr. Badger: Rather than just have it happenstance that the social worker
would choose one of the risk assessment instruments to assess the level ofdanger or lethality, we developed a checklist of all of the common items
found on selected risk assessment instruments that have been found to bevalid and reliable.  
Dr. Forgey: The expert panel did not think there was any one risk assessment instrument in particular that we should use since none of the existingrisk assessment instruments had been validated for a military population.
Instead we developed a checklist of the common items on risk assessment
instruments that had the best evidence of effectiveness. The checklist was atool to help workers evaluate the level of risk based on what they had learned
about the client’s situation. But, as its name implies, it is a checklist and nota scoreable instrument.
Dr. Badger: This checklist was one of the most highly regarded parts ofthe protocol by the social workers. They loved having that at the end as partof the formulations process when they summarized what they had been doing and what they had learned. They found it extremely helpful.
Dr. Forgey: I want to stress that the checklist was part of their formulation process. Following the interview the social worker was asked to analyze
and synthesize the information gathered during the interview. An actual
formulation form was developed to assist them in this analytic process. Imbedded in the formulation form was the checklist to help them assess theoverall level of risk in this case.
Dr. Badger: The formulation form also served as a summary of the hourlong social worker’s interview. At this point their head is swimming with all
this information. The formulation form was a way to summarize and capture that information in one place.
Dr. Forgey: Also, what can not be stressed enough is that the formulation form was an analytic tool to help the social workers identify the majorintervention issues and to determine the level of risk. The checklist that wasa part of the formulation form was designed to help them think about thelevel of risk  
Separate from the formulation form there was also a structured interview outline that included the interview content recommended for their
exploration. It was developed as a cheat sheet for the workers to use while
conducting the interview. It also got a lot of praise from the workers. They

Mary Ann Forgey, PhD, and Lee W. Badger, MSW, PhD 161

recommended that we actually laminate it because they wanted it at theirside during the interview.
Dr. Badger: I think they had also grown accustomed over the years tohaving a great deal of paper work on their lap during the actual interview
and they were at first uncomfortable with the fact that we were suddenly
presenting them with a whole different way of behaving that was more orless paperless during the time of the interview.
Dr. Forgey: The problem, though, and we could see it coming, was thatin spite of being freed from doing all that paperwork during the interview
itself, they still needed time subsequent to the interview to record all they
had learned. Often, what we heard from them is that they do not always havethe time right after the interview to gather their thoughts, summarize what
they learned and complete the formulation part of the assessment. That is an
issue that still needs to be resolved. If workers do an interview where they
are freer to use their clinical skills to explore certain areas, then they have tohave time after the interview to summarize and analyze what they learned.
Dr. Badger: They were really quite excited about using their clinical skills
more during the interview process. They found that they could conduct interviews without depending upon all that paperwork to guide them.  
Dr. Forgey: That gets us to the development and implementation of theassessment training curriculum, the third and fourth phase of the project.
After we developed the assessment protocol, we then had to develop a curriculum to train the social workers in how to use it, phase three. In phasefour we implemented this training curriculum.
We developed an evidence-based assessment protocol. But, as I said earlier, instead of just giving it to the workers, we were faced with the question,“OK. What would be the best way to train them in the use of it?” That iswhere the standardized clients came in. There was also another important
issue with the development of the curriculum: we wanted the workers to
become familiar with what we had learned from our literature review so thatthey would have a better appreciation of why they were exploring certain
areas. So, in addition to the use of standardized clients in the training, webuilt in a didactic component in addition to the experiential component that
informed them as to “the why” of the assessment.
Dr. Badger: For example, in the content area: “Why am I asking aboutalcohol?” “Why am I asking about brain injury?” “What is the research
evidence for including this?” Hopefully, we were developing more criticalthinkers. They were not asking just because they had to ask, but because they
had a better understanding why a topic was important. That was a struggle
with the curriculum. How do you teach practitioners? They are practitioners
because that is what they want to do. They do not want to be researchers.

162 Family Violence Research, Assessment and Interventions

Dr. McCarroll: What were the critical points in teaching them to workwith standardized clients in the training program?
Dr. Forgey: Most importantly, we developed realistic cases that werebased on real case material and grounded in the research literature.
Dr. McCarroll: Your curriculum consisted of cases that were written to reflect
the current Army family advocacy program clients and standardized clients.
You did a pre-test consisting of a knowledge test for their understanding of
the evidence and interviews of the standardized clients by the social workers
to assess their baseline assessment skills. The pre-test was followed by a didactic component and then an experiential component using standardizedclients. At the end, there was a post-test that included both a knowledge test
and an assessment interview. Is that correct?
Dr. Forgey: Yes. And as part of the training curriculum, the new assessment protocol was also presented to them. Interwoven into this presentation was the research evidence for the decisions made within the protocol
about what content to explore and the best way to explore it. Our purpose
was to make them more informed practitioners as to why and how they
were exploring certain areas with the hope that they would have a better
appreciation for the protocol itself. Once they understand the basics of the
protocol, we then had them practice interviewing using the protocol withthe standardized clients.  
Dr. Badger: The evaluation of the training was complex. All of the social workers completed the knowledge pre- and post-test. Half of the social
workers did the pre-test interviews. The other half did the post-test interviews. We used the same cases for pre- and post-tests, but the interviews
were done by different social workers. But, we were not specifically evaluating the social workers; we were evaluating the training. It is best not to thinkin traditional evaluation research language when the sample is just eightpeople. But, we did evaluate the training.
All the assessment interviews were videotaped for two reasons. First,
for evaluation purposes, but also for them to review their work. We evaluated 16 hours of videotaping very systematically using a qualitative researchanalysis software package
Dr. Forgey: Key to the analysis process was the development of an interview checklist that allowed the research assistants to evaluate the information obtained during the interview and the interviewing skills used. In otherwords, to evaluate the content and process of the interview we evaluatedwhat they learned during the interview about the dimensions of violence,
the risk factors in each particular case, and how they learned this information — what interviewing skills were used. Since we developed the cases

Mary Ann Forgey, PhD, and Lee W. Badger, MSW, PhD 163

we knew everything that was in them about the pattern of violence and thekinds of risk factors in that case. By using the interview check list, we could
evaluate how much of this information the social worker was able to obtainduring the interview.
It is also important to mention that we tried to ensure that the cases
selected were as typical as possible of family advocacy cases in relation to
the demographics, patterns of violence and risk factors. We analyzed thedata from the Army Central Registry to come up with the most typical caseprofiles.
Using standardized client methodology in the training curriculum alsomeant that we had to select and train the eight standardized clients to takeon the roles of husband and wife in the four cases. We selected the standardized clients to match the demographic characteristics of the cases. They
also had to have some knowledge of the military, either from being in the
military or being the spouse of a military member, so that they could more
realistically portray these clients.
Dr. McCarroll: We have discussed the role of the expert panel, your literature review, the development of the assessment phase and the formulation,
the selection and training of standardized clients, the training of the social
workers, and the evaluation of the curriculum.
Dr. Forgey: The final step was our recommended changes to the curriculum based on the analysis of the knowledge test and interview data, as wellas the feedback received from the social workers. One of the major recommended changes based on this analysis was that that the training needed tobe five days, not three. More time was clearly needed for the social workers
to review their standardized client interviews and more time was also needed to integrate the didactic training material, especially about risk factors,
back into the case interview follow-up discussion.  
Dr. Badger: That is really critical. One of the problems of teaching aboutrisk factors in the classroom is that it is just that. It is not real life. When you
have a standardized client in front of you and they are very persuasive, it islike having a real client. Then, suddenly, it does matter.
Dr. Forgey: Both the didactic and experiential components were equallyimportant but more integration of them was needed. The up-front didactic
presentation of the research evidence about violence patterns and risk factors set a foundation. This foundation was then built upon by having a live
interview with a standardized client where the social worker can actuallyexperience some of the research information conveyed in the didactic component. The subsequent discussion of the live interview is where the true
integration of the didactic and experiential component can happen. As the164 Family Violence Research, Assessment and Interventions

worker discusses what they learned or didn’t learn about the particular pattern of violence or risk factor(s) during the interview, the research evidence
about that pattern or risk factor can be woven into that discussion. If thecurriculum is lengthened from three to five days, we would have more timeto have these kinds of integrated discussions.
Dr. McCarroll: But, what you are also bringing out is how you used standardized clients. You are talking about training people to work with a realsituation and a real live person.
Dr. Forgey: Yes, we are. There could also be other delivery formats forthis type of training. We delivered this training in a total face-to-face format.
The subsequent discussion of each videotaped interview, however, does notnecessarily have to be done face-to-face. The social workers could analyze
and discuss their interviews in the comfort of their offices. They could dotheir own analysis and share it with their co-workers on-line.
Dr. McCarroll: You could also think about having an interactive system
where they could ask you questions about content or method as they analyzed their interviews on-line.
Dr. Forgey: Yes, this would be another possibility and the military is certainly an organization that has a lot of expertise in the area of on-line learning.
Dr. McCarroll: Thanks to both of you for your time and for your diligent
work in accomplishing a very complex and demanding project.
Dr. Forgey/Dr. Badger: Thank you. You are welcome.

Mary Ann Forgey, PhD, and Lee W. Badger, MSW, PhD 165

Key Points
You hear a lot about evidence-based practice being applauded bymany disciplines, but I think it is important that people know how
to go about actually developing it, which we did in our project.  
One of the debates that we had was to what extent should
standardized measures be used? Should the social worker justadminister the actual standardized measure during the interview
or should the inquiry about a particular risk factor take place in adifferent way?
The formulation form was an analytic tool to help the social workers
identify the major intervention issues and to determine the level ofrisk.  If workers do an interview where they are freer to use their clinicalskills to explore certain areas, then they have to have time after theinterview to summarize and analyze what they learned.
One of the problems of teaching about risk factors in the classroom
is that it is just that. It is not real life. When you have a standardizedclient in front of you and they are very persuasive, it is like having areal client. Then, suddenly, it does matter.

References
Schumacher JA, Slep AMS, & Heyman RE. (2001). Risk factors for male–to–female partner psychological abuse. Aggression and Violent Behavior;
6: 255–268.
Black DA, Heyman RE & Slep AMS. (2001). Risk factors for male–to–female partner sexual abuse. Aggression and Violent Behavior; 6: 269–280.
Schumacher JA, Feldbau–Kohn S, Slep AMS, & Heyman RE. (2001). Risk
factors for male–to–female partner physical abuse. Aggression and Violent Behavior; 6: 281–352.

166 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF JACQUELYN C. CAMPBELL,
PHD, RN, FAAN

Abuse of Active Duty Military Women
By James E. McCarroll, PhD, David M. Benedek, MD, andRobert J. Ursano, MD
Joining Forces Joining Families Volume 9, Issue 4, October 2006
Dr. Campbell has pursued a wide variety of research interests with a focus onunderstand­ing domestic violence. She has an extensive bibliography including such topics as domestic violence during pregnancy(Campbell, Garcia-Moreno, & Sharps, 2004), healthconsequences of intimate partner violence (Campbell,2002), lethality and other risks of domestic violenceagainst women (Campbell, 2004), and abuse of military
women (O’Campo, Kub, Woods, et al., 2006).
Decades of research have demonstrated that women who have been abused report a higher prevalenceof health problems, including mental health symptoms, than non-abused
women. Campbell’s review of this topic (2002) described the health consequences of physical or sexual assault as increasing the incidence of injury,
chronic pain, gastrointestinal and gy­necological diseases, depression andposttrau­matic stress disorder (PTSD). She also noted that intimate partner
violence has been found worldwide in 3-13% of pregnancies with detrimental outcomes to mothers and infants. She recommended increasing assessment and intervention in health care settings for intimate partner violenceagainst women.
Much of Dr. Campbell’s research has been on the prediction of the riskof homicide of women. She helped develop the Danger Assess­ment (DA)screening instrument. Her recent research on the murder of women is basedon a 12-city study of women who were killed or al­most killed by an intimate partner (Campbell, Webster, Koziol-McLain, et al., 2003; Campbell,2004). Based on her research, Campbell gives suggestions for safety plan-

168 Family Violence Research, Assessment and Interventions

ning and risk assessment for the criminal justice and health care systems,
and for advocates. She notes three types of risk that are commonly assessed,
but urges caution because they are often confused. These risks are: reassault,
lethality, and safety. Abused women themselves are good predictors of reassault, but usually the prediction can be improved by the use of an instrument (Heckert & Gondolf, 2002). Importantly, she notes that if a woman’s
perception of risk is very high, her assessment is more important than any
other factor. However, if it is low then a lethality as­sessment, such as with
the DA, becomes more important since it gives her additional informationthat she might not have previ­ously considered. In another commentary on
risk assess­ment of severe interpersonal violence against women, Campbell
notes that strate­gies for assessment are not either-or enterprises. In otherwords, the assessment instrument alone should not be the sole basis of decision-making at the present time. She recommends a combination of thejudgment of an experienced professional, a well-validated instrument, andthe input of the abused woman as the best approach to lethality assessment(Campbell, 2005).
While PTSD and depression have been studied as outcomes of abuse,
their co-morbid­ity has received less attention. Campbell and colleagues(O’Campo, Kub, Woods, et al., 2006) studied the prevalence of PTSD anddepression in abused and non-abused civilian and military women in asample of 2,005 civilian and 616 military women. They found the prevalenceof mental health symptoms was higher among abused than non-abused
women. Thirty-four percent of abused civilian women and 25% of abused
military women had symptoms of PTSD, depression, or both compared to
18% of non-abused civilian women and 15% of non-abused military women. Co-morbidity of PTSD and depression was more common in civilian
abused women than in abused women in the military. The authors notedthat military women are less likely than civilian women to have psychopathology because entrants for military service are screened for mental illness
and those with mental health problems are likely to be discharged.
In a separate study of the same sample, Gielen et al. (2006) reported thebeliefs of active duty military women about routine screening for domestic
violence by health care providers and the mandatory reporting of domestic
violence to commanders. At the time this research was conducted, reporting of domestic violence to commanders was manda­tory. The majority of
respondents supported mandatory reporting, but also recognized that there
were negative as well as positive conse­quences in terms of safety, privacy,
autonomy, and conflicts between personal and profession­al (career) priorities. However, abused women were much less likely to agree with mandatory
reporting. The authors concluded that much more work needs to be doneJacquelyn C. Campbell, PhD, RN, FAAN 169

on gaining an understanding of the complexities of women’s perceptions ofdomestic violence reporting policies in the military.
Key Points
If a woman’s perception of risk is very high, her assessment is more
important than any other factor. However, if it is low than a lethality
assessment such as the DA, becomes more important since it gives
her additional information that she might not have previously
considered.
Dr. Campbell notes that strategies for assessment are not either-or
enterprises and recommends a combination of the judgment of anexperienced professional, a well-validated instrument, and the inputof the abused woman as the best approach to lethality assessment.
Thirty-four percent of abused civilian women and 25% of abused
military women had symptoms of PTSD, depression, or bothcompared to 18% of non-abused civilian women and 15% of nonabused military women.

References
Campbell JC. (2002). Health consequences of intimate partner violence.
Lancet, 359:1331–1336.
Campbell JC. (2004). Helping women under­stand their risk in situations of
intimate partner violence. Journal of Interpersonal Violence, 19:1464–
1477.
Campbell JC. (2005). Commentary on Websdale. Violence Against Women,
9:206–1213.
Campbell JC, Garcia–Moreno C, & Sharps P. (2004.) Abuse during pregnancy in indus­trialized and developing countries. Violence Against
Women, 10:770–789.
Campbell JC, Webster D, Koziol–McLain J, Block C, Campbell D, Curry
MA, Gary F, Glass N, McFarlane J, Sachs C, Sharps P, Ulrich Y, Wilt SA,
Manganello J, Xu X, Schollenberger J, Frye V, & Laughon K. (2003). Risk
factors for femi­cide in abusive relationships: Results from a multisitecase control study. American Journal of Public Health, 93:1089–1097.
Gielen AC, Campbell J, Garza M, O’Campo P, Dienemann J, Kub J, Jones170 Family Violence Research, Assessment and Interventions

AS, & Lloyd, DW. (2006). Domestic violence in the military: Women’s
policy preferences and beliefs concerning routine screening and mandatory reporting. Military Medicine, 171:729–735.
Heckert DA & Gondolf EW. (2004). Battered women’s perception of risk
factors and in­struments in predicting reassault. Journal of Interpersonal
Violence, 19:778–800.
O’Campo P, Kub J, Woods A, Garza M, Jones S, Gielen AC, Dienemann J, &Campbell J. (2006). Depression, PTSD, and comorbidity related to intimate partner violence in civilian and military women. Brief Treatment
and Crisis Intervention, 6:99–110.

Jacquelyn C. Campbell, PhD, RN, FAAN 171

INTERVIEW WITH JACQUELYN C. CAMPBELL, PHD, RN, FAAN

Abuse of Active Duty Military Women
By John H. Newby, MSW, PhD
Joining Forces Joining Families Volumne 9, Issue 4, October 2006
Dr. Newby: How did you become involved in the study of intimate partner
violence (IPV) in the military?
Dr. Campbell: My first studies of domestic violence were of homicide
against women. I found that the majority of women who were killed in thiscountry were killed by a husband, boyfriend, ex-husband, or ex-boyfriend. I
was collaborating with someone who was active duty Army when a request
for proposals came out regarding the health of active duty military women. I
was interested in how much abuse these women were experiencing. Up until
then, research focused on active duty male service members abusing theircivilian spouses. There was almost nothing in the literature about the abuseof active duty military women. Data for that study were collected from January 1998 through October 2000.
Dr. Newby: Would you give us a brief summary of that research?
Dr. Campbell: We found that the preva­lence of physical and sexual IPV
among the military women sampled was 21.6% during their military service. It was not well known at the time that military women experienced
abuse. During military service, perpetrators of abuse were: other active
duty military members (43.2%), civilians (18.5%) and retirees (38.4%).
Emo­tional abuse is not included in the 21.6% rate of abused women. In our
survey of military women, in about 60% of the abused women, there wasan overlap of at least two different types of abuse, physical and emotional,
physi­cal and sexual, or emotional and sexual. About 22% of the womenexperienced all three kinds of abuse. We also found that during military
service IPV was more prevalent among enlisted women (30.6%) than officers (14.5%) and those with lower levels of education (high school=25.0%,
post-graduate=15.0%). It is interesting to note, however, the percentage of
IPV reported by officers, since a common belief is that such violence only
occurs among the enlisted ranks.
Dr. Newby: What do you think about the reliability of your findings considering the limitations of your study?
Dr. Campbell: I would love to conduct the study again now that there isa DoD confi­dentiality policy. Our biggest limitation was a requirement by172 Family Violence Research, Assessment and Interventions

the institutional review board that we had to have a statement in the consent
form that the research records could be re­viewed by the participant’s commanding officer. As a consequence our response rate was very low (13.2%).
Dr. Newby: Did they feel that it would be held against them or just did notwant the information to be known.
Dr. Campbell: They were afraid of being considered less competent if
they had a record of abuse even though they had been victimized. They also
believed that having a personal re­cord of being abused would hurt theirchances for promotion.
Dr. Newby: Are there any specific risk factors for military women that could
lead to violence?
Dr. Campbell: One risk factor was being separated or divorced. However, the cross-sectional aspect of the study did not tell us if the separation
or divorce came before or after the IPV. We know from civilian studies that
separation from an abusive partner may cause an escalation of abuse. Active
duty military women and their commanders should be made aware of thisdanger. As I mentioned before, we saw an increased risk for women in theenlisted ranks, although there was still considerable abuse among officers.
We also saw an increased risk for women who had three or more chil­dren.
When there is a lot of stress in the house­hold abusive situations can be exacerbated.
Dr. Newby: Are the risk factors different from what you would find in thecivilian community?
Dr. Campbell: Oftentimes, in the civilian community we find lower income related to recent abuse. If women do not have sufficient resources it isharder for them to escape from an abusive relationship. The low income factor may not be as important in a military context because of the economic
floor below which we hope most military families do not fall. We do not see
the degree of poverty that we see some­times in the civilian world.
Dr. Newby: What were some of the physical health and mental health consequences of IPV that you found in your study?
Dr. Campbell: We saw almost exactly the same pattern of physical healthconsequences for active duty women as we did among civilian women.
Symptoms clustered around stress-related problems such as gastrointestinal
symptoms and more overall physical symp­toms. We also saw more chronic
pain among women who were abused. The other cluster of symptoms that
we saw included gynecologi­cal problems probably related to forced sex.

Jacquelyn C. Campbell, PhD, RN, FAAN 173

There were also neurological problems such as headaches and other symptoms that were not so clearly defined.
Dr. Newby: Were there any distinct mental health consequences?
Dr. Campbell: We saw a different pattern of mental health consequences
for the active duty women than we saw for the civilian women. The prevalence of mental health symptoms was higher among abused than non-abused
women in both samples and also higher among the civilian sample comparedto the military sample. Additionally, 34% of the abused civil­ian women versus 25% of the abused military women had symptoms that met criteria fora major depressive disorder, posttraumatic stress disorder (PTSD), or theco-occurrence of PTSD and depression. That compares with 18% and 15%
of non-abused women in civil­ian and military groups, respectively. Military
women, more than civilian women, were pretty resilient relative to mental
health consequences.
Dr. Newby: What were the results of your research that addressed active
duty females’ perceptions of the positive and negative consequences of mandatory reporting and routine screening for IPV?
Dr. Campbell: About 57% of women thought that routine screening or
the routine assessment for domestic violence in health care settings wasa good idea, and 48% thought that there should be mandatory reporting.
Non-abused women were more in favor of mandatory reporting than abused
women. Both military and civilian women thought that they ought to beable to control the reporting process. The military women wanted to deter­mine whether the abuse would be reported to the commander or military
police. A powerful dimension of that research was its evidence-based linkto the formulation of a confidential­ity policy in DoD. During my time as amember of the congressionally appointed Defense Task Force on Domestic
Violence, I used the data from our study to help persuade the commit­tee tomake a recommendation to give victims more say in whether or not domestic violence is reported. Starting in January 2006, there is now for the firsttime a restrictive reporting policy that applies to health care providers aswell as domestic violence advocates. The reporting of domestic violence isrestricted to those the victim specifically designates unless there is a likelihood of imminent harm to someone, child abuse, a subpoena for a directly
relevant case, or a relevant disability hearing. Otherwise, neither the commanding officer nor the military police nor anyone else is notified of domestic violence if the victim so chooses. This is an example of an important
policy change based, in part, on our research.

174 Family Violence Research, Assessment and Interventions

Dr. Newby: Were there other barriers to the self-reporting of IPV by active
duty women.
Dr. Campbell: Yes. If a woman was on active duty and her husband wascivilian, she wanted her partner to become non-violent without the risk of him
getting a criminal record. If she was married to an immigrant, she was fearfulthat the reporting of IPV could possibly hurt her partner’s chances of obtaining
citizen­ship. Children may also serve as a barrier to self-reporting. Accordingly,
women often feel that the reporting of IPV will negatively affect the perceptionof them as parents by various authorities.
Dr. Newby: Are these barriers different from those experienced by civilian
women?
Dr. Campbell: The major difference for active duty military women was therole of the commander. If her partner is also active duty military, she may beafraid that he is going to be thrown out of the military. She may not want his
career to be ended. She just wants the vio­lence to end. It takes a woman a while
to realize that these two goals may be incompatible.
Dr. Newby: Would you comment on the possible overlap of IPV and sexualassault issues among active duty military women?
Dr. Campbell: Many women are not only physically abused by their partners; they are also being forced to engage in sexual activities. It really is sexualassault or rape even though the assault is done by an intimate partner. In ourstudy, 33% of the physically abused women also reported being forced into sex
by the same partner. This type of sexual assault can be a very common part of
intimate partner violence. There is a lot of shame that goes along with it and it
is difficult for a woman to admit that she is being raped by the person who is
supposed to love her. Our questioning of victims should focus on “forced sex”
rather then using rape or sexual assault language.
Dr. Newby: What are your current research interests relative to IPV?
Dr. Campbell: We have been looking at the occurrence of workplace violence relative to particular health-related out­comes. I would like to replicatethat in the military. I am also interested in our returning combat-exposedmale veterans and whether those veterans who have PTSD are more likely
to abuse their wives and children. Also, now that we have large numbers of
combat-exposed females, I would also like to know whether there will be anincreased risk for these women as either per­petrators or victims of domestic
violence. One other thing I would like to study is whether or not the new
DoD restricted confidentiality policy encourages more active duty women
to come forward and report intimate partner violence. I would like to deter-

Jacquelyn C. Campbell, PhD, RN, FAAN 175

mine if the policy is really increasing the perception of safety by active duty
military women.
Dr. Newby: Do you think the policy of providing soldiers and their families
with post-deployment classes, briefings, counseling and other interventions
will decrease the potential for negative repercussions?
Dr. Campbell: I certainly hope so. Oftentimes it is the non-abusing families
that step forward and become involved in those programs. Unfortunately, families that need the services the most often do not ask for help. We need to determine how best we can reach them. I do hope that our current post-deployment
interventions to help and support military families are effective. Sometimes wefind that what we think is going to be helpful is not. There is a need for much
more research in this area.
Key Points
In our survey of military women, in about 60% of the abused
women, there was an overlap of at least two different types of abuse.
The prevalence of mental health symptoms was higher among abused
than non-abused women in both samples and also higher among thecivilian sample compared to the military sample. Military women, morethan civilian women, were pretty resilient relative to mental healthconsequences. However, if they had been abused, they still experienced
significantly elevated mental health symptoms.

176 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF L. KEVIN HAMBERGER, PHD

Review of Research of L. Kevin Hamberger,
PhD
By James E. McCarroll, PhD, and David M. Benedek, MD
Volume 11, Issue 2, July 2009
In a series of studies, Hamberger and colleagues have examined personality patterns of batterers and non-batterers using a dual
approach. The first involves studying batterers only; thesecond compares batterers and non-batterers. These approaches yield different results. In the former, possible
differences between batterers can be examined; in the latter, one can attempt to find differences between batterers
and non-violent persons. To date, his research on batterer
characteristics has been exclusively on males because
during the time of data collection not enough female batterers had been
identified for study.  
Both personality and psychopathology are related to spouse abuse. An
early study of personality correlates of 99 men who battered their partners
and were part of a domestic violence abatement program found three categories of personality profiles reflecting general tendencies: schizoidal/borderline, narcissistic/antisocial, and dependent /compulsive personality disorders (Hamberger & Hastings, 1986). Only about 12% of batterers showedno psychopathology. They concluded that there was no general batterer personality profile, that the majority of batterers showed evidence of disordered
personality profiles, and that both personality types and psychopathologicalprocesses must be considered among the factors related to spouse abuse.
This research was extended to comparisons between domestically violent
and non-violent men (Hamberger & Hastings, 1991). The domestically violent group included men who were alcoholic and non-alcoholic. Both alcoholic and non-alcoholic abusive men showed higher levels of borderline
personality organization than nonviolent men.

178 Family Violence Research, Assessment and Interventions

Hamberger and colleagues continued to pursue batterer typology ina larger study of 833 men who were court-referred for evaluation prior
to participating in a domestic violence counseling program (Hamberger,
Lohr, Bonge, & Tolin, 1996). They found three main clusters of batterers,
which largely replicated the typology work of Holtzworth-Monroe and Stuart (1994). Cluster 1 was characterized as dependent-submissive, passiveaggressive negativistic, and avoidant; cluster 2, as narcissistic, antisocialaggressive, and histrionic-gregarious; cluster 3 was non-pathological. The
non-pathological men generally had the lowest maximum violence andtheir violence was restricted to intimate relationships. The antisocial andpassive-aggressive men did not differ in maximum violence. However, antisocial men were the most generally violent and had the most police contacts. Passive-aggressive and dependent men had the highest frequency of
violence.
Batterers, particularly those with borderline personality organization,
generally struggle with anger and hostility (Hamberger & HoltzworthMonroe, 2009). Anger is a common feature of domestic violence. However,anger, hostility, and aggression are different concepts: anger is the emotion,
hostility is the attitude, and aggression is the behavior (Del Vecchhio &O’Leary, 2004). Anger is infrequently mentioned in psychiatric diagnosic
nomenclature. In DSM-IV (American Psychiatric Association, 1994), anger
is not a diagnosis or more than part of a criterion for a mental disorder (e.g.,
post-traumatic stress disorder (p. 428), intermittent explosive disorder (p.
612), and borderline personality disorder (p. 654).  
Hamberger and Holtzworth-Monroe (2009) report that abusive men are
more hostile than non-abusive men. Anger is frequently seen in batterers
with borderline personalities, but also in depression and anxiety disorders.
Abusers have anger and hostility directed at themselves, but also less anger
control. Particularly important to the expression of anger in abusive menis the tendency to label and interpret their partner’s behavior with negative
intent. They note that these attributes occur in situations that most wouldinterpret as only moderately provocative, situations that non-violent men
would be likely to overlook or at least not react strongly. They ask the question as to whether batterers are mentally ill. In terms of personality disorders, at a minimum, the answer seems to be that many are.  
It is important for clinicians to know how anger and aggression are related to violence. Psychologists who work with personality profiles and haveexpertise in domestic violence have demonstrated a fair degree of interrater
reliability for sorting batterers into profile types, particularly borderlinedysphoric and antisocial/narcissistic (Lohr, Bonge, Witte, Hamberger, &Langhinrichsen-Rohling, 2005). This research represents a beginning effort

L. Kevin Hamberger, PhD 179

to determine whether providers can be taught to use personality profiles tocategorize the abusive clients — a necessary condition for being able to subsequently design treatment based on individually assessed needs.
In conclusion, Hamberger’s research indicates that batterers are a heterogeneous group, particularly in terms of the relationship between their typology and violence as well as anger and hostility. For example, while many
batterers show high levels of anger and aggression, some show lower levels
than non-violent men. Hamberger speculates that this finding may be dueto the fact that many batterers are superficially pleasant, but also that they
deny or deceive when anger is inquired on self-report measures (Hastings& Hamberger, 1988; Hamberger & Holtzworth-Monroe, 2009). Whatever
the pattern of personality, alcohol tends to increase violence severity andfrequency. It is noteworthy that Hamberger found no alcohol-abusive men
in his non-violent samples (Hastings & Hamberger, 1988). Because of thecomplexity of violent behavior, treatment is also complex. Given that mostpartner-violent men seemed to have some form of psychopathology consisting of personality disorder, depression, anxiety, dysregulation of affect, andsubstance abuse, treatment may call for specific approaches that target eachof these factors.
Key Points
Anger is frequently seen in batterers with borderline personalities,
but also in depression and anxiety disorders. Abusers have anger
and hostility directed at themselves, but also less anger control.
Batterers, particularly those with borderline personality
organization, generally struggle with anger and hostility.
Hamberger’s research indicates that batterers are a heterogeneousgroup, particularly in terms of the relationship between theirtypology and violence as well as anger and hostility

References
American Psychiatric Association. (1994). Diagnostic and Statistical
Manual of Mental Disorders (4th ed.). Washington, DC: Author.
Del Vecchhio T & O’Leary KD. (2004). Effectiveness of anger treatments
for specific anger problems: A meta–analytic review. Clinical Psychology

180 Family Violence Research, Assessment and Interventions

Review; 24:15–34.
Hamberger LK & Hastings JE. (1986). Personality correlates of men who
abuse their partners: A cross–validation study. Journal of Family Violence; 4: 323–341.
Hamberger LK & Hastings JE. (1991). Personality correlates of men whobatter and non–violent men: Some continuities and discontinuities.
Journal of Family Violence; 6: 131–147.
Hamberger LK & Holtzworth–Monroe A. (2009). Psychological correlatesof male aggression. In KD O’Leary and Erica Woodin (Eds.). Understanding Psychological and Physical Aggression in Couples: Causes andInterventions. Washington, DC: American Psychological Association,
pp 79–98.
Hamberger LK, Lohr JM, Bonge D, & Tolin DF. (1996). A large sample empirical typology of male spouse abusers and its relationship to dimensions of abuse. Violence and Victims;11: 277–292.
Hastings JE & Hamberger LK. (1988). Personality characteristics of spouseabusers: A controlled comparison. Violence and Victims; 3: 31–47.
Holtzworth–Monroe A & Stuart GL. (1994).Typologies of male batterers:
Three subtypes and the differences among them. Psychological Bulletin;
116: 476–497.
Lohr JM, Bonge D, Witte TH, Hamberger LK, & Langhinrichsen–Rohling
J. (2005). Consistency and accuracy of batterer typology identification.
Journal of Family Violence; 20: 253–258.

L. Kevin Hamberger, PhD 181

INTERVIEW WITH L. KEVIN HAMBERGER, PHD

Intimate Partner Violence: Function,
Treatment and Typologies
By James E. McCarroll, PhD
Volume 11, Issue 2, July 2009
Dr. McCarroll: How did you enter the field of intimate partner violence research?
Dr. Hamberger: In the very early literature on intimate partner violence
there were two concepts from the predominantly feminist model that gave
me pause. The first was that all men are at risk of battering. The second
viewed psychopathology as not being part of the battering spectrum. My
own clinical observations revealed many individual differences. Jim Hastings, one of my research colleagues, and I sought to highlight that heterogeneity within the population with which we were working. [Editor’s note: See
review of Hamberger and Hastings research in the review of Dr. Hamberger’s research.] Our goals were to demonstrate that batterers (abusive men)constitute a very heterogeneous population and to look at the frequency ofpsychopathology in our clinical samples.
Dr. McCarroll: Does the term batterer describe only the man who is the severe, pathological abuser or does it refer to a broader range of abusive behavior?
Dr. Hamberger: I view battering as a factor in determining how violence
works in the relationship, not as the overall severity of the violence. In aparticular relationship, pushing and shoving may function to dominate orcontrol the victim in the same way that more severe violence may function
in another relationship.
Dr. McCarroll: What is the focus of the power and control model today?
Dr. Hamberger: In clinical samples, we tend to see a predominance ofmale-to-female violence. Male-to-female intimate partner violence is related to and stems from broader sociopolitical forces that tend to place womenin a second-class status. That second-class status is reinforced within an individual relationship through the application of force, abuse, and controlling
behaviors. It may not be the whole story. One theoretical perspective does
not adequately explain all of intimate partner violence.

182 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Is anger management the recommended treatment for batterers?
Dr. Hamberger: Most state standards would argue against anger management as a treatment for batterers because it is too narrowly focused on thebatterer’s lack of skill in managing anger, and not enough emphasis is placedon using violence as a tool of power and control. The predominant modelis psychoeducational using a cognitive-behavioral skills-based approach inwhich the primary focus is on the function of violence to dominate and control an intimate partner. Studies show that abusive men, on average, do show
more anger and hostility relative to nonviolent men. One needs to be mindful of anger issues when assessing men for treatment as well as performing
treatment with them.
Dr. McCarroll: In your early work, you were not able to find enough female
batterers to include in your analyses. Is this still the case?
Dr. Hamberger: A larger number of women are now being arrested aseither the sole perpetrator or as part of a dual arrest scenario. Recent arrest
rates indicate that women constitute upwards of 20-25% of all people arrested for domestic violence. My research on female perpetrators has focusedon motivation for using force against their intimate partners rather than on
personality characteristics and psychopathology.
Dr. McCarroll: Do dual arrest policies require the arrest of persons who engage in violence for self-defense?
Dr. Hamberger: That has not been adequately sorted out. Most state laws
regarding mandatory arrest discourage dual arrest and promote determination of the predominant physical aggressor, but there is little research toguide determination of the predominant physical aggressor. My researchon motivations for use of intimate partner violence by men and women reveals that about two-thirds of men are using violence primarily to dominate
and control their partner. About 17% of men report self-defense or retaliation from a prior assault as a motivation. We see the mirror opposite withwomen. About two-thirds report their primary motivation for violence isself-defense or retaliation, and about 17-19% report domination and control. Motivations such as retaliation and self-defense may not prevent a person from being arrested, but are still important for the clinician to consider
when planning treatment.
Dr. McCarroll: Do you think batterer treatment works, and if so, how?
Dr. Hamberger: The evidence across the two or three meta-analyses that
I have read looks promising, but not conclusive. There is a small, but signifi-

L. Kevin Hamberger, PhD 183

cant effect size in batterer treatment. However, one can find a lot of flaws in
the research that argue against strong results. We have not looked carefully
at matching treatment to the characteristics of abusive men including readiness to change, trauma history, alcohol and drug abuse, and the need to deal
with a broad spectrum of treatment issues such as recidivism. The anger
management interventions alluded to earlier also need to be considered aspart of a broader intervention for emotion regulation.
Dr. McCarroll: How would you advise clinicians to think about using theresults of your typology research?
Dr. Hamberger: I have used the information from typologies more toassess aspects of risk of premature termination and recidivism. Borderline,
dysphoric men are at a high risk of dropping out of standard treatment. We
have also found that dropouts are at a higher risk of recidivating than completers. That information can inform the female partner’s safety planningand decision-making. We need to ramp up our expertise in pretreatment
assessment and in developing treatment plans that are more in line with theclient’s needs and personality style rather than just applying a “One size fitsall” model.
Dr. McCarroll: When do you involve a non-battering spouse in the treatment?
Dr. Hamberger: Primarily, I involve the victim-partner in collateral contacts early in the abusive partner’s assessment and at the end of his involvement in treatment. I gather information about the violence from her pointof view, provide community resource information, conduct safety planning,
discuss risks, and establish a set of criteria for ongoing contact, if necessary.
We do not involve the most disordered and severely violent people in couple
counseling. Couple counseling appears to be appropriate primarily whenboth partners are willing to attend and for people who commit less severe
levels of violence, not for those with the severe pathology that we might see
in the borderline-dysphoric and antisocial-narcissistic typologies.
Another problem for couple counseling is that batterers as a whole tend
to over-interpret and see their partner in a certain way such as “She’s doing
this on purpose,” or “She’s always doing this to disrespect me.” In contrast,
there are less drastic interpretations such as “She’s just misbehaving rightnow” or “We’re just having a difference and it’s not a big deal.” We would
also challenge him to think about the fact that he immediately jumps to theconclusion that his partner is likely to cheat on him and to change that typeof thinking, too.

184 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Since it may not be a good idea to include the spouse in thetreatment of a batterer, how do you bring their over-interpretation of cues
into therapy?
Dr. Hamberger: In batterer treatment, we frequently talk about various
interactions that men are having with their partners. That is part of the ongoing homework. When they feel upset, when they feel angry, when stressors are in their relationship, they are asked to record their thoughts about
what is going through their mind as they experience such a situation. Thenthey bring that homework into the treatment with them and we go over it.
Dr. McCarroll: Thank you for your insights and your contribution to our
newsletter.
Dr. Hamberger: You are welcome.
Key Points
I view battering as a factor in determining how violence works in
the relationship, not as the overall severity of the violence. Pushingand shoving may function to dominate or control the victim in
the same way that more severe violence may function in anotherrelationship.
Most state standards would argue against anger management as atreatment for batterers because it is too narrowly focused on thebatterer’s lack of skill in managing anger. Not enough emphasis isplaced on using violence as a tool of power and control.
The predominate model of batterer treatment is psychoeducational
using a cognitive-behavioral skills-based approach in which theprimary focus is on the function of violence to dominate andcontrol an intimate partner.

References
Holtzworth–Munroe, A., & Stuart, G.L. (1994). Typologies of male batterers: Three subtypes and the differences among them. Psychological
Bulletin; 116: 476–497.
Hamberger, L.K., & Hastings, J.E. (1986). Personality correlates of men
who abuse their partners: A cross–validation study. Journal of Family
Violence; 1:323–341.

L. Kevin Hamberger, PhD 185

Hamberger, L.K., Lohr, J.M., Bonge, D., & Tolin, D.F. (1996). A large
sample empirical typology of male spouse abusers and its relationshipto dimensions of abuse. Violence and Victims; 11:277–292.

186 Family Violence Research, Assessment and Interventions

INTERVIEW WITH KATHLEEN KENDALL-TACKETT, PHD

Trends in Interpersonal Violence (IPV)
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 2, August 2007
Dr. McCarroll: Drawing upon your new and comprehensive book, whatshould we know about the mental health effects of interpersonal violence(IPV) (Kendall-Tackett & Giacomoni, 2007)?
Dr. Kendall-Tackett: In our new volume, we have a section on leaving
abusive relationships. What struck me about this area
was how long it took people to recover from living in an
abusive relationship. Women have elevated levels of depression and PTSD even a year or longer after they leave.
Women leaving relationships may be substantially poorer
and they may be trying to balance multiple harms. For example, they may decide that staying in an abusive relationship is less risky than becoming homeless with their children.
Dr. McCarroll: What is new in the way risk assessment is being approached?
Dr. Kendall-Tackett: There has been much more empirical work on risk
assessment in recent years. For example, lethality is much more systematically approached than in the past. The development and validation of measures has improved over past practices, which tended to be based on what
people thought would work.
Dr. McCarroll: What do we know about women’s violence?
Dr. Kendall-Tackett: Importantly, women can be violent, but the extent
and type of women’s violence is argued. You may see similar rates of womencommitting violence, but often it is in self-defense and it tends not to be as
physically injurious as violence perpetrated by men.

188 Family Violence Research, Assessment and Interventions

Dr. McCarroll: What have been the trends on the use of evidence-based interventions?
Dr. Kendall-Tackett: Practice is moving much more toward an evidencebased model. I think this is a good trend, but I think that sometimes we canbe so evidence-based that we miss something really obvious right in front of
us. The evidence is only as good as the questions we ask.
Dr. McCarroll: Do strength and resiliency factors add to our knowledge?
Dr. Kendall-Tackett: Many of our domestic violence models are basedon a pathology approach to women in these relationships. A structured coping model may be better. Often the women are trying to balance multiple
possible harms. We need to acknowledge the fact that there is some coping
going on, but it may not be in the form that we are used to seeing or thinkis the best. Instead of focusing on “Can’t this woman cope?” we need to findout why she is staying in that relationship and what are the resources wecan bring to help her. Maybe she realistically knows that if she leaves thisrelationship she is going to be killed. Overall, she may have some positive
feelings about the relationship, but just want the abuse to end.
Dr. McCarroll: Are the legal issues changing?
Dr. Kendall-Tackett: It is not clear that mandated arrest is a good idea.
The consensus seems to be that this is not necessarily an effective policy, andcan be punishing to women. Not only does mandatory arrest increase thelikelihood of possible physical reprisals once the perpetrator is out of jail,but many women feel re-victimized by the system. It also does not allow
the woman’s input into the decision. Sometimes these policies backfire andreinforce the powerlessness that some victims feel.
Dr. McCarroll: So, the solution is not exactly clear, but at least to keep thewoman’s point of view in mind instead of making decisions for her?
Dr. Kendall-Tackett: Yes, there is still some debate about how to put this
into practice. An example is mandatory screening. I am hesitant about mandatory screening, at least in health care settings, mainly because we cannot
be sure of the qualifications of the people who are doing it. It can increase
the danger for women if done poorly (e.g., within earshot of the perpetrator). But screening is also an area where we can empower women. It is important to take into account women’s assessment of their risk. Women are
actually pretty accurate in their assessments about the danger they are in.
We need to give the women the freedom to disclose in health care settings.
Another problem in health care settings is what screeners are to do with theinformation. Are you going to expose her to some potential danger by ask-

Kathleen Kendall-Tackett, PhD 189

ing if she is being abused or if she feels safe in her own home when you do
not have a plan in place to protect her? Medical personnel will not screen if
they do not have some place to refer the clients. This should be consideredwhen an institution entertains plans for mandatory screening.
Dr. McCarroll: What about the effects of adverse childhood experiences(ACEs)?
Dr. Kendall-Tackett: The concept of ACEs, rather than focusing on asingle type of abuse, allows you to branch out into a broader frameworkin considering the effects of maltreatment on children. One type of ACE isparental mental illness, including depression. Depression impairs parenting
and one possible consequence is child neglect. Studies on maternal depression show that disengaging from their children is one possible response.
Dr. McCarroll: What do you see developing in terms of the intersection ofchild and spouse abuse?
Dr. Kendall-Tackett: The biggest development is that the child abuse anddomestic violence communities are talking to each other. I think for a longtime they have been very separate. Child protective services are developing
policies in cases where there is IPV. In the past, these communities weresuspicious of each other because of coming from different frameworks, butthat is starting to change and people see the overlap in protecting womenand protecting children.
Dr. McCarroll: What do we know about long-term health effects associatedwith maltreatment?
Dr. Kendall-Tackett: We have learned that abuse survivors have higher ratesof heart disease, diabetes and other diseases. There is a lot of evidence from theimmunology field that having been exposed to a traumatic event or experience,
the immune system is primed to respond to ensuing, stressful situations. Thishas been linked to heart disease, diabetes, and even cancer. Depression and hostility also activate the immune response. These health effects can continue longafter the abuse has ended.
Dr. McCarroll: Where do you think the field is going? What do you think is
the direction for the next 20 years of research?
Dr. Kendall-Tackett: I think what we are probably going to see is more intervention studies, particularly in health care settings. I think we will also look
more at the physical health effects—not only those related to current injuries,
but the long-term health effects. I think we are going to have more complex, but
realistic models of the victim’s experience by looking at both negative outcomes190 Family Violence Research, Assessment and Interventions

and resilience factors. And I think we will see more evidence-based interventions.

Dr. McCarroll: Thank you
Dr. Kendall-Tackett: You are welcome.
Key Points (Did you know?)
A recent study on screening for IPV in health care settings foundthat women preferred self-completed approaches over face-to-facequestioning (MacMillan, Wathen, Jamieson, et al., 2006).
The risk for anxiety disorders, major depression, and substancedependence were found to be three times as high in the offspringof depressed parents as in the non-depressed parents (Weissman,
Wickramaratne, Nomura, et al., 2006).
Adverse childhood experiences, including child abuse and neglectand household dysfunction, seem to begin to affect a child’s healtheven early in a child’s life (Flaherty, Thompson, Litrownik, et al.,2006).
A recent study found that posttraumatic stress disorder was
significantly associated with vascular, musculoskeletal, anddermatological problems (Dirkzwager, van der Velden, Grievink, &Yzermans, 2007).

Additional Key Points
Many of our domestic violence models are based on a pathology
approach to women in these relationships. A structured coping
model may be better.
Women leaving relationships may be substantially poorer and they
may be trying to balance multiple harms. For example, they may
decide that staying in an abusive relationship is less risky thanbecoming homeless with their children.

Kathleen Kendall-Tackett, PhD 191

References
Dirkzwager AJE, van der Velden PG, Grievink L, & Yzermans CJ. (2007).
Disaster-related posttraumatic stress disorder and physical health. Psychosomatic Medicine, 69:435–440.
Flaherty EG, Thompson R, Litrownik AJ, Theodore A, English DJ, BlackMM, Wike T, Whimper L, Runyan DK, & Dubowitz H. (2006) Effectof early childhood adversity on child health. Archives of Pediatric andAdolescent Medicine, 160:1232–1238.
Kendall-Tackett K. and Giacomoni SM. (2007). Intimate Partner Violence.
Civic Research Institute: Kingston, NJ.
MacMillan HL, Wathen CN, Jamieson E, Boyle M, McNutt L-A, Worster
A, Lent B, & Webb M. (2006). Approaches to screening for intimate
partner violence in health care settings. Journal of the American Medical
Association, 296:530–536.
Weissman MM, Wickramaratne P, Nomura Y, Warner V, Pilowsky D, &Verdeli H. (2006). Offspring of depressed parents: 20 years later. American Journal of Psychiatry, 163:1001.

192 Family Violence Research, Assessment and Interventions

REVIEW OF RECENT RESEARCH OF KATHLEENKENDALL-TACKETT, PHD

Sleep, Fatigue, and Trauma History in New
Mothers
By James E. McCarroll
February 2010
Dr. Kendall-Tackett’s interview features her recent research on sleep and fatigue in mothers (Kendall-Tackett & Hale, 2009). The study was conductedbased on recent news reports about mothers co-sleeping with their infants
and warning that bed sharing increases the risk of accidental strangulation(Shapiro-Mendoza, Kimball, Tomashek, et al., 2009). Kendall-Tackett andHale felt that more empirical data was needed on mothers’ sleeping practices. They also thought that a broad range of advice was given to mothers
about safe and unsafe practices of families. Thus, their point was to learn
what average families are doing in various areas of family and baby safety.
A second concern was to address whether nighttime breastfeeding increased the risk of postpartum depression. Their study examines the relationship between nighttime breastfeeding, sleep deprivation, maternal fatigue and depression while accounting for other depression risk factors suchas trauma history, postpartum pain, and lack of support. Their thought wasthat these and other factors could compromise nighttime sleep and increase
daytime fatigue.
The study was conducted via an online survey that was begun in July
2008. The sample consisted of mothers with infants from 0-12 months of age.
About one-half of the mothers who responded represented mothers werefrom the United States. Others were from Canada, the European Union/
Eastern Europe, Australia and New Zealand, the Middle East, Central andSouth America and Africa.
The average age of the mothers was 31 years; they were primarily Caucasian, 70% had a bachelor’s degree or higher, 91% were married, and 97%
were living with a partner, and income was said to be well distributed (fromless than $15,000 to more than $150,000 per year).
As Dr. Kendall-Tackett notes in her interview, data analysis is still underway. Preliminary analysis was conducted in three areas: where babies sleep,
mothers’ self-reported fatigue, and mothers’ history of psychological trauma(Kendall-Tackett & Hale, 2009). The largest percentage of mothers (44%)
reported that their infants slept in another room and 32.6% said their babies

Kathleen Kendall-Tackett, PhD 193

slept in their beds, 16.6% had babies in a crib or bassinet in their room,and 4.8% had their babies in a co-sleeper. Bed sharing was highest among
African-Americans (52%) and Mexican-Americans (51%). The percentage
of Caucasian mothers was 48%.
Mothers’ self-reported fatigue varied from “very” to “not at all” andvaried by feeding method. About 29% of breastfeeding mothers rated theirenergy on most days as very good or excellent compared to about 19% of
mothers who formula fed or who used a combination of feeding methods.
Trauma history is also a predictor of fatigue as it often compromises sleep
quality. They found that about 52% of respondents had experienced at least
one type of traumatic event, and one-third had been exposed to parental
substance abuse, mental illness, or intimate partner violence. In addition,
13% reported rape or other sexual assault as teens or adults and about 25%
reported some type of sexual trauma. About 59% of the sample reported thatthey had been depressed, with about 35% of the mothers reporting three ormore episodes. However, almost all of the mothers reported a happy, stable,
and safe relationship with their current partner. [Editor’s note: See Dr. Kendall-Tackett’s interview for more details about this study.]
Key Points
Kendall-Tackett and Hale (2009) recently completed a study on therelationship between nighttime breastfeeding, sleep deprivation,maternal fatigue and depression in new mothers.
Trauma history is a predictor of fatigue as it often compromises
sleep quality. About 52% of respondents of their respondents had
experienced at least one type of traumatic event, and one-third
had been exposed to parental substance abuse, mental illness, orintimate partner violence.

References
Kendall–Tackett K. & Hale TW. (2009). Survey of mothers’ sleep and fatigure: Preliminary findings. Medications & More, February: 3–5.
Shapiro–Mendoza CK, Kimball M, Tomashek KM, Anderson RN & Blanding S. (2009). US infant mortality trends attributable to accidental
suffocation and strangulation in bed from 1984 through 2004: Are rates
increasing? Pediatrics; 123: 533–539.

194 Family Violence Research, Assessment and Interventions

SECOND INTERVIEW WITH KATHLEEN KENDALL-TACKETT, PHD

Effects of Adverse Experiences on New
Mothers
By James E. McCarroll
January 2010
Dr. McCarroll: Your last interview was on the health effects of domestic violence. Have you have continued to pursue that path?
Dr. Kendall-Tackett: I have.
Dr. McCarroll: Your conducted a study recently in which you collected datafrom new mothers who had been sexually abused or assaulted and women
who had not been abused. In that study, you asked these women to reporttheir experiences with sleep, depression, fatigue, and breastfeeding.
Dr. Kendall-Tackett: We did a big survey of sleep and fatigue in new
mothers. I asked quite a few questions about trauma history because it impacts sleep. When you are talking about a new mother everybody assumes itis the baby that is keeping them awake and I think what our data really show
is that that is by no means the case.
Dr. McCarroll: Would you talk about your sample. How did you recruit
them?
Dr. Kendall-Tackett: It was generated by contacts from talks that I gave,
e-mails, and lists within the breastfeeding community. People from all over
the world cooperated. We thought we would only get mothers from Australia, New Zealand, Great Britain, the United States, and Canada, but wealso got mothers from Eastern Europe and Africa. We have mothers from59 countries.
Dr. McCarroll: Would you explain your sexual trauma data? Your major
theme seems to be the effect of sexual assault or abuse on childbearing women.
Dr. Kendall-Tackett: We collected data from almost 1,000 women who
are sexual abuse or assault survivors. I asked them if they had ever beensexually abused as children or sexually assaulted as a teen or an adult. We
had women who had experienced both. One of the variables we looked as
was the length of time it takes to get to sleep. It is a strong predictor of postpartum depression. The more trauma history they had, and in the case of theKathleen Kendall-Tackett, PhD 195

sexual assault, the more recent it was, the longer it took them to get to sleep
at night. Women who had been sexually assaulted had a hard time both getting to sleep and staying asleep. It did not seem to be related to baby care. All
the women in the sample had babies 0-12 months old. Our data has not yet
been published, but we are currently working on that.
Dr. McCarroll: You also asked about psychological or emotional aggression.
You asked questions like if a parent swore at them, made them afraid, hit
them hard enough to injure them, and whether their family felt close.
Dr. Kendall-Tackett: The relation of these items to sleep was also reallystriking.
Dr. McCarroll: One of your major themes seems to be the effect of previous
sexual assault or abuse on childbearing women. Your study included fourgroups in which you compared family of origin experiences and the women
who were sexually assaulted and those who were not assaulted. What is the
major issue you would communicate about sleep for this group of people?
Dr. Kendall-Tackett: We sometimes we overlook sleep problems. For
example, sleep quality may make post-traumatic stress disorder symptoms
worse. A lot of times if you can address sleep, other things get better. Asking
about sleep problems is a convenient entry point when talking to a patientor client.
We are also going to be able to tell a lot of things about the relationshipof adverse childhood experiences (ACEs) to mothering. About half of oursample reported at least one type of ACE. We have information on theirpregnancy, labor and delivery, sleep, and depression. We will have a lot toreport.
Dr. McCarroll: In your sample, you found that the women who had a historyof both rape and sexual assault reported that their family was not a sourceof support. What do you think about that?
Dr. Kendall-Tackett: First of all, it is very sad. But, I think it also gives thepeople who work with them some ideas of “How can you bolster a mom’s
existing support?” Often, it is not going to be her family of origin. But, we
also asked about was their relationship with their current partner. We asked“Do you feel like your partner really loves you?” and “Do you feel like you
can trust your partner?” The reason for asking these questions is because therelationship with the partner affects sleep quality. About 93% of them answered “Yes” to both questions. They thought that their partner loved themand they trusted their partners. They were also highly likely to indicate thatthe quality of their relationship with their partners was “excellent.” These196 Family Violence Research, Assessment and Interventions

women had chosen to go down a different path than how they were raised
and had found nurturing relationships.
Dr. McCarroll: There is a lot of complexity in the way you can look at relationships between families and childhood experiences, such as rape andabuse.
Dr. Kendall-Tackett: I have had a number of women tell me over theyears that their families never knew or asked even though their behavior
changed and sometimes changed radically. Even when they were not sexually abused in their families, I think it was missed because the families were
so impaired in other ways.
Dr. McCarroll: What surprised you in this study?
Dr. Kendall-Tackett: The main thing that really surprised me was how
common are the adverse experiences and also what looks like the compounding effect of sexual assault. The women who were sexually assaulted
had so many other bad things going on in their lives.
Dr. McCarroll: Thank you for your time. I enjoyed learning about yourwork.
Dr. Kendall-Tackett: You are welcome. Great to talk with you, as always.
Key points
We sometimes overlook sleep problems. For example, sleep quality
may make post-traumatic stress disorder symptoms worse. A lot oftimes if you can address sleep, other things get better. Asking about
sleep problems is a convenient entry point when talking to a patientor client.
What really surprised me from our study was how common are adverse
experiences and what looks like the compounding effect of sexualassault. The women who were sexually assaulted had so many other bad
things going on in their lives.

BACKGROUND OF RECENT RESEARCH OF SUZANNE C. SWAN, PHD

Women’s Violence: Research of Suzanne
Swan and David Snow
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 9, Issue 1, January 2006
Women’s violence in intimate relationships is not well understood. Swan andSnow (2002) note several factors that add urgency to the need for a greater
understanding of women’s violence. First, in more than
100 studies of intimate partner violence, women reportas much physical aggression as men. This finding is not
the whole story. Although surveys find that the numberof women and men who report using physical aggression
against their partners is equivalent, women are more likely
to report being injured. Women are also more likely to be
subjected to sexual assault from intimate partners. Finally,
mandatory arrest policies in some states have resulted in increasing dual arrests in which the criminal justice system treats both members of the couple
as perpetrators. When dual arrests occur without a careful analysis of thehistory of violence in the relationship, some women who were violent in
self-defense are criminalized. Swan and Snow argue that women’s violenceneeds to be examined in the context in which it occurs, which often includes
violence against them.
Dr. Swan and her colleagues have published a series of articles on women’s violence (Swan & Snow, 2002; Swan & Snow, 2003; Swan, Gambone,
Fields, et al., 2005; Swan & Snow, 2006). Their model proposes that women’s
violence occurs in the context of their victimization by their male partners,
their experiences of childhood trauma, and as a consequence of depression,anxiety, posttraumatic stress symptoms, and substance use. The studies by
Swan and Snow were derived from a sample of 108 women who had usedsome form of physical violence against a male intimate partner within thelast 6 months. The women provided descriptions of their own violence and198 Family Violence Research, Assessment and Interventions

that of their partners. The sample revealed that ninety-nine percent had
committed at least moderate physical violence, 57% had committed severe
violence, 54% had injured their partner, 28% had used sexual coercion, and
86% used some form of coercive control. Women committed equivalent levels of emotional abuse as men. However, almost all of the women were also
victims of violence. Only 6 of the 108 experienced no physical victimization or injury from their partners. Although a high percentage of womencommitted violence, their male partners committed significantly more of
the severe types of violence: sexual coercion, coercive control, and injury(Swan & Snow, 2002).
Swan and Snow (2002) developed a typology of the different types ofabusive relationships in which women were violent. Their typology consisted of the following types of relationships: women as victims (34%), womenas aggressors (12%), and mixed relationships (50%). There were two typesof mixed relationships. The first mixed type was called mixed-male coercive (32%). In this type, the female used more severe violence than the malepartner, but the male partner was more controlling (coercive). In the mixedfemale coercive type (18%), the male was more severely violent, but the female partner was more controlling. Four percent of the participants could
not be classified.
Overall levels of violence were highest in the victim and aggressor types.
In both the victim and aggressor types, there was a large disparity between
partners’ frequency of abuse. This suggests that the most dangerous and violent relationships are those in which there is a very different distribution of
power favoring one partner. Little is known about male victims: what is hislevel of fear, how much does he modify his behavior to avoid angering his
partner, what is the extent to which he feels controlled by her, and what is his
sense of disempowerment and helplessness? Swan and Snow believe that, inthe majority of relationships, women do not instill fear in men or succeed incontrolling their behavior.
Swan and Snow (2003) examined behavioral and psychological differences among women in the four typologies. The women in the women as
victims group fared the worst. They had the highest levels of harmful drinking and suppressed anger, and little anger control, as well as high levels of depression, anxiety, and posttraumatic stress symptoms. Their primary motive
for violence was self-defense and they had the highest frequency of injuries.
Women in the aggressor group were doing almost as poorly as the womenin the victim group. Their levels of depression, anxiety, and posttraumaticstress symptoms did not differ from the victims. Aggressors had much higher levels of childhood trauma, which predicted female aggression.
Women in the mixed-female coercive group had the most positive find-Suzanne C. Swan, Ph.D 199

ings on almost all measures. They were the least depressed, had the lowest
level of posttraumatic stress symptoms, and were the least anxious of allgroups. They were the least angry and were able to control their anger morethan other groups. They also experienced and inflicted the least amount of
injury.
In the mixed-male coercive group, male and female partners were approximately equal in their use of violence, but the men were much morecoercively controlling. Their outcomes were better than the women in thewomen as victims or the women as aggressors groups, but they did not fareas well as the women in the mixed-female coercive group.
Across all groups, childhood abuse and greater frequency of victimization from partners increased the likelihood of female aggression against
their partners, as well as posttraumatic stress symptoms, and depression.
Also, women with posttraumatic stress symptoms were more likely to express anger outwardly, which predicted an increased likelihood that theywould use aggression against their partner (Swan & Snow, 2005).
Swan and Snow (2003) believe that their findings may be explained by
the women’s sense of control over their lives, their autonomy, and their senseof agency within their relationships. The women in the mixed-female coercive group seemed to have the most even balance of power and control with
their partners. The women in the victim and the aggressor groups seemed
to be the most worrisome. Even though the women in the women as aggressors group may appear to have the greater power in terms of their levelof aggression, their poor outcomes (high rates of injuries, depression, andposttraumatic stress symptoms) may indicate little autonomy or control intheir lives.
Swan and Snow (2003) suggest their aggression was used to try to createa sense of control. Swan and Snow (2005) believe that it is important for violence cessation programs to have women assess their safety in their homes
and, when necessary, to develop safety plans. They also recommend that
programs for domestically violent women assess posttraumatic stress symptoms since these symptoms predict anger directed outward as well as aggression. They suggest that women will have difficulty reducing their violent behavior until they are no longer being victimized and have received treatment
for posttraumatic stress symptoms and other trauma-related disorders.
The study of women’s violence is important to the Army. The Army Central Registry recognizes both men and women as victims and perpetratorsof domestic violence. Whether abuse is unilateral or bilateral, the causes andconsequences of men’s and women’s violence are likely to be different. A
better understanding of the causes and dynamics of both male and female
violence will help the Army Family Advocacy Program (FAP) make better200 Family Violence Research, Assessment and Interventions

decisions about case substantiation and treatment of both victims and perpetrators.
Today’s military life with its high level of operational tempo and frequent,long, and hazardous deployments adds additional dimensions to the stressof relationships for both male and female soldiers and their family members.
These dimensions add to the context in which men’s and women’s violenceoccurs and should be considered in assessing case substantiation, treatment,
and follow-up of FAP clients.
Key Points
Although surveys find that the number of women and men who
report using physical aggression against their partner is equivalent,
women are more likely to report being injured.
The model by Dr. Swan and her colleagues proposes thatwomen’s violence occurs in the context of victimization by theirmale partners, their experiences of childhood trauma, and as aconsequence of depression, anxiety, posttraumatic stress symptoms,
and substance use.

References
Swan SC, Gambone LJ, Fields AM, Sullivan TP, & Snow DL. (2005).
Women who use violence in intimate relationships: The role of anger,
victimization, and symptoms of posttraumatic stress and depression.
Violence and Victims, 20:267–285.
Swan SC & Snow DL. (2002). A typology of women’s use of violence inintimate relationships. Violence Against Women, 8:286–319. Swan SC& Snow DL. (2003). Behavioral and psychological differences among
abused women who use violence in intimate relationships. Violence
Against Women, 9: 75–109.  
Swan SC & Snow DL. (2003). Behavioral and psychological differencesamong abused women who use violence in intimate relationships. Violence Against Women; 9:75–109.
Swan SC & Snow DL. (2006). The development of a theory of women’s useof violence in intimate relationships. Violence Against Women; 12:1026–
1045.

Suzanne C. Swan, Ph.D 201

INTERVIEW WITH SUZANNE C. SWAN, PHD

The Nature and Patterns of Women’sViolence
By James E. McCarroll
January 2006, Volume 9, Issue 1
Dr. McCarroll: It is important for the Army to understand the nature andpatterns of abuse by both men and women for developing more effective
prevention and treatment. As a scholar of women’s psychology, how does
domestic violence ﬁt into women’s studies?
Dr. Swan: I think it has been there for a while. Lenore Walker wrote inher classic book “The Battered Woman” (Walker, 1979) about how some of
the women that she interviewed tried to use violence to defend themselves
against their partners. Straus and Gelles, in the their national surveys of domestic violence (Straus & Gelles, 1986) asked men and women about using
physical violence against their partners and found that about the same number of women and men used vio­lence. But, people have not been comfortable talking about women’s violence until recently.
Dr. McCarroll: What are the current discus­sions about women’s use of violence?
Dr. Swan: Many feminists are now saying, “Of course women can beviolent”. We do not have to view women solely as victims, women can haveagency in these situations.
Dr. McCarroll: When power and control are issues in a relationship, what
are the impli­cations of gender?
Dr. Swan: It is more complex than we tend to think. Domestic violencealso occurs in gay and lesbian relationships. We have all learned a patriarchal system of power and control. In a relationship in which one person
has more power than the other, that position of power can give that person
permission to abuse the other person.
Dr. McCarroll: How do you differentiate be­tween gender and sex?
Dr. Swan: Sex is a pretty speciﬁc term where you are really talking about
biological differences. Gender is everything psychological including the entire cultural overlay that we add to sex. I think it is an important distinction.
People tend to exaggerate gender differences, i.e., “Boys do better on aver-202 Family Violence Research, Assessment and Interventions

age in math than girls.” Really the distributions overlap much more thanthey differ. The term gender is trying to get away from people’s assumptions
about differences that are based on sex and thought to be biologically determined. It is controversial. Some people argue that gender differences reallyare a result of brain structure and biology and genetics.
Dr. McCarroll: What does a clinician or health-care professional need toknow about relationship violence?
Dr. Swan: I think I would tell them that they are not going to ﬁnd too
many cases of female unilateral violence that would meet the criteria for
intimate terrorism. (See Johnson & Leone, 2005, for a discussion of intimate
terrorism.) Most of the time when they are dealing with women, both people are violent. At times, the violence by the woman is in self-defense, butthat is not always the case. Sometimes the woman’s violence is in responseto the man’s attempt to control her. She may not know what else to do. Our
cultural notions of gender are that men should have more power and con­trol in relationships. So, she is not going to be able to use power and control
to equalize the distribution of power. I think some women use violence because that is all they know.
Dr. McCarroll: How do you view existing vio­lence prevention programs for
adults?
Dr. Swan: I think education is helpful for adults to learn what is appropriate in relation­ships. Some people have grown up in homes where there
was violence and do not know other ways of handling things. They might
not deﬁne it as a problem or know what to do about it. At a minimum, letpeople know what resources are out there and give them a conﬁdential way
to access those resources.
Dr. McCarroll: What are the relationship impli­cations of your research on
typologies?
Dr. Swan: The typologies are relational, but I think gender is always
there. When you look at coercive control, you still ﬁnd that it is much morecommon for women to receive it than to be coercive toward their partners.
When they are coercive, they seem to be less effective than men. When weinterviewed women about how they might try to control their partner’s behavior, they would say something like, “Yeah, I told him he couldn’t go out,
but he would do it anyway. He would just laugh in my face and leave.” I think
many women, especially those in abusive relationships, would feel much
more constrained if their partner tells them, “You can’t go out.” It’s going tohave more of an impact on them.

Suzanne C. Swan, Ph.D 203

Dr. McCarroll: How would you measure those typologies clinically?
Dr. Swan: One could develop a list of crite­ria that a couple would haveto meet to ﬁt into a particular typology. I am really interested in a better understanding of coercive control and particularly how women do that. (While
there is currently no accepted measure of coercive control, see Dutton andGoodman, 2005, for a discussion of the concept and their efforts at developing a measure.) In all societies, women have some ways of maintaining
power and it is often indirect. Even women who are being terribly abused
are doing something. They are not just victims. They are active agents trying
to manage their situation. I am interested in learning more about that.
Dr. McCarroll: Could you expand upon the differences in causes for men’s
and women’s violence?
Dr. Swan: In looking at the literature of motivations for using violence,the studies tend to ﬁnd that women are more likely to use vio­lence in selfdefense than men. Men are more likely to use it to try to control their partner. But, I actually think that the motivations are really much more complex
and people often have multiple motivations. Fighting back may not be only
about self-defense, it may also be about retribution because the person isangry about experiencing this victimization. When we asked about motivations in some of my studies, about three out of four women said that they
had used violence in self-defense and one out of three said they had usedviolence at least once to try to make their partner do something. Forty-ﬁve
percent had used violence for pur­poses of retribution.
Dr. McCarroll: We look forward to your future research.
Key Points
In looking at the literature of motivations for using violence, thestudies tend to find that women are more likely to use violence inself-defense than men.
We have all learned a patriarchal system of power and control. Ina relationship in which one person has more power than the other,that position of power can give that person permission to do abusive
things to the other person.

204 Family Violence Research, Assessment and Interventions

References
Dutton MA & Goodman LA. (2005). Coercion in intimate partner violence: Toward a new conceptualization. Sex Roles; 52:743–756.
Johnson MP & Leone JM. (2005). The differential effects of intimate terrorism and situational couple violence. Journal of Family Issues; 26:322–
349.
Straus MA & Gelles J. (1986). Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. Journal of
Marriage and the Family; 48:465–479.
Walker, L.E. (1979) The battered woman. New York: Harper and Row.

Suzanne C. Swan, Ph.D 205

REVIEW OF RECENT RESEARCH OF SUZANNE C. SWAN, PHD

Context, Levels, Motivations, and Effects of
Men’s and Women’s Violence
By James E. McCarroll, PhD
May 14, 2009
Dr. Swan has continued her research on the context of women’s violence.
Swan and colleagues reviewed the scientific literature on women’s use of violence with male intimate partners to inform service providers in the militaryand civilian communities who work with abused women (Swan, Gambone,
Caldwell, Sullivan, & Snow, 2008). They described the context of men’s andwomen’s use of violence (physical, sexual, psychological, sexual, coercive
control and stalking), the level of violence (less serious and serious), themotivations and effects of violence, and how these differences may affectintervention for women. Their conclusions were that (1) men and women
perpetrate similar levels of psychological and physical violence, but men
perpetrate more sexual abuse, coercive control, and stalking, (2) low-level violence is about equally likely to be initiated by men and women, butwhen violence is serious, women are much more frequently to be victims
and to be injured, (3) women’s violence is more likely to be motivated byfear and self-defense, particularly less serious violence, and (4) women in
mutually violent relationships are more likely than men to suffer negative
effects. Women’s violence appears to generally occur in the context of violence against them by their male partner. They concluded that because of thedifferences in motivation and behaviors in men’s and women’s violence thatinterventions for women that are based on models of male partner violence
and not likely to be effective.  
The context of men’s and women’s violence was studied in a sample oflargely Hispanic male and female college students (Allen, Swan & Raghavan,
2008, online). Victimization and perpetration between intimate partners
were approximately equal, but women’s violence tended to be in reaction tomale violence. Men were more likely to initiate violence and their partners
to respond with violence. This study also explored sexist attitudes toward
violence and gender roles of men and women, a topic that underscores theimportance of understanding the cultural context in which violence occurs.
Such research will be of increasing importance as the U.S. society becomes
more multicultural.
Understanding help-seeking by women who use violence has had little

206 Family Violence Research, Assessment and Interventions

scientific scrutiny (Swan & Sullivan, 2008). In this study, of women who usedviolence against a male partner (94% of whom also experienced victimization) almost all the women utilized community resources in an attempt tomanage the violence in their lives. One of the key findings of this study wasthat the use of resources reduced the likelihood of women’s perpetration ofviolence. Social support was the most frequently used resource and support
played an important role as a predictor of resource utilization. However, themajority of women were also struggling with many other social, personal,
and mental health problems and they did not tend to use services provided
by the local domestic violence agency. Rather, they used services such as
the criminal justice system, housing assistance, substance abuse treatment
and therapy. The authors pointed out how important it is for workers in
the domestic violence field to recognize the linkages between domestic violence and other stresses and to work with other agencies, when feasible, toimprove the lives of domestic violence victims. This is key finding for bothresearchers and practitioners: what services people use, how they use them,and how both can work together to improve the lives of abuse victims.  
Swan and her colleagues further explored the context for women’ violence and developed a scale for measuring such violence (Caldwell, Swan,
Allen, Sullivan, & Snow, 2009). An exploratory factor analysis of the scale,“Motives and Reasons for IPV”, identified five factors: expression of negative
emotions, self-defense, control, jealousy, and tough guise. There were multiple motives for their behavior and all five of the factors were commonly
given by the women. An average of 14 of 26 items on the scale was endorsedby the participants. The most frequently endorsed motive was the expression of negative emotions (e.g., “Because he made you angry.”). Almost 90%
endorsed motives of control, both reacting to control by their partner andwomen’s attempts to control their partner. About 85% indicated that selfdefense was their motive for aggression; about 70% used aggression to intimidate or harm their partner, a motive driven by the desire to be taken seriously; about 67% due to jealousy; and about 45% actually wanted to harm
their partner.
Dr. Swan’s work illustrates the importance of exploring the interpersonal
context of violence. Her work and that of others increasingly demonstrates
that rarely are either women or men only the victims of aggression. The relationships between perpetration and victimization are complex. There are
significant gender and cultural differences that require more understanding.
It is also increasingly clear that treatment models for domestic violence victims and offenders need to be tailored to the context of violence as well as
the history of the individual and to previous relationships.

Suzanne C. Swan, Ph.D 207

Key Points
Swan and Sullivan (2008) found that the use of resources reduced
the likelihood of women’s perpetration of violence. Social support
was the most frequently used resource and support played an
important role as a predictor of resource utilization.
The research of Dr. Swan and her colleagues increasingly
demonstrates that rarely are either women or men only thevictims of aggression. The relationships between perpetration andvictimization are complex.

References
Allen CT, Swan SC, & Raghavan C. (2009). Gender symmetry, sexism, andintimate partner violence. Journal of Interpersonal Violence; 24:1816–
1834.
Caldwell JE, Swan SC, Allen CT, Sullivan TP, & Snow DL. (2009). Why I hit
him: Women’s reasons for intimate partner violence. Journal of Aggression, Maltreatment, & Trauma; 18:672–697.
Swan SC, Gambone LJ, Caldwell JE, Sullivan TE, & Snow DL. (2008.) A
review of research on women’s use of violence with male intimate partners. Violence and Victims; 23:301–314.
Swan SC, & Sullivan TP. (2009) The resource utilization of women who
use violence in intimate relationships. Journal of Interpersonal Violence;
24:940–958.

208 Family Violence Research, Assessment and Interventions

SECOND INTERVIEW WITH SUZANNE C. SWAN, PHD

Victim-Perpetrator Relationships inDomestic Violence
By James E. McCarroll, PhD
May 2009
Dr. McCarroll: What has been the overall direction of your work since thelast interview in Joining Forces Joining Families?
Dr. Swan: It is still the context of women’s violence within the larger
society as well as within the interpersonal context of their relationships.
Dr. McCarroll: We discussed your research on typologies of the perpetratorvictim relationship in our first interview. Have you had a chance to follow
up on that research by replicating or extending it?
Dr. Swan: I have, but the analyses at this point are preliminary. The number of participants in the first paper was small, 108 women. In this newer
data set we have 412. We tried to see if the four factors replicated. There wasa lot of overlap, but they were not completely the same. However, that leads
me to think that there is some validity to these factors.
Dr. McCarroll: Where did you obtain your samples?
Dr. Swan: They were community women in New Haven, Connecticut.
They all had used violence against a male partner in the past six months.
They volunteered in response to an ad and were not seeking treatment.
Dr. McCarroll: Do you think that these factors apply to other populations?
Dr. Swan: I would like to know that. I am probably going to work morewith college populations at this point because of where I am right now. I
think some of the same views might be there. For example, I think there aresome couples who are using low levels of violence like that mixed female
coercive group and are relatively better off. There are probably some otherrelationships where there is serious violence. But, because the population is
younger and they have not been engaging in this behavior for 20 years, there
will be differences.
Dr. McCarroll: Then this would be largely then dating violence?
Dr. Swan: Right.

Suzanne C. Swan, Ph.D 209

Dr. McCarroll: Your recent research on the context of men’s and women’s useof violence included sexual violence by women. Your questionnaire dealt
only with the behaviors of the women. Do you have a sense of their motivation for engaging in sexual violence against their male partners? Dr. Swan:
I would like to know that, too. We need to do some qualitative research because we do not know much at all about women’s sexual aggression or the
motives for it. I know that it goes on in college populations because students
in my classes talk about it.
Dr. McCarroll: In a previous paper, you speculated that women’s sexual aggression might be to frighten and intimidate men. Do you think still believe
that?
Dr. Swan: I thought that might be the case. I only have that one motive
item related to sexuality – “To get turned on sexually…” I really was not sure
how this would play out on the factor analysis. It ended up being a factor on
the “tough guise” subscale but, the drinking and drug items were there as
well. In that New Haven sample there was a subgroup of women who wereinvolved in the drug culture and they were pretty tough folks.
Dr. McCarroll: Do you think that women’s sexual aggression is more an expression of intimidation and humiliation or for sexual pleasure?
Dr. Swan: I think it is both. It is more complex than just a violent act inthat it uses sexuality for the purpose of putting yourself over somebody or
putting somebody down.
A nontrivial percentage of women had done some of those behaviors andmore had been victimized, but a higher number than I would have predictedendorsed perpetrating some of those behaviors.
Dr. McCarroll: One of the issues you found in your work with women’s violence is the expression of negative emotions. Would you elaborate on thatpoint?
Dr. Swan: My sense is that a lot of the women in the sample were experiencing coercive control from their partners and they responded by becoming extremely angry, frustrated, fed up and not knowing what else to do,so they lashed out in violence. It seemed to me that there was some part ofthe sample that did not have a lot of control over their emotional lives andwould become violent.
Dr. McCarroll: Is negative emotion largely anger?
Dr. Swan: Anger, frustration, and emotional hurt.

210 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Do you think that any in your sample of women were unilateral batterers or abusers and could be construed as female batterers in termsof being frequently and severely abusive?
Dr. Swan: That is an interesting question. In one sense “No” because allof them were victimized in some way by their partners. When we think ofbatterers we think of someone who is extremely violent and controlling andwho has a partner who is just totally under their thumb and is walking on
egg shells around that person in order not to have them blow up. In my sample the ones who were the most violent also were very highly victimized.
Dr. McCarroll: What do you see in terms of the gaps then that occur both inresearch and services on women’s violence?
Dr. Swan: It seems to me like the services are behind the where the research is. I have been out of that area for a little while now, but from what I
can tell the main way that we deal with domestic violence still is by arresting
people. We are not doing much with prevention. When people are arrested,
we tend to treat women’s violence and men’s violence as the same phenomenon. This is like assuming that men are only perpetrators and women are
only victims. So we put them into the same kinds of programs. Not everyone
is doing that, but I think that it is still common in most places. We know
something about the context of women’s violence now from the research,
but I do not think it is making its way prevention and treatment programs
yet.
Dr. McCarroll: What would you tell people if you had to address prevention
and treatment issues for women?
Dr. Swan: I will tell you a little about what I’m doing at the University ofSouth Carolina with respect to prevention. We have a program that I havebeen doing for two years named “Changing Carolina.” The basis of it is to involve college students, male and female, in the prevention of violence among
their peers. We know that in the college-aged years (whether you’re in college or not), dating violence tends to peak about that time, late teens andearly 20s. On a campus like this one there are 25,000 people that age, all ofwhom are all away from home for the first time and developing serious relationships. So, there will be a lot dating and sexual violence going on. I am
interested in having students feel like they can make a difference in violence
prevention. We know that most students are not violent themselves and do
not want it going on. I really tried to target men in the intervention. The
85% of men who are not violent can hold their peers accountable if they areusing violence. But, a lot of men don’t want to be the first one to speak up.
We are hoping to create an atmosphere where students feel empowered toSuzanne C. Swan, Ph.D 211

speak and if they see something happening (like if they’re at a party, they see
a women who is drinking and maybe she’s not very aware of what’s going on
and there’s someone else who is trying to take advantage of her), that theywould speak up and do something about that and not just look the otherway. Bystander intervention is the formal name for it. So I have been teaching a class for the last couple of years where we train students to do that. If
I can get some funding in for it, I would really like to bring bystander intervention training here. The University of Kentucky has a four hour training
they do on a voluntary basis with students who are interested in doing it. The
point of that is really to raise students’ awareness about the violence goingon around them and to have them become violence prevention advocatesthrough daily behaviors really. They let their peers know that they are opposed to violence. So, if someone tells a joke about rape, hopefully people
who have had this training would speak up and talk about why this is not
appropriate.
Dr. McCarroll: Is there a website for your program now?
Dr. Swan: I have a little bit about it on my website.
Dr. McCarroll: Have you collected any data on it yet?
Dr. Swan: We have been collecting data through the class. I want to try
to get a paper out about that this summer. It looks like it is doing the things
we would like it to do in terms of hostility towards women. Sexism is oneof the measures. So far, it looks like at the end of the semester people are
more comfortable with intervening in violent situations and they feel more
empowered that they can take an active role. The other piece of it that weare looking at is the extent that masculinity and men’s expectations about
what they have to do to be accepted by their male peers impedes their involvement in violence prevention. We talk a lot about that in the course I
teach, which is called ‘Men and Masculinity.’ Among our measures are men’s
conformity to masculine norms. Scores tend to improve toward the end of
the semester.
Dr. McCarroll: I think that your work on relationship typologies is really
important. Other typology work has been largely mental-health and individual-male-batterer oriented (e.g., Hamberger & Hastings, 1986; Holtzworth-Monroe & Stuart, 1994; Hamberger, Lohr, Bonge, & Tolin,1996). If
you were advising people who were working with women as either victims orperpetrators both, as your data show, how would you advise people to treat
them? Would it be differently from men?
Dr. Swan: Yes. I think the key is to recognize that there is almost always

212 Family Violence Research, Assessment and Interventions

going to be both victimization and perpetration going on. If you are doing
anger management with a woman and she is being victimized, then it does
not seem like anger management is going to help much because she is still
being beaten at home. If you are working with a woman through victim services and she is using violence herself, if you are not addressing the violence
that she is using and the context for it, then it seems like will miss part ofthe picture.
Dr. McCarroll: Thank you for being so generous with your time.
Dr. Swan: Thanks for having me again.
Key Points
My sense is that a lot of women in my study who experienced
coercive control from their partners responded by becoming
extremely angry, frustrated, and fed up. Not knowing what else todo, they lashed out in violence.
We know something about the context of women’s violence now
from the research, but I do not think it is making its way prevention
and treatment programs yet.

References
Hamberger LK & Hastings JE. (1986). Personality correlates of men who abuse
their partners: A cross–validation study. Journal of Family Violence; 4:
323–341.
Hamberger LK, Lohr JM, Bonge D, & Tolin DF. (1996). A large sample empirical typology of male spouse abusers and its relationship to dimensions ofabuse. Violence and Victims;11: 277–292.
Holtzworth–Monroe A & Stuart GL. (1994).Typologies of male batterers:
Three subtypes and the differences among them. Psychological Bulletin;
116: 476–497.

BACKGROUND OF RESEARCH OF K. DANIEL, O’LEARY, PHD

Adult Psychological Abuse
By James E. McCarroll, PhD
Joining Forces Joining Families, Volume 11, Issue 1, March 2009
Psychological abuse (also sometimes referred to as emotional abuse) is adistinct component of domestic violence. While adult physical abuse andsexual abuse are widely recognized as domestic violence,
psychological abuse has received much less at­tention. The
definition of psychological abuse is difficult, particularly
in regard to satisfying both the mental health and legal
professions (O’Leary 1999).
Hostility, in many forms, is psychologi­cal aggression.
It is relatively common, even in happily married couples,particularly in young couples with or without marital discord (O’Leary 1999). But, psychological aggression is not the same as psychological abuse. O’Leary and others have distinguished between aggres­sion
and abuse on the basis of the frequency and intensity of negative remarks
and threats.
The strict definition of psychological abuse is broad and often not clear.
O’Leary (1999) defines it as acts of recurring criticism, verbal aggression,acts of isolation and domina­tion toward an intimate partner. Non-verbal
psychological abuse, such as stalking, can also be considered psychologicalabuse. Potentially abusive behavior can be grouped under the following four
primary dimensions (O’Leary and Mai­uro, 2001):■■ 1. Damaging to partner’s self-image or self-esteem through denigration,■■ 2. Passive-aggressive withholding of emotion­al support and nurturance,■■ 3. Explicit and implicit threatening,■■ 4. Restricting personal territory and freedom.
In couples’ therapy, psychological abuse is often recognized as a difficult
issue with which to work. The seriousness of the effects of psy­chologicalabuse was shown in an early study (Follingsted, Rutledge, Berg, et al., 1990).

214 Family Violence Research, Assessment and Interventions

They studied six types of emotional abuse of 234 women with a history ofphysical abuse and related these types to the frequency and severity of thephysical abuse. The six types were: verbal attacks, social or financial isola­tion
or restriction, jealousy or possessiveness, threats of abuse or harm, threats to
end the marital relationship or have an affair, and dam­age to or destructionof the woman’s property. Ninety-nine percent of the women had experi­enced
some form of emo­tional abuse and 72% reported experiencing four or moretypes. The most frequently reported type of abuse was ridi­cule, but threatsof abuse, jealousy, and restriction all occurred to a large percentage of thewomen. Ridicule was reported as having a negative impact by the highest
percentage and threats of abuse were the second most negatively impact­ing
type. Seventy-two percent of the women reported that psychological abusehad a more negative impact on them than physical abuse. None of the individual types of psychological abuse was related to the frequency of physicalabuse or severity of injuries. However, about half the women (54%) used theemotional abuse incident, particularly threats of abuse and restriction, to
predict an occurrence of physical abuse.
The effects of psychological aggression compared to physical aggression were also reported in a community sample of couples (Taft, O’Farrell,
Torres, et al., 2006). In this sample, psychological aggression victimization
was associated with greater distress, anxiety, and physical health symptoms
beyond the effects of physical aggression. Psychological victimization was
also uniquely associated with higher levels of depression for women only.
Possible distinct etiologies were suggested for male and female perpetratorsand highlighted the need for dif­ferent models of psychological aggression
for men and women.
O’Leary and Maiuro (2001) reviewed measures of psychological abuse
and measures derived from them. Eight measures that have been used are
the Conflict Tactics Scale (Straus, Hamby, Boney-McCoy, et al., 1990), theIndex of Spouse Abuse (Hudson & McIntosh, 1981); Spouse Specific Aggression and Asser­tion (O’Leary & Curley, 1986), Psychological Maltreatment of Women (Tolman, 1989), Index of Psychological Abuse (Sullivan,
Pari­sian & Davidson, 1991), Severity of Violence Against Women (Marshall,
1992), and the Dominance Scale (Hamby, 1996).
Psychological abuse has substantial negative health effects. Female gastroenterology patients with irritable bowel syndrome, a bowel condition
without a known organic basis, reported signif­icantly higher levels of emotional abuse, self-blame and self-silencing than comparison pa­tients who
had irritable bowel disease, a bowel condition with a known organic basis(Ali, Toner, Stuckglass, et al., 2000). Emotional abuse remained associatedwith irritable bowel syndrome even when physical and sexual abuse histo-

K. Daniel O’Leary, PhD 215

ries were controlled. The authors concluded that women who experienced
emotional abuse may be more likely to develop response patterns of inhibiting self-expression and taking responsi­bility for negative events, all of which
may lead to increased levels of stress affecting the gastro-intestinal system.
Psychological abuse was also associated with an increased risk of smoking in a cohort of white, well-educated, and employed women. Further,when it co-occurred with physical or sexual abuse, the risk was increased(Jun, Rich-Edwards, Boynton-Jarrett, et al., 2008). Dominance and isolation
predicted increases in depressive symptoms over time in dating women.
These effects were moderated by their levels of perception of interpersonal
control (Katz & Arias, 1999). Psychological abuse and stalking contributed
uniquely to post-traumatic stress disorder (PTSD) and depression symptoms after controlling for the effects of physical and sexual violence and injuries (Mechanic, Weaver, & Resick, 2008). In a study of living in a shelter,
psychological abuse was a significant predictor of PTSD and intentions toleave the abusive partner even after controlling for the effects of physicalabuse (Arias & Pape, 1999). Male-to-female psychological aggression has
also been associ­ated with distress in mothers and internalizing and externalizing behavior in children (Clarke, Koenen, Taft, et al., 2007).
Importantly, psychological abuse nearly al­ways seems to precede physicalabuse and thus prevention of psychological abuse may prevent later physicalabuse and injury (O’Leary, 1999).
Key Points
Psychological abuse (also sometimes referred to as emotional abuse)
is a distinct component of domestic violence.
Hostility, in many forms, is psychologi­cal aggression. But,
psychological aggression is not the same as psychological abuse.
The strict definition of psychological abuse is broad and often not
clear. O’Leary (1999) defines it as acts of recurring criticism, verbal
aggression, acts of isolation and domina­tion toward an intimate
partner. Non-verbal psychological abuse, such as stalking, can also
be considered psychological abuse.

216 Family Violence Research, Assessment and Interventions

In an early study of psychological abuse, 99% of the women had
experienced some form of emotional abuse and 72% reported
experiencing four or more types.
Psychological abuse has substantial negative health effects.

References
Ali A, Toner BB, Stuckless N, Gallop R, Diamant NE, Gould MI, & Videns
EI. (2000). Emotional abuse, self–blame, and self–silencing in womenwith irritable bowel syndrome. Psychosomatic Medicine; 62: 76–82.
Arias I & Pape KT. (1999). Psychological abuse: Implications for adjustment and commitment to leave violent partners. Violence and Victims;
14: 55–67.
Clarke SB, Koenen KC, Taft CT, Street AE, King LA & King DW. (2007),
Intimate partner psy­chological aggression and child behavior prob­lems.
Journal of TraumaticStress; 20: 97–101.
Follingstad DR, Ritledge LL, Berg BJ, Hause ES & Polek DS. (1990). The
role of emotional abuse in physically abusive relationships. Journal of
Family Violence; 5: 107–120.
Hamby SL. (1996). The Dominance Scale: Pre­liminary psychometric properties. Violence and Victims; 11: 199–212.
Hudson WW & McIntosh S. (1981). The index of spouse abuse. Journal of
Marriage and the Family;43: 873–888.
Jun HJ, Rich–Edwards JW, Boynton–Jarrett R, & Wright RJ. (2008). Intimate partner violence and cigarette smoking: Association between
smoking risk and psychological abuse with and without co–occurrenceof physical and sexual abuse. American Journal of Public Health; 98:
527–535.
Katz J & Arias I. (1999). Psychological abuse and depressive symptoms
in dating women: Do different types of abuse have differential ef­fects?
Journal of Family Violence; 14: 281–295.
Marshall LL. (1992). Development of the severity of violence against
women scales. Journal of Family Violence; 7: 103–121.
Mechanic MB, Weaver TL, & Resick PA. (2008). Mental health consequences of intimate part­ner abuse: A multidimensional assessment offour different forms of abuse. Violence Against Women; 14: 634–654.
O’Leary DK. (1999). Psychological abuse: A vari­able deserving critical attention in domestic violence. Violence & Victims; 14: 3–23.

K. Daniel O’Leary, PhD 217

O’Leary KD & Curley AD. (1986). Assertion and family violence: Correlates of spouse abuse. Journal of Marital and Family Therapy; 12:
281–289.
O’Leary KD & Maiuro RD. (2001). Psychological abuse in violent domestic
relations. New York: Springer Publishing Company.
Straus MA, Hamby SL, Boney–McCoy S, & Sugarman DB. (1990). The
Revised Conflict Tactics Scale (CTS2). Journal of Family Issues; 17:
283–316.
Sullivan CM, Parisian JA & Davidson WS. (1991). Index of psycho­logicalabuse: Development of a measure. Poster presented at the annual conference of the American Psychological Association, San Francisco, CA.
Taft CT, O’Farrell TJ, Torres SE, Panuzio J, Monson CM, Murphy M, &Murphy CM. (2006). Examining the correlates of psy­chological aggression among a community sample of couples. Journal of Family Psychology; 20: 581–588.
Tolman RM. (1989). The development of a measure of psy­chological maltreatment of women by their male partners. Violence and Victims; 4:
159–178.

218 Family Violence Research, Assessment and Interventions

INTERVIEW WITH K. DANIEL O’LEARY, PHD

Psychological Aggression and Psychological
Abuse: Is There a Difference?
By James E. McCarroll, PhD
Joining Forces Joining Families, Volume 11, Issue 1, March 2009
Dr. McCarroll: How would you explain psychological aggression?
Dr. O’Leary: Unlike physical aggression that is easily classified into various acts like pushing, slapping, and shoving, psychological aggression can
run the gamut from behaviors such as re­fusing to talk to the person, giving him/her the cold shoulder, constant belittling, and/or con­trolling their
whereabouts — almost keeping them imprisoned. There are many problems
with the definition of psychological abuse. It is easier for the legal and mental
health profes­sions to agree on a definition of physical abuse because there iszero tolerance for unwanted physical aggression. Some form of psychologi­
cal aggression against a partner is committed essentially by everybody atsome time. Thus, if one wishes to differentiate between psycho­logical aggression and psychological abuse, it is necessary to agree on what constitutes
the boundary from one to the other. We have characterized four types ofpsychological abuse (O’Leary & Maiuro, 2001):■■ Critical comments that damage a partner’s self-esteem;■■ Passive-aggressive withholding of support (the silent treatment);■■ Threats of physical harm;■■ Restriction of freedom.
Dr. McCarroll: Do you differentiate between psychological aggression andpsychological abuse?
Dr. O’Leary: In my clinical work, I do not generally try to distinguish between the two because it often is unclear where to draw the line. It is akin to
the difference between physi­cal aggression versus battering. You can easily
categorize certain psychologically aggressive behaviors as abusive like taking the spark plugs out of a car or restricting money and check­book access.
However, if pressed, I would cat­egorize recurring acts of any of the fourtypes of psychological aggression described above as psychological abuse.
Such recurring acts are likely to make a partner lose self-esteem and/or be
fearful.

K. Daniel O’Leary, PhD 219

Dr. McCarroll: Does psychological abuse predict physical abuse?
Dr. O’Leary: Not necessarily, but it is the single best predictor, even better
than alcohol. There are examples of actions taken to harm another person
where there was not a verbal argument immediately preceding it, but these
are the rare exceptions. Most acts of physical aggression follow a verbal argument or are in the context of a verbal argument. We know that people canexperience a great deal of psycho­logical abuse, even if it never occurs withphysi­cal abuse. We also know that it is associated with a great deal of relationship discord. You can predict that physical abuse will later occur if there
is a tendency for people to have psycho­logical aggression across time. In
other words, it is the extent of psychological aggression that is predictive ofwhether a physically aggressive act will occur (Murphy & O’Leary, 1989).
Dr. McCarroll: What is the trigger in which psychological aggression escalates to physical abuse?
Dr. O’Leary: One of the triggers is alcohol or any substance that lowers
inhibitions. An­other trigger is if the argument taps into what is really at yourcore, your sense of who you are as a person or your firmly held beliefs andvalues.
Dr. McCarroll: One of the missions of the Army Family Advocacy Program(FAP) is prevention. What should FAP personnel who give domestic violence prevention classes tell people about psychological abuse?
Dr. O’Leary: My first task would be to tell people that psychological aggression is a serious issue. I try to tell mental health audiences the importance of reducing psychological aggres­sion whether it is through relaxation,
medica­tion, relationship enhancement, or financial consultation. Anythingthat will reduce psycho­logical aggression will make physical aggression lessprobable.
Dr. McCarroll: How do you differentiate between verbal abuse and psychological aggression?
Dr. O’Leary: Individuals who have a dif­ference of opinion and who attempt to resolve their relationship differences can do so without being psychologically aggressive, i.e. calling their partner names, screaming at themor say­ing things to make the partner feel inferior. To differentiate assertion
from verbal aggression, Curley and I developed a measure of spouse specificassertion and spouse specific aggression (O’Leary & Curley, 1986).
Dr. McCarroll: How damaging is psychological abuse?
Dr. O’Leary: There are a few descriptive studies where women who have

220 Family Violence Research, Assessment and Interventions

been physically abused or battered have also reported psychological abuse.
They reported that the psychological abuse had a more negative effect thanthe physical abuse (Follingstad, Rutledge, Berg, et al., 1990; Arias & Pape,
2001). Any­thing that goes to the core of one’s self-esteem, is most likely tobe emotionally damaging to the person.
Dr. McCarroll: Do you see people in your clinic who come in for help withpurely psychological abuse or verbal abuse?
Dr. O’Leary: We found that if you ask men and women to briefly describe their major marital problems, about 50% of men and 60% of womenreport communication. Lack of sexu­ality and personality style problems arereported as the next most frequent problems by both husbands and wives(O’Leary, Vivian, & Malone, 1992). Another form of psychological abuse,
which is particularly damaging, is threatening to leave the relationship.
When people come into therapy, we say that one of the ground rules is not
to tell the other that you are thinking about divorce or you are threatening
divorce. It just sets things back and instills more distrust.
Dr. McCarroll: How do you measure psychological aggression?
Dr. O’Leary: We use a variation of the Conflict Tactics Scale (Straus,
Hamby, Boney-McCoy, et al., 1990), a self-report of aggressive behavior, withpotential clients for therapy. We ask them to describe any major argumentsthat have taken place. In the interview, we try to get a more detailed elaboration of what happened in the most recent incident and to get a sense ofwhat both of them will own up to. Both men and women underreport negative things that they have done, though men tend to underreport more than
women, particularly on the more serious aggressive acts. We have found that
if you look at the agreement about psychological aggression or physical aggression it is not sub­stantially different than agreement on positive activities
like kiss your partner, engage in outside activities together, laugh together(O’Leary & Williams, 2006).
Dr. McCarroll: The literature on psychological abuse seems largely to beabout psychological abuse of women. Is there any literature about womenas perpetrators?
Dr. O’Leary: If you look at all the published studies on husband and wife
interactions in marital assessments, women actually engage in more negative, more critical behavior than do men whereas men engage in more withdrawing-type behav­ior (Woodin, 2008). So, it would make some sense thatwomen might score as high or higher on measures of psychological abuse.
We know that on measures of psychological aggression like the Straus scale

K. Daniel O’Leary, PhD 221

and even on a scale like dominance and jealousy, women in our samples had
scores that were essentially not different from those of men.
Dr. McCarroll: Is adult psychological abuse recognized in state laws?
Dr. O’Leary: In New York State it is. It is not uncommon to have orders ofprotection based on threats. When a person is alleged to have made threatsagainst an individual’s person or their animals, an order of protection can beinitiated through the courts without any evidence of physical contact.
Dr. McCarroll: Thank you for your time and your insights.
Dr. O’Leary: You are welcome.
Key Points
O’Leary & Maiuro (2001) have characterized four types ofpsychological abuse:■■ Critical comments that damage a partner’s self-esteem,■■ Passive-aggressive withholding of support (the silent treatment),■■ Threats of physical harm,■■ Restriction of freedom.
Psychological abuse is associated with a great deal of relationshipdiscord.
Most acts of physical aggression follow a verbal argument or are in
the context of a verbal argument.

References
Arias I, & Pape KT. (2001). Psychological abuse: Implications for adjustment and commitment to leave violent partners (pp. 137–151). In
O’Leary, K. D., & Maiuro, R. D. Psychological Abuse in Violent Domestic
Relations. New York: Springer Publish­ing Co.
Follingstad DR, Rutledge LL, Berg BJ, Hause ES, & Polek DS. (1990). The
role of emotional abuse in physically abusive rela­tionships. Journal of
Family Violence; 5: 107–119.
Murphy CM & O’Leary KD. (1989). Psychological aggression predicts
physical aggression. Journal of Consulting and Clinical Psychology; 5:579–582.

222 Family Violence Research, Assessment and Interventions

O’Leary KD & Curley AD. (1986). Assertion and family violence: Correlates of spouse abuse. Journal of Marital and Family Therapy; 12:
281–289.
O’Leary KD & Maiuro RD. (2001). Psychological Abuse in Violent Domestic
Relations. New York: Springer Publishing Co.
O’Leary KD, Vivian D, & Malone J. (1992). Assessment of physical aggression against women in marriage: The need for multi­modal assessment.
Behavioral Assessment;14:5–14.
O’Leary KD & Williams MC. (2006) Agreement about acts of ag­gression in
marriage. Journal of Family Psychology, 20, 656–662.
Straus MA, Hamby SL, Boney–McCoy S, & Sugarman DB. (1990). The
Revised Conflict Tactics Scale (CTS2). Journal of Family Issues; 17:283–
316.
Woodin E. (2008). Communication and problem solving in mar­riage: A
meta–analytic review. Unpublished manuscript. Stony Brook University.

SECTION INTRODUCTION

Mental HealthThis section addresses two of the most important mental health topics related
to family maltreatment: depression and alcohol misuse. William Beardslee
has had a long and very productive career in studying the role of depression
in families. His research has included both the prevention and treatment
of depression in children and adults. Particularly important in the current
environment has been his work in adapting his interventions for depressionin other cultures.
Christopher Murphy has addressed the role of alcohol in domestic violence. Alcohol is one of the biggest contributors to domestic violence as wellas one of the most difficult areas of practice for domestic violence counselors.
Both Dr. Beardslee and Dr. Murphy address areas of needed intersection
for family maltreatment in that both impact children and other systems ofservice delivery that often do not work together. Both emphasize the importance of a broad view of these problems, depression and alcohol misuse, as
they impact the family.

224 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF WILLIAM R. BEARDSLEE, MD

Depression in Children: An Emphasis on
Prevention
By James E. McCarroll, Ph.D.
Joining Forces Joining Families Volume 8, Issue 3, Summer 2005
Dr. Beardslee has studied the mental health and resilience of children living in families affected by parental depression, poverty or vio­lence. He has
extensive experience in adapting interventions devised in one setting to other settings and has adapted the original preventive intervention approachfor Latino families, for African-American families,
and in other contexts. He has been especially interested in the protective effects of self-understanding
in enabling youngsters and adults to cope with adversity and has studied self-understanding in civilrights workers, survivors of cancer, and children of parents with affective
disorders.
The study of childhood depression and the impact of parental depression
on children is a relatively recent scientific endeavor. The following article
summarizes Dr. Beardslee’s research on educating a family about depression
and facilitating their ability to talk about it and its effects in order to resume
and strengthen healthy and meaningful communication and functioning.
An important part of Dr. Beardslee’s work is building resilience in children of depressed and non-depressed parents. The interventions he employs
are practical and can be applied by all levels of family advocacy personnel.
Although not necessarily easy to implement, they have undergone rigorous
scientific tests through a series of studies of randomized trials.
Children of affectively ill parents are more likely to have increased ratesof psychiatric disorder and other negative psychosocial outcomes than children from homes with parents without affective illness (Beardslee & Glad-226 Family Violence Research, Assessment and Interventions

stone, 2001). Beardslee sees the processes that underlie the emergence of
health or illness as dynamic and influenced by developmental changes. In
his view, it is these developmental influences as well as societal adversity(e.g., living in poverty, exposure to violence, job loss, and other social ills)
that are critical to understanding the risk for and the prevention of depression.
Risk factors are events, characteristics, or conditions that make a negative
outcome more likely (Carbonell, Reinherz, Giaconia, et al., 2002). Such risk
factors (often referred to as multiple adversities by Beardslee) act concurrently to predict the onset of serious affective disorder in adolescents morethan single risk factors. In families with multiple risk factors (e.g., numberof child diagnoses, duration of depression in a family member, and numberof parental non-affective diagnoses), 50% of the children became ill withserious affective disorders compared with 7% of children who became ill infamilies with none of these three risk factors (Beardslee, Keller, Seifer, et al.,1996).
Beardslee and colleagues in Finland investigated children’s responses tolow parental mood and found that their responses are sensitive to family
dynamics (Solantus-Simula, Punamaki, & Beardslee, 2002; Solantus-Simula,
Punamaki, & Beardslee, 2002). Four patterns were found among the children: active empathy with the parent, emotional over-involvement, indifference, and avoidance. Discrepancies in the children’s perceptions of parenting and the parents’ perceptions of child distress can be meaningful inunderstanding family interactions, child well-being, and child development.
These differences in perception can be the basis of a discussion of family
dynamics and lead to increased understanding of the effects of depression
on children.
In a randomized trial of a group cognitive intervention for preventing
depression in adolescent offspring of parents with a history of depression,
adolescents were given 15 sessions of cognitive restructuring therapy while
the control group was given the usual HMO treatment (Clarke, Hornbrook,
Lynch, et al., 2001). The cognitive restructuring was focused on identifying
and challenging irrational, unrealistic, or overly negative thoughts, with a
special focus on beliefs related to having a depressed parent. The usual treatment (control) group consisted of the randomly assigned study participants
who initiated or continued any non-study mental health treatment or othernon-health care services provided by the HMO or outside the HMO including medication. Those adolescents treated with cognitive restructuring techniques did better than adolescents treated with the usual treatment. Only
9% of the adolescents treated with cognitive therapy had a later depressive
episode compared with 29% of those receiving the usual treatment during

William R. Beardslee, MD 227

a median 15-month follow-up period. Thus, brief cognitive therapy can reduce the risk for depression in adolescent offspring of parents with a historyof depression.
In a series of studies, Beardslee and colleagues developed a family-based
selective intervention program for preventing depression. These studiesof the prevention of depression tested two preventive approaches, both ofwhich can be used by pediatricians, internists, school counselors, nurses,
and mental health providers (Beardslee, Gladstone, Wright, et al., 2003).
Their research method was an efficacy trial of two manualized approaches.
They targeted non-symptomatic, relatively healthy children and adolescents,
between the ages of 8-15, at risk for future depression due to the presencechildren and adolescents, between the ages of 8-15, at risk for future depression due to the presence of significant affective disorder in one or bothparents.
Families were randomly assigned to either a lecture group or a clinicianfacilitated condition. The goals of both interventions were to (1) decrease
the impact of family and marital risk factors, (2) encourage resilience inchildren through enhanced parental and family functioning, and (3) preventthe onset of depression or a related mental illness. The lecture condition
consisted of 2 separate group meetings in which psychoeducational material was presented to parents about mood disorders, risk, and resilience andefforts were made to decrease feelings of guilt and blame in children. The
clinician-facilitated condition consisted of 6 to 11 sessions in which separate
meetings were held with parents, with children, and as a family in which theparents led a discussion of the illness and of positive steps that can be taken
to promote healthy functioning of the children.
Both groups reported significant changes in child-related attitudes andbehaviors and the amount of change reported increased over time. Parents inthe clinician-facilitated group reported significantly more change than thosein the lecture condition. Parents who changed the most in response to theintervention had children who also changed the most. Their most important
finding was that greater parental benefit (changes in illness-related behaviors and attitudes) was associated with significant global change among children. These changes included enhanced understanding of parental illness
and improved communication with parents. They concluded that the connection between parental change and child change was mediated throughfamily change. The positive interaction between parents and children andthe understanding of the illness by everyone in the family (e.g., information about mood disorders) equip parents to communicate information totheir children and to open a dialogue with their children about the effects ofparental depression. Providing parents with factual information regarding

228 Family Violence Research, Assessment and Interventions

risk and resilience in children, and linking this to family illness can result
in behavioral change among parents that ultimately can translate into better
functioning among children.
In a study of the relation between children’s exposure to violence andmental health in a low income community, exposure to violence was correlated with internalizing symptoms (e.g., anxiety and depression), but more
so for girls than for boys (Buckner, Bassuk, & Beardslee, 2004). Beardslee
and colleagues hypothesized that the effects of violence on self-esteem andchronic danger might mediate the link between violence exposure and mental health symptoms. The task was to find a way to improve children’s mental
health in this environment. The mother’s mental health was a strong predictor of children’s mental health and behavior problems. Although the twomost important variables in this study, the mother’s mental health and thechildren’s exposure to violence, are amenable to interventions, much more
information is needed to design the most effective community interventions.
For example, the role of the fathers in this sample was unknown and more
information is needed about the differences in exposures and reactions ofboys and girls to violence.
Previous studies of depressed adults and children have identified manyrisk factors. While studies of resilience have been much more recent andmore limited than studies on risk, several important protective factors havealso emerged. Protective factors are conditions or processes that moderate
the negative effects of risk factors and decrease the risk itself, the effectsof the risk factor, or enhance coping capacity. Adolescent protective factors
were identified in a longitudinal, community-based study that were associated with resilient outcomes in adulthood. Significant protective factors
included family cohesion, positive self-appraisal, and good interpersonal
relations (Carbonell, Reinherz, Giaconia, et al., 2002).
Positive factors identified in other research on adolescents included highlevels of family cohesion at child age 15, higher self-concept and self-appreciation, and spending more time in the company of others (Reinherz,
Stewart-Berghauer, Pakiz, et a., 1989). In another study, resilient youth had
greater self-regulatory skills, higher self-esteem, and more active parental
monitoring (Buckner, Mezzacappa, & Beardslee, 2003). Self-understanding,commitment to relationships, and the ability to think and act separatelyfrom their parents also characterized adolescents whose parents had majoraffective illness (Beardslee & Podorefsky, 1988). These studies of risk andprotective factors indicated that it was possible to identify children at highrisk for depression.
Depression itself may also serve as a risk factor for additional adverse
outcomes. From the National Longitudinal Study of Adolescent Health, itWilliam R. Beardslee, MD 229

was found that depression in boys (but not girls) predicted increased risk ofacquiring sexually transmitted diseases (STD). The authors concluded thatscreening for depression among sexually active adolescents may identify
many of those at risk for later STD (Shrier, Harris & Beardslee, 2002).
Dr. Beardslee advocates strongly for more mental health services, particularly for underserved populations such as those in poverty and who lackhealth insurance or lack coverage for mental health conditions. His view isbuttressed by the powerful evidence amassed by his research and that of hiscolleagues on the prevention and treatment of childhood depression. Part of
the approach to the problem of depression is to advance beyond psychiatrictreatment and attempt to ameliorate adverse societal factors that predisposeor directly contribute to depression. Among these conditions are poverty,
exposure to violence, and social isolation. Successful prevention of depression would be of enormous benefit to society in terms of relief of the burdenof suffering and associated negative outcomes thought to be associated withdepression such as child and spouse maltreatment, substance abuse, and suicide.
The future of depression research may lie in better understanding of childand adolescent development and how much it can be modified by interventions. Current research on genetics and its interaction with the environment
may someday lead to improved understanding of the genetic-environment
interface and its relation to stages of development. It may be possible toidentify critical periods in a child’s development for intervention and tailor
interventions based on the child’s sensitivities and particular environmental risks. Also, advances in brain research and other organic mechanismsthat can be treated pharmacologically may enhance the opportunities forintervention at many levels for children and adults (Beardslee & Gladstone,2001).
The incidence and prevalence of depression in active duty military personnel and their families is not known. It is likely that many of the same risk
factors identified in research on civilian communities are also present in the
military. Such risk factors (multiple adversities) may be more concentrated
in the current military environment of frequent, rapid, and hazardous deployments. We encourage military family advocacy program personnel toconsider the possible role of depression in the treatment of families in whichmaltreatment has occurred and in violence prevention efforts where it islikely that a broader audience can be reached and prevent new cases of depression. Examples of such arenas are education classes for military personnel, the various parenting programs sponsored by the military and public
education events such as depression screening.

230 Family Violence Research, Assessment and Interventions

Key Points
Children of affectively ill parents are more likely to have increased
rates of psychiatric disorder and other negative psychosocial
outcomes than children from homes with parents without affective
illness.
Risk factors are events, characteristics, or conditions that make anegative outcome more likely.
Protective factors are conditions or processes that moderate thenegative effects of risk factors and decrease the risk itself, the effectsof the risk factor, or enhance coping capacity. Significant protective
factors included family cohesion, positive self-appraisal, and goodinterpersonal relations.
The incidence and prevalence of depression in active duty military
personnel and their families is not known. It is likely that many of
the same risk factors identified in research on civilian communities
are also present in the military.

References
Beardslee WR & Gladstone TRG. (2001). Prevention of childhood depression: Recent findings and future prospects. Biological Psychiatry; 49:
1101–1110.
Beardslee WR, Gladstone TRG, Wright EJ, & Cooper AB. (2003). A
family–based approach to the prevention of depressive symptoms inchildren at risk: Evidence of parental and child change. Pediatrics; 112:
119–131.
Beardslee WR, Keller MB, Seifer R, Lavori PW, Staley J, Polorefsky D, &Shera D. (1996). Prediction of adolescent affective disorder: Effects ofprior parental affective disorders and child psychopathology. Journal of
the American Academy of Child and Adolescent Psychiatry; 35: 279–288.
Beardslee WR & Podorefsky D. (1988). Resilient adolescents whose parents
have serious affective and other psychiatric disorders: The importanceof self–understanding and relationships. American Journal of Psychiatry; 145: 63–69.
Buckner JC, Bassuk EL, & Beardslee WR. (2004). Exposure to violence andWilliam R. Beardslee, MD 231

low–income children’s mental health: Direct , moderated, and mediatedrelations. American Journal of Orthopsychiatry; 74: 413–423.
Buckner JC, Mezzacappa E, & Beardslee WR. (2003). Characteristics ofresilient youths living in poverty: The role of self–regulatory processes.
Development and Psychopathology; 15: 139–162.
Carbonell DM, Reinherz HZ, Giaconia RM, Stashwick BA, Paradis AD, &Beardslee WR. (2002). Adolescent protective factors promoting resilience in young adults at risk for depression. Child and Adolescent Social
Work Journal; 19: 393–412.
Clarke GN, Hornbrook M, Lynch F, Polen M, Gale J, Beardslee WR,
O’Conner E, & Seeley J. (2001). A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring ofdepressed parents. Archives of General Psychiatry;58: 1127–1134.
Reinherz HZ, Stewart–Berghauer G, Pakiz B, Frost AK, Moeykens BA, &Holmes WM. (1989), The relationship of early risk and current mediators to depressive symptomatology in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry; 28: 942–947.
Shrier LA, Harris SK, & Beardslee WR. (2002). Temporal associations
between depressive symptoms and self–reported sexually transmitted
disease among adolescents. Archives of Pediatric and Adolescent Medicine; 156: 599–606.
Solantus–Simula T, Punamaki RL, & Beardslee WR. (2002). Children’s
responses to low parental mood. I: Balancing between active empathy,
overinvolvement, indifference, and avoidance. Journal of the American
Academy of Child and Adolescent Psychiatry; 41: 278–286.
Solantus–Simula T, Punamaki RL, & Beardslee WR. (2002). Children’s responses to low parental mood. II: Associations with family perceptionsof parenting styles and child distress. Journal of the American Academyof Child and Adolescent Psychiatry; 41: 287–295.

232 Family Violence Research, Assessment and Interventions

INTERVIEW WITH WILLIAM R. BEARDSLEE, MD

The Impact of Depression on Children andFamilies
By James E. McCarroll, Ph.D.
Joining Forces Joining Families Volume 8, Issue 3, Summer 2005
Dr. McCarroll: We are pleased to in­troduce you and your work to the readers of Joining Forces Joining Families. We believe that the professionals whoare committed to the well-being of our Army soldiers and families will ﬁnd
the subject of your interview to be timely. Would you tell us about the background of your work and how long you have been study­ing depression?
Dr. Beardslee: I started studying depres­sion in 1979 with a small grant tolook at the children of depressed parents. A larger study of preventive interventions for families facing depression began in 1984 and has continued to thepresent time.
Dr. McCarroll: We use many different words, such as blue, down-in-thedumps, and gloomy to describe a less than happy mood. What is clinicaldepression and how would you describe it?
Dr. Beardslee: Any of us — parents, teach­ers and children— can have a badday. We may even say, “I’m depressed.” But, what we mean by clinical depression is a more long-term and persistent change in functioning characterized byfeeling down and blue and not being able to shake it. In the diagnostic manual
it is two weeks or more of one major symptom and ﬁve associated symptoms.
In practice, in the real world, it is the difference between having a couple of baddays because of some event in one’s life and bouncing back versus having a hostof different adversities at the same time, getting down because of them, and thenjust not simply being able to get back on one’s feet.
Dr. McCarroll: How then does the individual know when treatment is needed?
Dr. Beardslee: Studies have shown that depression is common. One in ﬁve
Americans will experience a depression in their lifetime. Those with a highnumber of risk factors will experience even more, but only about a third of thetime is depression recognized and profes­sionally treated.
For the individual, I think it would be an awareness that something isn’tright. If I am de­pressed, I don’t feel the way I used to. I am not accomplishing
things the way I used to. Often, one might be gripped by a persistent sadness,a sense of foreboding about the future. Some people have a sense that life isWilliam R. Beardslee, MD 233

not worth living; some feel suicidal. Very often depression comes after a majorloss, after bereavement, after mov­ing abruptly to a new community, not being
able to establish social bonds, or after the loss of a job. The key is to say “It’s notnormal to feel hopeless and depressed.” There is help available in the recognition
and treatment of depression. We often tell families the ﬁrst place to turn is thepediatrician or the family practitioner who will be able to recognize depression
and make an appropriate referral if need be.

Dr. McCarroll: Would you say that depression affects men and women differently?
Dr. Beardslee: Depression in a parent has profound effects on the otherspouse and on the kids, but probably in different ways. So often, men and women in families are in different roles. Often, women are the primary caretakers
and run the household. If they get depressed, those routines get disrupted. Withmen, often out in the workplace, the work gets disrupted. So, although the depressions are diagnosed in similar terms, the effects on families depend on therole of the person.
Dr. McCarroll: Do boys and girls manifest depression differently?
Dr. Beardslee: There is a sex difference and it is very interesting. Before
puberty, boys are three times more likely to be depressed than girls. After
puberty, girls are about twice as likely to get depressed as boys. In adulthood,
women are two times more likely to get de­pressed than men. I don’t think
we know why that occurs. We know that women are more likely to seek help
and women are more likely to talk about their feelings, on average. The con­cern one has with boys is that they tend to shut off what is bothering themand either ﬁght or get into trouble because of aggression or turn to substanceabuse or develop other problems in adolescence.
The key for all of us who are concerned about youth is to recognize that
depression is real and that it is treatable. There are very good treatments,
among the best in medicine, among the best in psychiatry, for depression.
Those of us who are professionals need to work very hard to make it easy forpeople with depression to get help.
Dr. McCarroll: If a parent is depressed, how likely is it that the child will
become depressed?
Dr. Beardslee: If you compare families with depression and other adversities such as job loss or victimization by violence or bereave­ment to families
with no depression then the rates of depression in the children of parents
with depression are two to four times as high in adolescence to those with nodepression. Why do I say “With other adversities in addi­tion to depression?”

234 Family Violence Research, Assessment and Interventions

Because we have come to understand that depression in a parent often serves
as an identiﬁer of a constellation of adversities. We ﬁnd that the families atgreat­est risk are those in which there are multiple adversities experienced atonce. On the other hand, for depressed parents it means that if depression occurs without these associated adversities and if treatment can begin quickly
then the prognosis for both them and the chil­dren is very good.
Dr. McCarroll: If the parents are not depressed how likely is their child tobecome depressed?
Dr. Beardslee: Kids can still get depressed in the absence of parental depression. In addi­tion to having parents and other relatives with depression,
there are other experiences that put children at higher risk for depression:under­going loss experiences such as bereavement, loss of community, being the victim of bully­ing, having real trouble in school, and learning disabilities or hyperactivity. In adolescence, kids often become depressed after
relation­ships fail or they fail in grades or in sports or some endeavor thatthey didn’t do as well in as they thought they would. Most of the time, appropriate treatment can turn this around. Many kids with these problems do
not become depressed, but kids with these problems do become depressedat higher rates.
Just to summarize, childhood and adoles­cent depression are largely unrecognized and untreated so parents need to be alert to the signs of depression and seek help. The signs are a real change in the usual way a child isbehav­ing: a child who has become more irritable, who shows less interest infriendships or pleasurable things, and who is withdrawing (see Table 1).
Dr. McCarroll: What can be done to prevent the children of depressed parents from also becoming depressed?
Dr. Beardslee: That is what we have re­ally focused on over the last 20
years. What we found is that we can help parents most by helping them get
Table 1. Signs of Depression in Adolescents and Younger Children■■ Diminished interest in friends and friendships.
■■ Decline in school performance.
■■ Irritability.
■■ Aches and pains, especially in young children, and resistance to attend-

ing school.

■■ If any or a cluster of these signs persist for several weeks, it may signal

depression and professional help should be sought.

William R. Beardslee, MD 235

back on track with being good parents. Many parents with depression feeloverwhelmed. They feel they have irrevocably harmed their children andthink that nothing can be done. That sense of helplessness and hopelessness
goes along with depression. In fact, many people who have depression canbe excellent parents and any parent with depres­sion can do things to help
their children. So, the ﬁrst communication has to be one of hope. You can bea good parent despite depression.
What does a parent with depression need to do? Number one, get treatment for the depres­sion. Getting treatment will help the energy and thegood parenting come back. Secondly, work to build resiliency in children.
We think that all parents can do this.
Building resilience is a basic aim of education, health care, and parenting.
Resilience training is really tied to very speciﬁc actions. In our own workin the three core areas (kids’ activities, kids’ relationships, and kids’ under­
standing), we take speciﬁc steps. The ﬁrst is tell­ing our kids what we aredoing and the second is taking concrete actions. We ask families, for example, “How have your child’s friendships been disrupted because of thismove or be­cause of this depression?” And then “What very concrete steps
in your own life can you take to move this along?” We found that depressedparents welcomed the idea of building resilience and were frankly relieved
and overjoyed to ﬁnd that there were positive things that they could do (seeTable 2).
Table 2. How Depressed Parents Can Build Resiliency in Children■■ Support your child’s involvement in normal activities and routines suchas going to school, to sports, to a place of worship, and so on.
■■ Do not let depression disrupt the usual patterns of your child’s life.
■■ Build and support your child’s relationships within the family and outsidesuch as letting your children’s friends continue to come to your home tovisit and letting your children go to other houses.
■■ Provide an age-appropriate explanation for the way you are feeling sothat your family can understand depression is a medical illness, and thatyour are receiving treatment to get better.
■■ Break the silence that often surrounds depression by having a family
conversation that can help remove feelings of guilt, blame and confusion
for both parents and children.
■■ Continue to have more conversations to sustain family communicationthat often facilitates the recovery process for the depressed parent andbuild resilience in children.

236 Family Violence Research, Assessment and Interventions

We often found that in families with de­pression, they were not talking toeach other. We believe that the family can understand depression as a medical illness and can have a conversation about it that makes sense and helps
remove the guilt, the blaming and the misunderstanding that so often occurs with de­pression. Our work has been very much to help families master
depression by talking about it.
When the initial conversation about de­pression was successful it thenoften led to suc­cessful conversations about other things. Fami­lies learned
that family meetings, strategically planned to talk about difﬁcult issues, werevery helpful. As families mastered depression they got back on track. They
made peace with the illness and moved on the way one does with a medical illness. It is also important to note that explanations, however good, arenever static when children are involved. As children grew older they drove
the need for understanding depression anew, for new conversations and forunderstanding it differently.
Much to my surprise and to my real pride and pleasure, we did a longterm study com­paring two forms of getting this prevention across: one, alecture followed by a group discussion, and the second, a clinician-based
intervention where a clinician works with the family over a few sessions
to help the family hold a meeting. We found that these interven­tions led
to long-term and sustained effects in the family’s ability to understandthe illness and in the family’s ability to protect the children. So, we are
conﬁdent that these approaches can help. The book I wrote (Beardslee,2002) is for both clinicians and families to try to learn about these techniques. The basic point is that not only did we have these ideas, but wetested them in a randomized trial design and have been able to show sustained effects.
Dr. McCarroll: What are your thoughts on how to deal with the combinationof violence, depression, and alcohol?
Dr. Beardslee: That particular vicious cycle is toxic for the individual,
toxic for the spouse, and toxic for families. People who have been injured
by violence are likely to be depressed and likely to use alcohol to medicatethem­selves. I would say categorically as a psychiatrist, as a doctor, as a parent,
and as someone who has worked with depression for years, alcohol inevitably makes depression worse. It is not a treatment; it doesn’t help. So, recognizing that is a ﬁrst step. Secondly, the key point about depression is that itis treatable and people feel dramatically different when they get treatment.
When interpersonal violence occurs in a family, the ﬁrst question to ask is“Are the individuals safe?” All of us in the caregiving professions ﬁrst have to
make sure that the environment is safe and then work on getting treatment

William R. Beardslee, MD 237

for alcoholism or talking through what the difﬁcul­ties are or getting treatment for depression..
Dr. McCarroll: What do you see as future directions for depression researchand, particularly, with regard to violence?
Dr. Beardslee: One thing that we have learned is that if a violent event
occurs, we need to intervene very quickly to support those who have been
victimized. Secondly, we need to spend more time thinking about effective
prevention: recognizing when people are reach­ing the breaking point andtrying to provide support for them. In psychiatry and in public health weare recognizing the value of preven­tive intervention. We are trying to put
preven­tive intervention programs in place. There are certainly examples ofthis, such as home visitation and high quality day care that have reduced
interpersonal violence and led to very positive outcomes. So, as we move
forward, I believe we are going to see more effective treatments and more
effective preven­tions that will help us.
Dr. McCarroll: What else would you like to say to our readers?
Dr. Beardslee: One, hope is always available. Two, the dominant fact ofour mental existence as parents, and I speak as a humble parent myself, is thecare of our children. Thirdly, I think that one of the im­portant things about
our work with depression in families is that it didn’t improve as a result ofjust one conversation. It is a process we refer to as “breaking the silence.”
Parents had one conversation with the kids followed by another and another.
Whether as a practitioner or as a parent, if you are thinking about using
some of the things that we learned, say, “We don’t have to do this all at once.”
Our ﬁrst conversa­tion with kids should be a successful one and we shouldmake ourselves open to continued conversations as the time evolves.
Dr. McCarroll: Thank you for sharing your thoughts with us. I believe thatyour eloquence and your optimism are very exciting and I thank you foryour time.
Dr. Beardslee: You are welcome.

238 Family Violence Research, Assessment and Interventions

Key Points
What we mean by clinical depression is a more long-term andpersistent change in functioning characterized by feeling down andblue and not being able to shake it.
If you compare families with depression and other adversities suchas job loss or victimization or bereavement to families with nodepression then the rates of depression in the children of parents
with depression are two to four times as high in adolescence tothose with no depression.
We found that we can help parents most by helping them get backon track with being good parents. any parents with depression feeloverwhelmed.
I would say categorically as a psychiatrist, as a doctor, as a parent,
and as someone who has worked with depression for years, alcohol
inevitably makes depression worse. It is not a treatment; it doesn’t
help.

Reference
Beardslee WR. (2002). When a Parent is Depressed: How to Protect yourChildren from the Effects of Depression in the Family. Boston: Little,
Brown, and Co., 294 pp.

William R. Beardslee, MD 239

REVIEW OF RECENT RESEARCH OF WILLIAM R. BEARDSLEE. MD

Extending Programs to Prevent Depression
to Communities
By James E. McCarroll
September 2009
Dr. Beardslee and his colleagues have been extremely productive in conducting research on the prevention of depression. In our first interview with Dr.
Beardslee, we summarized his research on the prevention and treatment ofchildhood depression and the impact of parental depression on children. He
used an educational format to teach a family about depression and facilitate
their ability to talk about its effects. This approach has strengthened healthy
and meaningful communication and functioning in those families. He has
extended his prevention interventions to additional locations in the UnitedStates and abroad including a population that is largely Spanish speaking.
This approach was also used in the Boston area to depressed mothers whosechildren are in Head Start programs.
The program for depressed mothers (Family Connections of the Children’s Hospital, a teaching hospital of Harvard Medical School, Boston) of
children in Head Start is at http://www.childrenshospital.org/clinicalservices/
Site2684/Documents/introduction_final.pdf. It includes an explanation of
why this program is important based on the following three principles: Head
Start families are often in chronically adverse situations including poverty,
exposure to violence, and social isolation; depression is a common reaction
to such adversity; and these adversities and depression affect the ability ofparents and Head Start staff to take care of children. Further explanation is
given as to why it is important to treat depression in this setting, how materials help engage parents, why the focus on Head Start staff, and how thestaff can better work with parents. Several papers are provided for staff aswell as a brief description of four training modules.
Also on the website is background material for professionals. It describes
why depression is a topic for early childhood programs, why and how to focus on childhood provider staff, and how the Family Connections program
works. The material is also in Spanish at http://www.childrenshospital.org/
clinicalservices/Site2684/mainpageS2684P7.html.
In a recent study, Dr. Beardslee and colleagues compared two treatment
programs (informational versus a brief clinician-based approach) for 105
families in which at least one parent suffered from depression and at least

240 Family Violence Research, Assessment and Interventions

one non-depressed child was in the 8 to 15 age range (Beardslee, Wright,
Gladstone, et al., 2007). Both interventions addressed poor communication,
misunderstanding, feelings of guilt and blame, and lack of recognition of depression. The informational intervention consisted of two lectures given tofamilies without children present in a group format with additional consultation by the investigators, as requested by the families. The clinician-based
intervention consisted of an average of seven sessions that included meetings
with parents and children. Both interventions produced sustained effects
approximately 4.5 years after enrollment. First, child and family functioning
increased and internalizing symptoms decreased in both groups. Secondly,
families in the clinician-based intervention had significantly more gains inparental child-related behaviors and attitudes in child-reported understanding of the parent’s mood disorder. The authors concluded that brief familycentered preventive interventions for parental depression may contribute tolong-term improvements in family functioning.
A multi-site (four U. S. cities) randomized control study of the prevention of depression in adolescents compared the intervention to usual care,non-study mental health or other health care (Garber, Clarke, Weersing, etal., 2009). The intervention was group cognitive behavioral (CB) therapy
conducted for parents in eight 90-minute sessions plus six monthly sessions for adolescents whose parents who were currently depressed or hadprior depression. The adolescents themselves had either a past history ofdepression, currently elevated but sub-diagnostic symptoms of depression,or both. The results were that the incidence of depressive episodes was lower
during the 9-month follow-up period for the CB group than the usual caregroup and adolescents in the CB group had lower self-reported depressive
symptoms than those in the usual care group. However, the presence of parental depression had an effect on the effectiveness of the interventions. The
CB prevention program was more effective than usual care for adolescents
whose parents were not depressed at baseline. For adolescents whose parent
was depressed at baseline, there was no difference between the two groups
in preventing the later incidence of depression. This important study has
a number of important findings. It shows that the preventive intervention
can be reliably and effectively delivered by different clinicians in different
settings. It also shows that the CB intervention is a preventive program thancan reduce or significantly delay the incidence of depression in offspring ofdepressed parents.
Extending his research on the prevention of depression to a low-income
predominantly Latino population, Dr. Beardslee and colleagues provided
the preventive intervention program (PIP) to nine families experiencing
maternal depression (D’Angelo, Llerena-Quinn, Shapiro, et al., 2009). Mak-

William R. Beardslee, MD 241

ing the intervention culturally sensitive required extensive literature review,
focus groups, pilot testing of the intervention manual adapted for this population, conducting the intervention in either Spanish or English, and the useof the contextual experiences of Latino families in the United States withspecial attention to cultural metaphors. While the numbers of families was
too small for statistical analysis, the families found the intervention to be
helpful with results similar to the intervention as applied in other U.S. populations. Personal stories were very important. People described day-to-day
struggles to raise children in difficult environments with limited support aswell as triumphs over adversity, personal and family resilience. Metaphors
were found to be a useful way of talking about depression. This applicationof Dr. Beardslee’s program is an important step in extending prevention research in a sensitive manner to an underserved population. Providing culturally sensitive programs is an important research and practice topic as the
U.S. population continues to become more culturally diverse.
An analysis of the National Survey of Child and Adolescent Well-Being(NSCAW) examined changes in depression status and its relation to psychological aggression, physical assault, and neglect over an 18-36 month period
by 2,683 mothers who retained custody of a child following a maltreatment
incident (Conron, Beardslee, Koener, et al., 2009; NSCAW Research Group,2002)). The NSCAW data were obtained from the National Data Archive ofChild Abuse and Neglect at Cornell University (National Survey of Child andAdolescent Well-Being, 2004) http://www.ndacan.cornell.edu. Neglect was
the most common form of alleged maltreatment (54.2%), followed by physical abuse (32.7%), and emotional abuse (10.7%). During the study period,
15.2% of the mothers experienced depression onset, 12.9% experienced theremission of an episode, and 7.4% experienced both onset and remission ofdepression. Overall, the onset of depression was associated with an increasein psychological aggression. In addition to changes in depression, the presence or absence of other factors frequently influenced acts of aggression orneglect: alcohol and drug dependence, employment status, the addition of
an intimate partner to the household, exposure to intimate partner violence,and increases in child behavior problems. Not surprisingly, depression interacts with many personal and situational variables to increase or decreasechild maltreatment. These findings show the need to consider the multitudeof factors influencing families, particularly those that are amenable to prevention and treatment programs.
Dr. Beardslee is part of a team led by Dr. Patricia Lester of UCLA with
substantial input from Drs. William Saltzman and Robert Pynoos of the National Child Traumatic Stress Network, which has been working with theUnited States Navy over a number of years to develop brief, prevention ori-

242 Family Violence Research, Assessment and Interventions

ented programs for military families facing multiple deployments.
Based on careful study of the stresses families face during deployment,
the intervention, Project FOCUS, is a combination of an intervention forfamilies with parents with AIDS developed by Drs. Mary Jane RotheramBorus and Patricia Lester, an intervention for family trauma developed byDrs. William Saltzman and Robert Pynoos, and the Family Talk Intervention developed by Dr. William R. Beardslee and his colleagues at Children’s
Hospital Boston. It uses a narrative approach and emphasizes both self-regulation and communication. It focuses both on practical strategies to deal
with deployment and also on helping the families develop a single coherent
narrative while understanding each other’s experience. [Editor’s note: See
Saltzman WR, Babayon T, Lester P et al., (2009) for additional material by
Dr. Beardslee and others on treating traumatized children.]As noted in the interview in this issue, Dr. Beardslee participated in Institute of Medicine (IOM) panels that described the state of current research
to prevent mental, emotional, and behavior (MEB) disorders in children
and adolescents (O’Connell, Boat, & Warner, 2009). It is an exhaustive survey of current knowledge about the prevention of mental, emotional, andbehavioral (MEB) disorders among young people (up to age 25). The perspective is developmental, from early childhood to young adulthood. This
work has contributed to a better understanding of the achievements of prevention science and gives practical results that can be applied to a variety of
programs to prevent MEB disorders. Highlights of the successes of prevention interventions include the prevention of child maltreatment, academic
achievement, violence prevention, substance abuse, depression, anxiety, andmental health multiple disorders. It is also an excellent source of historicaland statistical information on MEB disorders.
The IOM report provides a sophisticated view of risk and protective factors. For example, some variables that are characteristics of parenting can
be a risk factor or a protective factor. Their review of studies of risk andprotective factors and their implications can also be used for program development. Examples are how risk and protective factors influence each otherover time and how risk and protective factors operate at multiple levels ofanalysis. High risk groups for prevention programs can be identified at multiple levels including individuals, families, and communities. Poverty, childmaltreatment, and family disruption are particularly important risk factorsthat are associated with multiple disorders including MEB disorders, sexual
behavior, substance abuse and others. Also, victimization, bullying, academic failure, association with deviant peers, and antisocial behavior are risk behaviors that have been linked to schools and communities. The authors discuss avenues to prevention for all of these risk factors for MEB disorders.

William R. Beardslee, MD 243

Environment and experience have powerful effects of brain structureand function. The IOM report includes a wide variety of additional information summarizing current knowledge in neuroscience including genetics,
brain development, and neural systems to the development of prevention
approaches. Interventions that modify experience and the effects of the environment have the potential to promote healthy brain development and toprevent mental, emotional and behavioral disorders.
This brief summary of the approach and results of prevention science
to mental, emotional and behavioral disorders leaves out many of the additional important topics of the report. Specific information is given on
family, school, and community interventions; methodologies for prevention
research, development of infrastructure, costs, and other topics. This book
is a valuable resource for data about prevention when one is asked to explain and defend prevention programs. Also extremely valuable are almost
100 pages of references of the contributions of others on which this book isbased.
Key Points
Brief family-centered preventive interventions for parental
depression may contribute to long-term improvements in family
functioning.
A multi-site (four U. S. cities) randomized control study of theprevention of depression in adolescents showed that the cognitive
behavioral intervention can be reliably and effectively deliveredby different clinicians in different settings and can reduce orsignificantly delay the incidence of depression in offspring ofdepressed parents.
Poverty, child maltreatment, and family disruption are particularly
important risk factors that are associated with multiple mental,
emotional and behavioral disorders.

References
Beardslee WR, Wright EJ, Gladstone TRG, & Forbes P. (2007). Long–term
effects from a randomized trial of two public health preventive interventions for parental depression. Journal of Family Psychology; 21:703–713.

244 Family Violence Research, Assessment and Interventions

Conron KJ, Beardslee WR, Koenen KC, Buka SL, & Gortmaker SL. (2009).
A longitudinal study of maternal depression and child maltreatment ina national sample of families investigated by Child Protective Services.
Archives of Pediatric and Adolescent Medicine; 163:922–+930.
D’Angelo, EJ, Llerena–Quinn R, Shapiro R, Colon F, Rodriguez P, Gallagher
K, & Beardslee WR. (2009). Adaptation of the preventive intervention
program to depression for predominantly low–income Latino families.
Family Process; 48:269–291.
Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, Gladstone
TRG, DeBar LL, Lynch FL, D’Angelo E, Hollon SD, Shamseddeen
W, & Iyengar S. (2009). Journal of the American Medical Association;
301:2215–2224.
National Survey of Child and Adolescent Well–Being. (2004). Combined
Waves 1–4; Data File User’s Manual, Restricted Release Version. Ithaca,
NY: Cornell University.
NSCAW Research Group. (2002). Methodological lessons from the National Survey of Child and Adolescent Well–Being: The first three yearsof the USA’s first national probability study of children and families
investigated for abuse and neglect. Child and Youth Services Review;
24:513–541.
O’Connell ME, Boat T, & Warner KE (Eds.). (2009). Institute of Medicine(Author). Preventing Mental, Emotional, and Behavioral Disorders
Among Young People. Washington, DC: The National Academies Press.
Saltzman WR, Babayon T, Lester P, Beardslee W, & Pynoos RS. (2009).
Family–based treatment for child traumatic stress: A review and reporton current innovations. In Brom D, Pat–Horenczyk R, & Ford J. (Eds.).
Treating traumatized children: Risk,Resilience and Recovery. New York,New York: Routledge.

William R. Beardslee, MD 245

SECOND INTERVIEW WITH WILLIAM R. BEARDSLEE, MD

Preventive Interventions for Depression andPromotion of Resiliency in Children andFamilies
By James E. McCarroll, PhD
September 2009
Dr. McCarroll: In your earlier interview we discussed your research on themental health and resilience of children living in families affected by parental depression, poverty or violence. You have described your work leading
to the development of evidence-based intervention “breaking the silence” asa means to facilitate communication and functioning in families affectedby depression. Have you continued your work on the prevention of mental
health problems in families?
Dr. Beardslee: We had a large grant from Head Start to develop an approach to depression in parents of children in Head Start (Beardslee, Avery,
Ayoub et al., 2009). In Early Head Start, they estimated that the rate of depression is as high as 48% in mothers of kids ages 0-3. We took the samematerial that we used in our other studies and adapted it for much younger
children. We approached this endeavor in stages. First, we set up teacher
training. Once we trained the teachers, we coupled the training with inclass consultation and then, finally, teaching and training for the parents. It
went very well. We eventually tested the programs in nine centers throughout Boston and got very good responses from the teachers. This material isavailable on the Web (www.childrenshospital.org/familyconnections).
Dr. McCarroll: You also developed to a program to prevent depression in
low-income Latin families (D’Angelo, Llerena-Quinn, Shapiro, et al., 2009).
This work addressed many community issues in preventing depression.
Dr. Beardslee: I had the privilege of working with our team on developing the Latino version of the preventive intervention project, a three year
effort. In developing this project, we worked with the Department of Mental
Health Services. We carefully reviewed our original intervention methodology, reviewed the applicable literature, conducted focus groups with Latinoclients, and then brainstormed what the intervention might look like. Then
we actually conducted an open trial of the revised intervention for ninefamilies.

246 Family Violence Research, Assessment and Interventions

Several things were really striking. One is that overall we were able toadapt the intervention effectively, but we also transformed it. Eight of nineclients were single parents; all were immigrants, many of them fairly recent
immigrants. There were many challenges posed by having children who go
to school in Boston and speak English in school and having parents who
have come from a different country and culture and speak primarily Spanish. Some parents did not speak any English. If you think about having afamily meeting where people are more comfortable in different languages,
you get some sense of the challenge. It was also really striking how profoundly committed were these Latino clients to their families and, at thesame time, how flexible were the members of our team. I am glad we wereable to bring it to a successful conclusion.
I am interested in this process because we will face this situation again
and again. We will have prevention or treatment interventions or other approaches to improving health that have been developed in English and usually in the dominant culture. Knowing how to apply it to another cultureis going to be crucially important because we do not have the time or the
resources to develop completely new interventions for each cultural group
and, more positively, there is no reason that something that works well in
one culture cannot work well in another.
Dr. McCarroll: There are many interesting clinical implications from the intervention for low-income Latin families that might be generalized to others
raising children in a stressful environment. The examples I found applicable
are telling personal stories, focusing on resources in addition to depression
and parenting, and deciding which concerns are most important to them.
This paper also emphasized the importance of resilience. Do you find similaremphasis in the research communities of whose work you are aware?
Dr. Beardslee: There is a growing awareness that when we talk about risk
factors, whether these are the ones I have worked with, poverty and depression or others, we need always to bear in mind that in any population exposed to risk there is large variability in the outcomes. Many people do well
despite the risk and those are due largely to protective factors and protective
mechanisms. I was a member of an Institute of Medicine (IOM) panel that
described the state of current research to prevent mental, emotional, andbehavior (MEB) disorders in children and adolescents (O’Connell, Boat, &Warner, 2009). We found that most of the good preventions are built on anunderstanding of resiliency in people who face the risk condition and master that risk. So, it is much more prominent in the prevention area, but it isalso important in many areas of traditional treatment and in the unfoldingof various kinds of difficulties. It is vital to recognize that resilience occurs at

William R. Beardslee, MD 247

four levels: in the individual, in the family, in the care giving system, and in
the larger community. There are factors in all four areas that can predispose
people to do well even if they face risk or loss of risk.
Dr. McCarroll: Resilience is difficult to define.
Dr. Beardslee: That is true. Resilience may look different in different cultures and in different settings. Before we began to develop preventive interventions for families with depression, we did a large study of risk andresilience. We identified three qualities in the kids and one quality in theparents that were both resilient characteristics and amenable to change. On
the kids’ side, in the face of parental depression, they were able to activity engage in age-appropriate developmental tasks such as going to school or going to church, actively engage in relationships, and have some understanding of the parent’s illness. These children did well. Correspondingly, thoseparents who were committed to being good parents despite the depression
also did well. We now understand that there are much fuller and richer waysof understanding resilience. People talk about the capacity to self-regulate
and also about dimensions such as having religious faith or having an active
imagination. These are all aspects of resilience.
Similarly, we are much more aware of resilience in terms of care-giving
systems. For example, there are ways to run public schools and day carecenters that are effective and ways that are not. When those settings are wellrun, they can do a lot to foster resilience. At the societal level, one of the
big issues in mental illness is stigma. You can certainly think about waysthat the community can engage in anti-stigma activities. Beyond that, ofcourse, communities also differ in the amount of resources they have and in
the resources families can access. We should be thinking about those larger
community forces as having an impact on individual lives.
Dr. McCarroll: It appeared to me that your preventive interventions apply toa number of levels of possible distress or disorder. Is this approach what one
might have at one time called primary, either secondary or tertiary prevention?
Dr. Beardslee: It is a little different. Primary, secondary, and tertiary prevention are the older public health terms. The IOM uses the terms universal, selected, and indicated. These are similar to primary, secondary, andtertiary prevention, but not the exactly the same concepts. Universal means
the intervention is for everyone, selected is for high risk, and indicated is for
those who are already manifesting some symptoms, but not yet to the levelof disease or disorder.

248 Family Violence Research, Assessment and Interventions

Dr. McCarroll: This terminology moves away from a disease model to a
population model?
Dr. Beardslee: I think we would say that. The reason that it is interesting
is because we do not have a particularly good way of characterizing interventions across more than one generation or for family interventions. Theinterventions with which we have been engaged are selective preventions forthe children in the sense that they are a high risk group and we are trying toprevent the emergence of depression or enhance the development of competence. On the other hand, if the parents are depressed we have included in
the intervention helping them get treatment for their depression. Thus, wehave included both straightforward treatment, but also added a component
to strengthen and focus on their parenting. We think that this also has preventive effects for the kids, but it also has some positive effects on the parents. You might say that in the old model we were doing primary prevention
for the kids because we were trying to prevent episodes of depression andsecondary prevention for the parents in trying to help their depression getbetter and avoid complications. It is really more complicated than that, butthat is how I see it. So, I prefer the terms universal, selective, and indicated.
Dr. McCarroll: What do you think could be done on a large scale to build
resilience, prevent depression, or otherwise help a population such as Armyfamilies who are struggling with managing their family in a stressful environment?
Dr. Beardslee: That is a good question. In our work we have tried to think
about population-based interventions from three points of view. First you
have to determine the basic information that somebody might need about
depression or about resilience and ways to deliver that information in different doses so everyone can have access to information. A second level
would be a lecture-discussion group where people can have more information and then a third level for people who are having more difficulty or for
people who are highly motivated. You think about the same principles indifferent sorts of interventions. For example, in our first major randomized
trial for the prevention of depression we used two public health delivery
mechanisms that can be widely applied: one was lectures in a group discussion format and the other was five or six sessions with a clinician. Anotherimportant point is to construct interventions that can be widely used by arange of disciplines. I think you are raising a question that we need to thinkmuch more fully about than we have.
Dr. McCarroll: As you know, interventions for the military are on a large
scale, are generally educational, and have to be fairly simple in order to haveWilliam R. Beardslee, MD 249

fidelity. How would you think about constructing such interventions and forwhat targets? You probably cannot target everything at one time.
Dr. Beardslee: I believe that you have to think about two dynamics. One
is information sharing. How could you make information available? You
could use the Internet to transmit information. We are now in the process ofdeveloping web-based training for the family talk intervention for the same
reasons you have stated. We talked earlier about the Latino intervention.
One of the things that we were very careful to do in that intervention waseach time we met with those families, was to ask them, “What are you mostconcerned with right now?” I think the other side of effective broad publichealth information campaigns is to be able to time the access to information
to what the person is most interested in at that time.
For example, the first aim of psychological first aid is to have that kindof program available at the time that people need it the most: right after thedisaster or trauma. In a similar way, people who are raising young children
need and want information about how to raise young children at the timethey have young children.
Dr. McCarroll: We have tried to adapt psychological first aid and to expand
it from reacting to an acute stressor to building life skills.
Dr. Beardslee: I think that is very important. You may draw people intoa particular educational piece or intervention that is directed toward something that is fairly acute whether it is psychological first aid or getting treatment for a parental depression. But, then you want to use that opportunity
to interest people in broader communication skills, healthy habits, stress
reduction, and other things that they can do on their own. I think that thework on resilience is crucial because it is an easy way to reach people: “Hereare some things that you can do that will strengthen you or strengthen yourfamily or strengthen your children.” This is preferable to threatening themby saying “Here are some things that if you don’t do them there will be badoutcomes.” People are going to respond and take more in when the risk is
acknowledged, not minimized, but also when there is discussion of the positive aspects.
Dr. McCarroll: You can think of all sorts of creative ways people could use
the Internet. These may be more beneficial than an in-person program because people can work at their own speed and review the material again andagain. I think that is the way to go on a lot of this material.
Dr. Beardslee: I agree. Given the amount and volume of material that weare all dealing with, it makes a whole lot of sense to work when your timeallows and at your own pace.

250 Family Violence Research, Assessment and Interventions

In the broader context of prevention research and evaluation, I mentioned the work I have been involved in with the Institute of Medicine(IOM). Periodically, IOM committees review a particular area of researchor practice and write a report that has findings, conclusions, and recommendations. I was on the Board of Youth and Families and on two of theircommittees. One committee evaluated the prevention of mental illness inchildren and the other focused on parental depression. The approach has
a very strong developmental perspective. We talk about risk and resilience
across the span of childhood.
The Substance Abuse and Mental Health Services Administration(SAMSHA) has a website called the National Registry of Effective Programs (http://www.nrepp.samhsa.gov). Submitted material is reviewed andscored on a ranking scale in terms of the evidence. The committees usually used the standard of multiple randomized trials as the highest level ofevidence, but there are many situations in which you cannot do that. Oneof the striking findings is that prevention science is much better than it
used to be.
Dr. McCarroll: Are you familiar with the U.S. Preventive Services Task Force
http://www.ahrq.gov/CLINIC/uspstfix.htm/? It is an independent panel ofexperts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive
services. An example of a preventive intervention that has been shown to beof high value in preventing injuries is the use of seat belts.
Dr. Beardslee: I am familiar with that process. We have been trying to get
CDC to take on surveillance in mental illness prevention. Trying to apply
some of the processes and findings from the prevention of physical illness tomental illness is a really good idea.
Dr. McCarroll: I have always thought that the individual is a mix of resilience and vulnerabilities, but I think that teaching and even clinical work
may in fact tend to focus on one of those. Do you think there is any modelthat might be able to combine those two?
Dr. Beardslee: I think they have to. A dynamic balance or interplay isreally important. In the IOM report we talked again and again about developmental transactions. This requires some knowledge of the individual,
knowledge of the surround, and of the interaction and it involves a resiliency perspective.
Dr. McCarroll: So much of your work has ties to other areas such as adverse
childhood experiences. How do you deal with them as risk factors in yourWilliam R. Beardslee, MD 251

work, particularly on depression and on later development?
Dr. Beardslee: We do consider that, but I would go further. The prevention of depression and its risk factors fall into two broad classes. One category is the specific risk factors for depression, such as having had a priordepression, having a family history of depression, or bereavement and loss.
But, there are also non-specific risk factors such as poverty, exposure to violence, social isolation, and various forms of family difficulties. You get depression on the one hand with either class of risk factors, but you can also get
depression through their interaction. After all, depression is almost always
some combination of vulnerability and an adverse current event whether
it is divorce or failure of some sort. So, when we think about the comprehensive prevention of depression, we also need to address both sets of risk
factors, but in somewhat different ways. For the children who have parents
who are depressed, we know a fair amount about the specific risks so we canmount specific preventions, but we also have to think about such factors as
decreasing poverty and decreasing abuse and neglect in childhood because
those are potent factors for poor outcomes in a variety of ways in adulthood.
I think there are some things we can do about that.
Dr. McCarroll: Do you think that your programs and your clinical interventions require a threshold level or can it apply to depression at a variety oflevels?
Dr. Beardslee: I think they can be applied at a variety of levels. We worked
on depression because we thought that starting with something specific,
something treatable, was a better approach than trying to address all the different risk factors at once. But, we have always done depression plus, whichmeans depression and whatever goes along with it whether that is alcoholism or anxiety disorders or whatever. I think the answer to your question isthat we are coming to more general perspectives based on building from theexperiences with specific interventions. Here is one example. In the IOM
report we make the point that if you look across a variety of intervention
programs, you find very strong support for programs that enhance parenting. So, you can make the argument that we need to think about how to enhance parenting generally. Then you can select, depending on the particularsituation, the dimension that you want to work on. Let me take it back to
the military. Right now, we have a very large number of young soldiers andyoung families. These are people who join the military right out of highschool or not too long thereafter. They tend to marry young and raise children. Therefore, it is a real opportunity to try to get some kind of parent
education and preventive services to these families.

252 Family Violence Research, Assessment and Interventions

Dr. McCarroll: Would you comment on the applicability of your work to
PTSD?
Dr. Beardslee: We have dealt with a number of people who have had
both depression and PTSD. We did not exclude people who had both diagnoses. It is really striking to me that after the Oklahoma City bombing therate of PTSD went up, but so did the rate of depression. Trauma can trigger
depression as well as PTSD. The second point is that in our work, we havefound that a narrative, talking about the experience one has gone throughand mastering it, has been very important. This has certainly also been very
helpful in working with families exposed to trauma and I think a family
narrative is a useful approach. I have been involved with a new intervention,
the FOCUS Intervention, which combines elements of the Family Talk Intervention with work by Mary Jane Rotheram Borus and Patricia Lester onfamilies with AIDS and work by Bob Pynoos and Bill Saltzman on trauma. It
is an intervention devised for military families facing multiple deployments
and does have a strong narrative component.
Dr. McCarroll: We all have a lot more work to do. Thank you for your contributions to mental health intervention and for this interview.
Dr. Beardslee: You are welcome. I enjoy getting the word out on ourwork.
Key Points
Knowing how to apply a prevention or treatment intervention to
improving health that has been developed in English and apply it
to another culture is going to be crucially important because we
do not have the time or the resources to develop completely new
interventions for each cultural group. Most of the good preventions
are built on an understanding of resiliency in people who face therisk condition and master that risk.
It is vital to recognize that resilience occurs at four levels: in theindividual, in the family, in the care giving system, and in the larger
community. There are factors in all four areas that can predispose
people to do well even if they face risk or loss of risk.

William R. Beardslee, MD 253

In the face of parental depression, we identified three qualities in kidsthat were both resilient characteristics and amenable to change:■■ They were able to activity engage in age-appropriate
developmental tasks such as going to school or going to church,■■ Actively engage in relationships, and■■ Have some understanding of the parent’s illness.
■■ These children did well.
■■ Parents who were committed to being good parents despite thedepression also did well.
The prevention of depression and its risk factors fall into two broadclasses: specific risk factors for depression, such as having had aprior depression, and non-specific risk factors such as poverty andvarious forms of family difficulties.

References
Beardslee WR, Avery MW, Ayoub C, & Watts CL. (2009). Family Connections: Helping Early Head Start/Head Start staff and parents address
mental health challenges. Journal of Zero to Three, National Center for
Infants, Toddler, and Families, 29(6):34–42.
D’Angelo EJ, Llerena–Quinn R, Shapiro R, Colon F, Rodriguez P, Gallager
K, & Beardslee WR. (2009). Adaptation of the preventive intervention
program for depression for use with predominantly low–income Latino
families. Family Process; 48:269–291.
O’Connell ME, Boat T, & Warner KE (Eds.). (2009). Institute of Medicine(Author). Preventing mental, emotional, and behavioral disorders
among young people. Washington, DC: The National Academies Press.

254 Family Violence Research, Assessment and Interventions

BACKGROUND OF RESEARCH OF CHRISTOPHER M. MURPHY,
PHD

Alcohol and Interpersonal Violence
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 4, September 2008
The research of Dr. Murphy and colleagues has focused on the relationshipof alcohol consumption to interpersonal violence (IPV). The studies reviewed here examine many of the risk factors associatedwith IPV and alcohol misuse.
In a study of partner violent and nonviolent alcoholicmen, the partner-violent alcoholic men had more antisocial personality traits, greater alcohol problem severity,
greater use of other drugs, higher relationship distress,
and stronger beliefs in the relationship between alcohol drinking and relationship problems. Relationshipdistress and alcohol problem severity were independently associated withpartner violence (Murphy, O’Farrell, Fals-Stewart, et al., 2001). The numberof drinks consumed by the alcoholic husband in the 12 hours prior to aphysical assault incident was significantly higher prior to violent compared
to non-violent conflicts (Murphy, Winters, O’Farrell, et al., 2005).
In another study, rates of domestic violence by alcoholic men were compared before and after alcohol treatment. In the year before treatment, 56%of the alcoholic men had been violent toward their female partner (O’Farrell,
Fals-Stewart, Murphy, et al., 2003). After treatment, partner violence in thealcoholic sample decreased to 25%, but remained higher than the comparison group (14%). Among alcoholics whose alcoholism remained in remission, the prevalence of violence was reduced to a level (15%) that was nearly
identical with the non-alcoholic comparison sample.
Greater drinking by wives prior to violent conflicts has also been observed. Women in addiction treatment programs reported a high level ofboth victimization and perpetration of violence. They committed more vio-

256 Family Violence Research, Assessment and Interventions

lent acts and were more likely to commit severely violent acts than the menin these couples (Chase, O’Farrell, Murphy, et al., 2003).
Finding successful treatment for substance abusers has also been a focusof the research of Dr. Murphy and colleagues. Recent studies have foundthat behavioral couples therapy, an intervention that emphasizes sobriety,teaches communication skills, and increases positive activities has strong research support in improving relationships and decreasing domestic violence(O’Farrell, Murphy, Stephan, et al., 2003).
Key Points
In a study of partner violent and nonviolent alcoholic men, thepartner-violent alcoholic men had more antisocial personality traits,
greater alcohol problem severity, greater use of other drugs, higher
relationship distress, and stronger beliefs in the relationship between
alcohol drinking and relationship problems.
The number of drinks consumed by the alcoholic husband in the
12 hours prior to a physical assault incident was significantly higher
prior to violent compared to non-violent conflicts.
Alcoholics in remission had about the same prevalence of violence(15%) as the non-alcoholic comparison sample.
Greater drinking by wives prior to violent conflicts has also been
observed. Women in addiction treatment programs reported a highlevel of both victimization and perpetration of violence.

References
Chase KA, O’Farrell TJ, Murphy CM, Fals–Stewart W, & Murphy M.
(2003). Factors associated with partner violence among female alcoholic patients and their male partners. Journal of Studies on. Alcohol andDrugs; 64:137–149.
Murphy, C. M., O’Farrell, T. J., Fals–Stewart, W., & Feehan, M. (2001).
Correlates of intimate partner violence among male alcoholic patients.
Journal of Consulting and Clinical Psychology; 69:528–540.
Murphy CM, Winters J, O’Farrell TJ, Fals–Stewart W, & Murphy M. (2005).
Alcohol consumption and intimate partner violence by alcoholic men:Christopher M. Murphy, PhD 257

Comparing violent and non–violent conflicts. Psychology of Addictive
Behaviors, 19:35–42.
O’Farrell TJ, Fals–Stewart W, Murphy M, & Murphy CM. (2003). Partner
violence before and after individually based alcoholism treatment for
male alcoholic patients. Journal of Consulting and Clinical Psychology,
71:92–102.
O’Farrell TJ, Murphy CM, Stephan SH, Fals–Stewart W, & Murphy M.
(2004). Partner violence before and after couples–based alcoholism
treatment for male alcoholic patients: The role of treatment involvement and abstinence. Journal of Consulting and Clinical Psychology,
72:202–217.
For additional reading on alcohol and domestic violence in the Army, see:Bell NS, Hartford T, McCarroll JE, & Senier L. (2004). Drinking and spouseabuse among U.S. Army soldiers. Alcoholism: Clinical and Experimental
Research, 28:1890–7.
Bell NS, Harford TC, Fuchs CH, McCarroll JE, & Schwartz CE. (2006).
Spouse abuse and alcohol problems among white, African American,
and Hispanic U.S. Army soldiers. Alcoholism: Clinical and Experimental
Research, 30:1721–1733.

258 Family Violence Research, Assessment and Interventions

INTERVIEW WITH CHRISTOPHER M. MURPHY, PHD

Domestic Violence and Alcohol Misuse
By James E. McCarroll, PhD
Joining Forces Joining Families Volume 10, Issue 4, September 2008
Dr. McCarroll: Please tell us about your center for domestic violence counseling and your research on the relationship between domestic violence andalcohol use.
Dr. Murphy: I have an appointment at the University of Maryland, Baltimore County (UMBC) and I also help coordinate a community-based counseling program for domestic violence offenders in Howard County, Maryland. About 80 to 100 abusive individuals come through our counselingprogram each year. My clinical work has been mainly in domestic violencetreatment. I also collaborate with people in the VA system whose primaryexpertise is in substance abuse.
Dr. McCarroll: People can be referred for treatment for violence or for alcohol abuse. How well does each program screen for the other problem andhow well do they work together?
Dr. Murphy: Surveys in both of those areas have shown that there istremendous variation in the extent to which each program assesses for theother problem. There are some theories that help to explain why this is thecase. In domestic violence, it has traditionally been thought that substanceuse is viewed as an excuse rather than a contributing factor and certainly nota cause of violence. Because of that, some domestic violence programs haverejected the idea that they can do much about the substance abuse or they
have said that substance abuse is not something that they handle in theirprogram. In the substance abuse field, there is a traditional belief that once
the addiction is cured, all other aspects of one’s life will start getting back on
track.
Dr. McCarroll: How would you advise a clinician working in the domestic
violence field to assess for the involvement of alcohol misuse or abuse indomestic violence?
Dr. Murphy: There are several methods that are very helpful. One is touse a general screening tool such as the AUDIT (Alcohol Use Disorders
Identification Test) (Saunders, Aasland, Babor, et al., 1993). [Editor’s note:
The CAGE is also used for screening for problem drinking (Buchsbaum,
Buchanan, Centor et al., 1991).] Although the AUDIT detects early signs ofChristopher M. Murphy, PhD 259

alcohol dependence, we have found that it misses a lot of people who were
intoxicated at the time of an abuse incident. The approach I take is to go overdetails of conflicts where there has been abuse and ask the person whether
they had had anything to drink or were using any drugs at that time. We also
ask how often they drink and how much they typically drink on weekdays
and weekends to screen for unhealthy levels of alcohol consumption.
Dr. McCarroll: If you find somebody who has a high level of drinking, butthey were not drinking during the incident, what do you do with that information?
Dr. Murphy: It is still valuable for them to have some type of intervention
for a couple of reasons. First, they might be doing damage to themselves orothers through that level of drinking. Second, their drinking may interferewith their getting benefits from domestic violence counseling.
Dr. McCarroll: Is the person who drinks moderately more likely to be involved in domestic violence than one who does not drink?
Dr. Murphy: There is no good evidence to that effect. It is binge drinking
and chronically high levels of alcohol consumption that are associated withdomestic violence. There are two different patterns of drinking among thosewith serious alcoholism: stable and unstable drinking. Unstable drinking
applies to people with serious alcohol problems who do not drink the sameamount every day, or may not drink every day, but who drink quite excessively at times. They also tend to drink outside the home. Stable alcoholic
individuals tend to drink at home, every day, in roughly the same amount.
We have found that domestic violence is more common among those withunstable drinking patterns. In our studies of persons with severe alcohol
problems we have found that if they are able to achieve stable recovery or
remission from their problem drinking, their domestic violence rates substantially decline and their level of risk looks fairly similar to demographically matched people in the population who do not have alcohol problems.
This suggests that stable remission of drinking is a major protective factor
against further domestic abuse.
However, risks may still exist. One risk is the limited success of alcohol
treatment. People with antisocial personalities and longer histories of substance abuse tend to have poorer outcomes in addiction treatment. They
might have continued risk for partner violence because they are less likely
to remit in their substance abuse. It is also possible that even when they
overcome their substance abuse they will continue to be controlling or abusive in their relationships due to generalized tendencies toward anger andviolence.

260 Family Violence Research, Assessment and Interventions

Dr. McCarroll: What are some differences between the populations seen indomestic violence treatment and those in alcohol treatment?
Dr. Murphy: The vast majority of people in domestic violence treatment
are court-mandated whereas alcohol programs have tended to be primarily voluntary or have a mix of mandated and voluntary clients. In actual
practice, a lot of people in court for alcohol problems do not get referrals fordomestic violence even when there is evidence or testimony that they haveboth problems. However, when domestic violence offenders are referred to
addiction treatment programs, those programs would not always view thedomestic violence client’s drinking problems as warranting substance abuse
services. For example, domestic violence offenders may not have many negative consequences of their substance abuse other than its negative effects on
their family relationships. Also, substance abuse programs do not necessarily gather information from the relationship partner about substance abuseand violence.
Dr. McCarroll: What are the goals of most substance abuse programs?
Dr. Murphy: Abstinence is the goal for people with significant substancedependence disorders. Once they have a certain level of alcohol problems, it
is unlikely that they could drink in a controlled fashion. There are also binge
drinkers who come to domestic violence programs. They may get into trouble when they binge drink, but not have symptoms of alcohol dependence.
Non-abstinence might be a reasonable goal for those individuals if they canregulate their drinking and have harm reduction as a goal.
Dr. McCarroll: Do you find common barriers to treatment in most domestic
violence offenders?
Dr. Murphy: The first barrier is blaming the partner for the difficulties
and problems and being very frustrated and angry at the system that put
them there. Clients feel like they have been railroaded or they did not get achance to have their part of the story heard by the police or the courts. It is
often very hard for them to look at their own behavior.
Dr. McCarroll: Many states mandate lengthy domestic violence treatment
programs, six months and more. In the military, that option is limited by thefrequency and length of deployments. What is the length of time necessary
for an effective treatment for violence and for alcohol abuse?
Dr. Murphy: In substance abuse, some brief interventions have goodoutcomes, particularly motivational enhancement therapy where the goal is
to stimulate the individual to a self-directed change process. In the domestic
violence field, we are still struggling to clearly identify effective interven-Christopher M. Murphy, PhD 261

tions. There is a general clinical sense that we need to see people for at leasta few months to try to understand their problems and to give them someskills to supplant their abusive behavior. There is not much evidence to suggest that a one-year program is better than a six-month program or that asix-month program is clearly better than a three or four-month program.
Dr. McCarroll: What is the distinction between motivational therapy andcognitive behavioral therapy?
Dr. Murphy: Motivational therapy is less directive than cognitive behavioral therapy. It uses more reflective listening and focuses on the issues of
why someone would want to change, the barriers to change, developing aplan for change, and stimulating movement through the stages of change.
A lot of the original motivational interviewing is based on the five stages ofchange model (Prochaska, DiClemente, & Norcross, 1992). Motivational interviewing emphasizes a self-directed change process. Cognitive behavioral
therapies tend to focus on the active ingredients of change. Once someone
is motivated to change, they need to alter their thought processes and learn
new behaviors such as example strategies to handle relationship disagreements and conflicts more constructively. We have studied motivational therapy as an early intervention for domestic violence offenders. A lot of clientsare resistant when they show up for treatment and hostile toward the systemand the treatment providers. We need a clinical strategy to get them pastthat initial resistance and hostility in order to open them up to some of thesubsequent interventions that are more cognitive and behavioral. You may
have the best cognitive behavior therapy in the world, but people are not going to benefit if they do not practice the listening and communication skills
taught in the treatment.
Dr. McCarroll: Can you use the stages of change model in both the domestic
violence and alcohol fields?
Dr. Murphy: Yes. It was originally developed in the addictions field. The
model fits well for stopping smoking. It gets more complicated when you
apply it to domestic abuse because you have another person involved in therelationship and a complex set of behaviors that might involve control, emotional abuse, physical assault, and other kinds of difficulties so it is not as
simple to conceptualize as smoking.
Dr. McCarroll: Do you think that a clinician can function effectively addressing both violence and alcohol misuse?
Dr. Murphy: Yes. It would require evaluation of some of their assumptions. People in the domestic violence field might have to reevaluate some262 Family Violence Research, Assessment and Interventionsof their thoughts like substance abuse is just an excuse for violence and byacknowledging that it might contribute directly to people’s bad judgment
and impulsive behavior. People on the substance abuse side might have toreevaluate the extent to which they believe that family relations may play arole in someone’s addiction and not just think that all their clients’ problems
are as simple as a secondary consequence of their substance abuse. A lot of
the clinical and counseling skills would be very similar in both these areas.
Dr. McCarroll: Thank you for your insights.
Dr. Murphy: You are welcome.
Key Points
There are two different patterns of drinking among those withserious alcoholism: stable and unstable drinking.
Binge drinking and chronically high levels of alcohol consumption
are associated with domestic violence.
Stable remission of drinking is a major protective factor against
further domestic abuse.
Some common barriers to treatment in most domestic violence
offenders are blaming the partner for the difficulties and being very
frustrated and angry at the system that put them there.

References
Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, & Lawton MJ.
(1991). Screening for alcohol abuse using CAGE scores and likelihood
ratios. Annals of Internal Medicine; 115:774–777.
Prochaska JO, DiClemente CC, & Norcross JC. (1992). In search of how
people change. American Psychologist; 47:1102–1114.
Saunders JB, Aasland OG, Babor TF, De La Fuente JR, Grant M. (1993).
Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons withharmful alcohol consumption. II. Addiction; 88:791–804.

Christopher M. Murphy, PhD 263

REVIEW OF RECENT RESEARCH OF CHRISTOPHER M. MURPHY,
PHD

Review of Associations between Alcohol Use
and Interpersonal Violence
By James E. McCarroll, PhD
January 2010
Dr. Murphy and his colleagues have continued to explore relationships
between substance use (primarily alcohol) and intimate partner violence(IPV). It is well known that men with alcohol problems have a higher prevalence of IPV than non-abusing men (Leonard, 2005) and that alcoholism
treatment lowers violence prevalence (O’Farrell & Murphy, 1995). A recent
study of treatment-seeking female alcoholics and their male partners who
received 5-6 months of behavioral couples therapy (BCT) found that IPV
prevalence decreased significantly (31%) for the female patients compared
to pre-treatment levels (68%). In yearly follow-ups, 45% of patients withviolence were remitted at year 1 and 49% at year 2. In year 1, the violence
prevalence among remitted female alcoholics was 22% whereas among therelapsed patients it was 38%. Year 2 results showed that the post-treatment
reductions were stable: violence prevalence for remitted patients was 19.5%
versus 29% among relapsed patients. They also found that male perpetrated
IPV decreased after behavioral couples therapy (BCT).
The authors discussed the need for further study necessary to understand the basis of the reductions in IPV for alcoholic men and women andfor their partners. The fact that reductions in IPV occurred even among therelapsed group suggests that there may other avenues by which BCT reduces
violence other than through reducing substance abuse. Another suggestion
was to find whether the BCT procedures aimed at improving communication and conflict resolution might impact the reduction in IPV in addition to
the procedures directed at sobriety. In addition to other suggestions, future
research might assess whether verbal interactions or arguments between thepartners over drinking and problems related to drinking lead to escalationof violence and the nature of their violence. This type of investigation wastermed contextualizing the violence.
The association between IPV and substance use problems is a criticalissue for both study and practice. Murphy and Ting (In press) reviewed research on the prevalence of IPV before and after substance abuse treatment
and among remitted and relapsed cases after treatment. Their review pro-

264 Family Violence Research, Assessment and Interventions

vides the results of a wide variety and large number of studies of the relationship between IPV and substance use. Some of the most important findings
are summarized here.
■■ The annual prevalence rate of IPV was about three times higher among
those who binge drink compared to abstainers (Kaufman-Kantor &Straus, 1987).
■■ Among newlyweds, alcohol use predicted male-to-female IPV independent of other risk factors (Leonard & Senchak, 1996).
■■ The general increase in IPV rates for those with alcohol problems is evident across ethnic groups (Cunradi, Caetano, Clark, et al., 1999).
■■ The risk of IPV is about double among those in the upper half of the
distribution of alcohol consumption compared to those in the lower half
(Lipsy, Wilson, Cohen & Derzon, 1997).
■■ High rates of IPV have also been found in treatment-seeking populations
with alcohol abuse or dependence (see, for example, O’Farrell, Murphy,
Stephan, et al., 2004).
■■ Similar results have been found in persons in domestic violence counseling programs. In one study, about 25% of persons in an IPV programs
met the diagnostic criteria for alcohol abuse or dependence (Winters,2005).
■■ Substance abuse predicts lower attendance and poorer engagement in
IPV counseling (Ting, Murphy, Jordan-Greene, et al., 2009).
■■ Follow-up of persons who participated in IPV counseling found thatthose who reported frequent binge drinking were over three times more
likely to re-assault a domestic partner and those who were drunk nearly every day were 16 times more likely to re-assault (Jones & Gondolf,2001).
Murphy and Ting’s review examines the effect sizes for the reductions
in partner violence (physical and psychological) before and after treatment
for alcohol problems. [Editor’s note: Effect sizes were calculated as the meandifference from pre-treatment to follow-up divided by the pooled standard
deviation of the two estimates, which takes the variability of the two estimates into account in the calculation of the effect size.] For physical assault,
the reduction in the effect size for both male-to-female and female-to-maleviolence was small to moderate. [Editor’s note: Husbands were the identified
patients, not the wives.] The effect sizes for both partners for the reductionin psychological aggression were large, considerably greater than for physical assault.
For all studied reviewed, IPV was higher for relapsed cases. The risk ofhusband-to-wife assault was two to three times greater than for remitted

Christopher M. Murphy, PhD 265

cases. These differences held for two years of follow-up.
In spite of the convincing findings of the relationship between IPV andsubstance abuse (primarily alcohol), Murphy and Ting cite many remaining
unanswered questions. In several of the studied reviewed here, behavioral
couples therapy (BCT) has been used to treat the substance abuse patient(usually the husband) (see, for example O’Farrell et al, 2004). The study by
O’Farrell and colleagues (2004) found that enhancement in relationshipfunctioning and reductions in alcohol consumption accounted for reductions in IPV after treatment. Nevertheless, questions remains regardingwhether the reduction in IPV is due to relationship enhancement, reducing
substance abuse, or to other aspects of change. Another subject of research
may be to measure aspects of relationship violence not typically measured
such as forms of controlling, coercive, and emotionally abusive behaviors.
This suggests the need for further research on the changes in dyadic relationships that need to be addressed during treatment and how these changes
may be manifested following treatment.
Finally, there is a need for integration of treatment of substance abuse
and IPV as well as how to incorporate treatment for both partners of a relationship. As Murphy and Ting point out, both of these approaches are controversial. However, as shown by this review, much progress has been madein the understanding of the relationship between IPV and substance abuse.
Key Points■■ Men with alcohol problems have a higher prevalence of IPV than

non-abusing men and alcoholism treatment lowers violence prevalence.

References
Cunradi CB, Caetano R, Clark C, & Schafer J. (1999). Alcohol–Related
Problems and Intimate Partner Violence Among White, Black, andHispanic Couples in the U.S. Alcoholism: Clinical and Experimental
Research; 23:1492–1501.
Jones AS & Gondolf EW. (2001). Time–varying risk factors for reassault
among batterer program participants. Journal of Family Violence; 16:345–359.
Kaufman–Kantor, G., & Straus, M.A. (1987). The “drunken bum” theory ofwife beating. Social Problems; 34:213–230.

266 Family Violence Research, Assessment and Interventions

Leonard KE. Alcohol and intimate partner violence: when can we saythat heavy drinking is a contributing cause of violence? Addiction;
100:422–5.
Leonard, K.E., & Senchak, M. (1996). The prospective prediction of husband marital aggression among newlywed couples. Journal of Abnormal
Psychology; 105:369–380.
Lipsey MW, Wilson DB, Cohen MA & Derzon JH. (1997). Is there a causal
relationship between alcohol use and violence? A synthesis of evidence.
In: M. Galanter (ed.), Recent Developments in Alcoholism, vol. 13. Alcohol and Violence (pp. 245–282). New York: Plenum Press.
Murphy CM & Ting LA. (In press). The effects of treatment for substanceuse problems on intimate partner violence. Aggression and Violent
Behavior.
O’Farrell TJ, Murphy CM, Stephan SA, Fals–Stewart W, & Murphy M.
(2004). Partner violence before and after couples–based alcoholism
treatment for male alcoholic patients: The role of treatment involvement and abstinence. Journal of Consulting and Clinical Psychology; 72:
202–217.
Ting L, Murphy CM, Jordan–Greene L & Pitts SC. (2009). Substance use
problems, treatment engagement, and outcomes in partner violent men.
Research on Social Work Practice; 19:395–406.
Winters JE. (2005). A comparison of partner violent men with alcohol
problems and partner violent men without alcohol problems. Unpublished Doctoral Dissertation, University of Maryland, Baltimore
County.

Christopher M. Murphy, PhD 267

SECOND INTERVIEW WITH CHRISTOPHER M. MURPHY, PHD

Domestic Violence Counseling: Men,
Women, and Substance Abuse
By James E. McCarroll, PhD
January 2010
Dr. McCarroll: In your last interview we talked about your work in domestic
violence counseling. Many of your clients are court-referred for domestic violence and some of them also have substance use problems. Is that correct?
Dr. Murphy: That is correct. I work mostly in a site in Howard County,
MD. The vast majority of folks are court-ordered to treatment for partner
violence. Some of them also have substance use problems. My backgroundis in the field of domestic violence treatment. Some of my colleagues havedone more research in substance use research, so we work collaboratively on
a lot of these projects.
Dr. McCarroll: Are you starting to see more court-referred female domestic
violence offenders?
Dr. Murphy: We do have a small program for women who are courtordered for partner violence. We tend to work with them separately frommen. Some programs combine them, but that approach is controversial.
There is some sensitivity in the field as to whether some of the women weare treating may also be victims and whether they would have a difficult time
being in a group with men. The tradition has been to hold separate groups
for men and women. However, many of the same issues seem to come up
in these groups. For example, there are very consistent problems in relationships, negative attitudes about the other gender, communication issues,poor listening skills, and poor problem solving skills. There are some otherthings that might be a little different. There might be differences in their
willingness to talk about their histories of victimization. A lot of the women
we see have histories of abuse in their own background. Many of the men do,too, but it tends to be discussed more openly in the women’s groups.
The theories about the treatment of partner violence grew out of thebattered women’s and shelter movements. They were very much feministoriented in their perspective. The tendency has been to see issues of powerand control and gender oppression as being very wrapped up in the wholeproblem of partner violence. So, a lot of the programs for men who are abusive involved a large component of looking at gender roles, gender attitudes,

268 Family Violence Research, Assessment and Interventions

and similar kinds of processes as promoting the controlling behaviors thatlead to the abuse of women.
Dr. McCarroll: Do you still follow that model?
Dr. Murphy: To some extent. My personal perspective is that violence inrelationships is more equal than some of those theories would maintain. We
now have good evidence that violence is common in lesbian and gay male
relationships where the gender roles and dynamics would be expected to bedifferent. Also, a lot of women are physically aggressive and assaultive withmen. The perspective also depends on whether you look at the actual behaviors like slapping and pushing and shoving or whether you look at the effectsof those behaviors in producing fear and injuries. When you look at the actual behaviors themselves you find a lot more gender equality in the prevalence of violence by men and women; when you look more at the effects ofthe behavior you tend to find more gender disparity. Another way to look at
gender differences in aggression is to look developmentally at girls and boys
where there is a big difference in aggressive and violent behavior. Boys are
more aggressive in general than girls, but intimate relationships are the one
area where we tend to see more gender parity in aggressive behaviors.
Dr. McCarroll: Would you say that the need to exert power and control occurs in both genders?
Dr. Murphy: No. I would not necessarily say that. I think there are socialand historical traditions that support men in feeling dominant and exertinga need for power and control, which is part of the feminist analysis of spouseabuse. But, there are other things that go wrong in relationships as well andcontribute to abuse. A lot of what we look at and treat in domestic violencealso includes inadequate self-regulation of emotion, impulsive behavior,poor communication, and poor problem solving.
I think the feminist theory might not be a complete analysis or fully
applicable in all situations. These other problems that can lead to violence
are also important, but are not well characterized by a power and control
model.
Dr. McCarroll: Do you see power and control issues by women?
Dr. Murphy: To some extent. There’s a lot of variation within the population of women with whom we work. You could call their behavior controlling because it often involves things like intense jealousy and checking up
on the partner. Some of those behaviors look very similar for women andmen who are abusive, but some things look different. For example, womenare more likely to describe their aggression as a way to communicate intense

Christopher M. Murphy, PhD 269

frustration and anger. Sometimes it does not look so much like control as inforcing the other person to do what you want, but more a way of getting thepoint across of how upset the individual is. Although these things occur inboth genders, we tend to see more of a tendency for women to use violence
to vent frustration and anger and more of a tendency for men to exert dominance and control.
Dr. McCarroll: To what extent do you focus on psychological aggression?
Dr. Murphy: That is a very common part of almost all treatment programs for partner violence. We have to realize that the physical assault is justthe tip of the iceberg. It is very important to help people become aware thatthey are also emotionally and psychologically abusing their partners and tohave a clear sense of how this damages their relationship. Working on thesemore subtle forms of abuse also helps identify the need for enhanced communication and problem solving.
Dr. McCarroll: Do you have a sense that the psychological violence is seen
as harmful by your clients?
Dr. Murphy: At the time that people describe these things, they sometimes seem immune or inured to their effects. However, if you interview
formerly battered women after they have gotten out of their abusive relationships and ask them what was the most hurtful or damaging part of what
they experienced, over three quarters of them say it was the psychologicaland emotional abuse more than the physical violence. Actions and words
that are denigrating and humiliating are very common in abusive relationships and often produce more lasting emotional scars than physical violence.
These attacks on self-esteem often leave the partner feeling very bad about
themselves and can be very difficult to recover from.
We try to help people understand their underlying motivation for doing
those things and try to figure out how they can cope with their own emotions and their relationship issues without needing to resort to words andactions that are hurtful, intimidating, or denigrating to the partner.
Dr. McCarroll: Do you treat couples?
Dr. Murphy: We occasionally do couples work, but only after the abusive
partner has been through individual work to help them identify and address
their controlling and abusive behavior.
Dr. McCarroll: In your last interview you also talked about your work indomestic violence counseling and also about the relationship of substanceabuse to domestic violence. Please discuss the differences between drug use

270 Family Violence Research, Assessment and Interventions

and alcohol use and how they relate to intimate partner violence (IPV).
Dr. Murphy: Most of the research on drug treatment is on what we used tocall hard drugs, specifically with people who are dependent on cocaine, heroin
or other opiates or amphetamines. Drugs of that sort tend to be much morecommonly the focus of treatment. Most of the research looks at a variety ofdifferent substance abusers. Of course, most people who abuse drugs sort are
not abusing just one substance, but there are poly-substance problems.
Dr. McCarroll: Is marijuana in the picture in terms of interpersonal violence?
Dr. Murphy: There are mixed findings. Laboratory research does notsuggest that marijuana intoxication increases aggressive behavior. However,some studies find an association between marijuana abuse and partner violence. We have explained this finding through a general deviance model. In
this model, folks who are prone to abuse a variety of substances, including
marijuana, tend to have more impulsive behavior and anti-social characteristics and are therefore also more likely to be violent. But, in terms of thespecific day-to-day associations between drug use and violence, what weknow so far is that the stimulant drugs, particularly cocaine and amphetamines, seem to be linked more with the day-to-day tendency to be violent
as compared to sedative drugs and marijuana.
The acute use of the opiate drugs tends not to be associated with an increased risk of violence. But, people who abuse drugs like heroin may beviolent or engage in criminal activities in order to obtain money to get thesubstances. I am making a distinction here between the acute effects of thesubstance versus the general lifestyle problems that often go along with drug
abuse. Stimulant drugs and alcohol have been much more specifically linked
to violent behavior than some of the other drugs of abuse including marijuana and opiates.
Dr. McCarroll: Do you see differences in the behavior of male and female
alcoholics?
Dr. Murphy: There are some differences that are fairly well known at thispoint. For example, there are different patterns of onset of alcohol problems.
Men are more likely to have an early onset that starts in adolescence and iscorrelated with antisocial and violent tendencies, whereas women are more
likely to have a later onset in early to middle adulthood that is correlatedwith stress and trauma exposure. This latter pattern may be seen as drinking in response to life’s problems and stresses. Both patterns occur in bothgenders, but the early onset antisocial pattern is much more common inmen than women.

Christopher M. Murphy, PhD 271

Another gender difference in alcohol problems is called a telescoping
process where the time between the initiation of heavy drinking and thedevelopment of complications and problems with alcohol seems to be shortened for women. This might be due to differences in tolerance for alcoholor biological differences, but it does seem to be the case that men often consume unhealthy amounts of alcohol over longer periods of time before developing signs of dependence and life complications.
There are many different typologies of substance abuse problems, but
no universally accepted statistical method for subtyping. Different methods
come up with different groups. It also depends on the variables used to subtype individuals. For example, one might find different subgroups by looking at age of problem onset, correlated emotional and psychological problems, life stressors and living conditions, or the specific patterns of substanceabuse. As research progresses my guess is that genetics will become an important element of that work, and that research will identify certain risk
genes and then combinations of those genes with life experiences that leadto substance problems, but we are not at that level of understanding yet.
Dr. McCarroll: In your recent paper (Schumm, O’Farrell, Murphy, et al.,2009), you talked about the need to contextualize violence. Would you explain what you mean by that?
Dr. Murphy: The general issue involves the association of situational factors in the perpetration of violence. There is a tendency in the domestic violence field to think about men as always being perpetrators and women as
always being victims or recipients of abuse. However, survey data in partner
violence research shows that abuse is often mutual and that women perpetrate aggression in relationships. That raises questions: whether the violence has the same intention and whether it occurs under the same sorts ofcircumstances and conditions. For example, to what extent is violence inself-defense or reactive to the other person’s aggression or is it pro-active innature. So, there are questions about whether women’s aggression is similar
in motivation and effect to men’s aggression.
Part of the issue about contextualizing our understanding of violence
has to do with the extent to which both relationship partners have substanceuse problems versus only one of them. Most of the studies that have been
done in this field look at couples where only one person is an identified drugor alcohol dependent individual and yet in the real world, there are a lot of
couples where both partners are drug or alcohol-dependent. We have notadequately studied some of these patterns.
There is some evidence that there is more assortative mating in this area
for women. People who abuse substances tend to find others who also do,272 Family Violence Research, Assessment and Interventions

but that seems to operate even more for women. Women who have severe
substance abuse problems are quite likely to be in relationships with men
who have them also. When men are alcohol or drug-dependent, it is fairly
common for them to have partners who do not abuse substances. These
partners often fit more of a caregiver model of someone who is taking careof the substance-abusing man and often taking care of the household chores,
childrearing, and family finances as well.
Dr. McCarroll: Let’s talk about treatment. I assume that your treatment isprimarily with IPV clients some of whom have alcohol problems and some
do not. How do you sort them into treatment groups?
Dr. Murphy: In treating IPV clients, we tend to use adjunctive treatments
for the substance users. Most commonly, the client receives both substanceabuse intervention and group treatment for partner violence. However, in
the alcohol field, traditionally, problems like partner violence have been
largely ignored or not directly addressed in most treatments. We have foundthat even if IPV is not addressed directly in the substance abuse treatment,
there is still a substantial reduction in violence associated with successful
substance abuse treatment. The philosophy there has typically been thatyou treat the substance abuse problem and then other life issues like family difficulties, relationship difficulties, and employment problems stabilize.
There is a lot of evidence that this is actually a reasonable model. Although
improvements are not inevitable in all areas of life, with the resolution ofsubstance dependence, other aspects of life start normalizing over time andsubstantial improvements in life functioning and resolution of difficulties
are very common.
In our IPV group we discuss substance abuse. Everybody gets some education and basic information, but we do not think that that is a sufficientintervention or treatment for those with substance use problems. We wantsomeone to get additional help with that. We have also experimented withbrief alcohol interventions which we deliver before someone goes into thedomestic violence treatment program. We have found that we can get some
substantial reductions in alcohol consumption from those brief interventions either based on motivational interviewing or based on an education
model.
Dr. McCarroll: How is the alcohol treatment structured?
Dr. Murphy: Typically, we would have it start either before the person
starts the domestic violence program or at the same time. Part of what wehave been working on is addressing alcohol problems for people who havepartner violence, but who do not fit well into traditional addiction programs

Christopher M. Murphy, PhD 273

because the level of substance abuse and dependence is not as high as what
they are used to treating. These individuals may not meet all the criteria fordiagnosis, but yet they might binge drink on occasion and get into fights
with their partner when they are drinking. So, one question of our ongoing
research is whether these individuals can benefit from less intensive interventions than are normally provided in substance treatment facilities, andwhether they can exercise better control over their drinking and reduce therisk of alcohol-related violence. These are things we are studying right now,
but we do not have answers yet.
Dr. McCarroll: Is there a particular time period for the alcohol treatment?
Dr. Murphy: That varies a lot depending on the program and the expectations for the treatment. It also varies with the severity of their problem.
Dr. McCarroll: How should IPV and alcohol counselors communicate?
Dr. Murphy: The more that those efforts can be integrated, the better. It isgood for people to work closely together and to share perspectives with one
another. That is especially true in this work because there is such a big disparity between the two fields as to how these problems tend to be viewed.
Dr. McCarroll: Do you have outcome criteria for the alcohol counselor before a client can go into IPV counseling?
Dr. Murphy: No. Not typically. We do not expect that any treatment isgoing to work all the time. The issue for me is always whether clients are ina state of mind or have problems that make it very unlikely that they will
benefit from the IPV treatment program. If they have co-occurring problems like drug or alcohol dependence, we have found that they are unlikely
to complete our program, unlikely to be compliant with program activities,
and less likely to benefit from it. Their outcomes are likely to involve continued violence if those other problems are not addressed. So, for us thecriterion for being in our program is that we want the person to have somechance that the program will be successful in helping them to end their violence and abuse. Therefore, we require them, as a condition of treatment, toaddress problems that are likely to impede progress. That is true for major
psychiatric conditions as well as substance dependence. But, it is not true
for more minor problems. For example, if they have social anxiety or mild
reactive depression we are not going to say, “You have to have that treated to
be in our program.” because we do not think those problems will necessarily impede their ability to benefit from our treatment. We may recommend
other services, but not require them.
Dr. McCarroll: I can see how the motivational interviewing and motivation-

274 Family Violence Research, Assessment and Interventions

al therapy would fit into determining how you evaluate and treat clients.
Dr. Murphy: The real key there is to see if you can help people identify
intrinsic motivations that they have to want to work on these problems andchange their behavior. This is true both in the partner violence and substance abuse areas. The more you can get someone to really take a serious
look at those issues and start developing some motivation to change and tohave good compliance with treatment, the better the outcome.
Dr. McCarroll: Are your counselors trained in motivational interviewing?
How long do you think it takes for people to acquire that skill?
Dr. Murphy: A training plus consultation model seems to be the mostsuccessful in imparting the motivational interviewing skills. That model isactually true for a lot of skill training. If you just do a one-shot workshop I
do not think that people necessarily acquire the clinical skills. They might
acquire some knowledge and information, but the how-to piece also needs
ongoing support and training over time. The other piece that I would justmention is that there are individual differences among therapists in termsof how easy it is for them not to be directive. Motivational interviewing is
not as overly directive as a lot of other types of therapies such as cognitivebehavior therapy, for example. Some folks have a hard time getting over the
initial hump of shifting their habitual reactions in the counseling session.
The biggest problem for many people is to learn to have high levels of empathic reflection. As you know, that is the first thing that you learn in any
counseling or helping skills class or program, but it is the hardest skill formany professionals to practice consistently.
You also have to be clear that motivational interviewing is mostly geared
to helping people to become prepared to change. It is not necessarily theclinical technique that is necessary to actually help people to accomplishchange in a longer term treatment.
Dr. McCarroll: Then you have to know when to switch models.
Dr. Murphy: Yes. That is an area where we really do not have muchknowledge about how to integrate motivational interviewing with othertherapies, like cognitive behavior therapy, and how to help therapists learn
to know when to switch modes. That is a very interesting and challenging
topic for those of us who are training therapists. This is particularly true
when working with difficult, resistant clients. But, my sense from our research is that the big thing that motivational interviewing does for domestic
violence offenders is to diffuse their hostility toward coming into treatment.
It really takes the wind out of their sails and helps them leave in a state where
they are not angry and frustrated and they feel understood. Once you getChristopher M. Murphy, PhD 275

over that initial hump you often have an opportunity for some openness
and they stand a better chance of benefiting from the treatment program. If
you do not get over that hump then you often get stuck in their rejection ofwhatever the treatment program has to offer.
Dr. McCarroll: What differences have you seen between relapsed and remitted patients alcoholic clients?
Dr. Murphy: From the results across a whole series of studies, we knowthat that those who relapse to their substance abuse after treatment haveconsiderably higher rates of partner violence than those whose substanceabuse problems remit stably. That is a very consistent finding. There is a
big difference between those two groups over time. For example, in studying just domestic violence treatment programs, ongoing abuse of alcohol isa major predictor of recidivism of violence. Ongoing abuse of alcohol appears to be a major risk factor for partner violence recidivism whether theindividual is initially referred for treatment of substance abuse problems orpartner violence.
Dr. McCarroll: How you determine if clients will nor will not be successfulin treatment?
Dr. Murphy: We have not found anything that is particularly useful inthat regard. That is a good news story in some ways because I do not think
there are any factors that would say that you should not try to treat someone.
The severity of problems tends to be the best predictor of ongoing issues. We
look at the extensiveness and severity of the substance abuse problem, howlong that person has had it, how severe it is, and how many different drugs
they abuse. Those sorts of issues are generally predictive of poor outcome
or at least more of a challenge to treatment. The same goes on the domestic
violence side. The more severe and the more frequent the violence has been
the more likely they are to keep doing it. But, that having been said, there isa lot of variation and some people with severe problems appear to respondto treatment and some with less severe problems do not.
Dr. McCarroll: What are the gaps in either your research or practice thatyou would explore if you could do that?
Dr. Murphy: One big gap is in the need for combined treatments for substance abuse and partner violence. Behavioral couples therapy seems helpful, but that is only relevant to people who have a stable relationship partner.
A lot of people are not in stable relationships or their partner also has theirown severe problems with substance abuse. We do not have good combined
treatment models that address both substance abuse and partner violence.

276 Family Violence Research, Assessment and Interventions

That is an area where there is not a lot of research. We need to know how
these problems go together. Why do they go together? What makes somebody who is abusing substances prone to be abusive toward their partner?
What are the different factors involved? Is it more of a personality factor?
Is it more of a relationship and stress-based process? To what extent is it afunction of acute intoxication and poor impulse control while intoxicated orare broader, more general factors involved? Some answers to those questions
might influence our treatment models.
We also need a longer term perspective on treatment in all these areas.
We do not have the dental model with checkups over time or following people over time because they may have good initial response to treatment, but
may relapse down the road and end up with the same old problems. So, wereally need to develop models that help us be more involved, even if contact
is not as frequent, but occurs over an extended period of time, a model thatwould help people maintain changes in their own life contexts.
Dr. McCarroll: We very much appreciate the opportunity to talk with you.
Dr. Murphy: Thank you.
Key Points
Psychological aggression is a very common part of almost all
treatment programs for partner violence. We have to realize thatphysical assault is just the tip of the iceberg.
If you interview formerly battered women and ask them what was
the most hurtful or damaging part of what they experienced, overthree quarters of them say it was the psychological and emotional
abuse more than the physical violence.
Those who relapse to their substance abuse after treatment haveconsiderably higher rates of partner violence than those whose
substance abuse problems remit stably.
We need a longer term perspective on treatment. We do not havethe dental model with checkups over time. They may have a goodinitial response to treatment, but may relapse down the road andend up with the same old problems.

Christopher M. Murphy, PhD 277

Reference
Schumm JA, O’Farrell TJ, Murphy CM, & Fals–Stewart W. (2009). Partner violence before and after couples–based alcoholism treatment for
female alcoholic patients. Journal of Consulting and Clinical Psychology;
77:1136–1146.

278 Family Violence Research, Assessment and Interventions