JOINING FORCES

Joining Families

Volume 18, Issue 2 • Spring 2019

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

Children Exposed to Intimate Partner Violence:
Concerns for their Physical and Emotional Safety
An interview with Melissa Kimber, PhD, RSW and Harriet MacMillan, CM, MD
Melissa Kimber, PhD, RSW (top photo)

Melissa Kimber, PhD, RSW, is an Assistant Professor within the Department of
Psychiatry and Behavioural Neurosciences at
McMaster University, a Core Member for the
Offord Centre for Child Studies, and an Associate Member with the Department of HealthResearch Methods, Evidence, and Impact. She isalso a registered social worker with the Ontario
College of Social Workers and Social Service
Workers. Complementing her clinical work is
her research examining the antecedents, correlates, and outcomes of child maltreatment,
intimate partner violence, and mental health

In This Issue
This issue of Joining Forces Joining Families (JFJF) features an interview
with Melissa Kimber and Harriet MacMillan on children exposed to intimate
partner violence (IPV). Separate articles address issues of the prevalence,
evidence of harm, assessment, and interventions for children exposed.
Additional articles describe the importance of the police response to IPV whenchildren are exposed and the importance of emotional safety at home and atwork. Our research methods article describes qualitative research, some ofits procedures, and how it is often used. Websites of interest includes a wide
variety of online resources that can be used to educate families about effectsof IPV on children and resources for information and intervention.
Contents
Children Exposed to Intimate Partner Violence: Concerns for their
Physical and Emotional Safety ………………………………………… 1
Exposure to Intimate Partner Violence: Effects on and Experiences ofChildren and Adults……………………………………………………… 5
What is Qualitative Research and How is it Used?……………………… 8
Police Respond Differently to Intimate Partner Violence
When Children Are Present……………………………………………… 9
Emotional Safety: An Important Human Need at Home and at Work……11
Websites of Interest………………………………………………………12

concerns among children and adolescents. She
was awarded McMaster University’s Faculty of
Health Sciences Outstanding Dissertation Awardin 2017 and has received fellowships from theOntario Ministry of Health and the Canadian
Institutes of Health Research.

Harriet MacMillan, CM, MD 		(bottom photo)

Harriet MacMillan, C.M., M.D. is a psychiatrist and pediatrician conducting family violence
research. She is a Distinguished University
Professor in the Departments of Psychiatry and
Behavioural Neurosciences, and of Pediatrics
at McMaster University. She holds the Chedoke
Health Chair in Child Psychiatry and is a member of the Offord Centre for Child Studies. Dr.
MacMillan’s research focuses on the epidemiology of violence against children and women; she
has led randomized controlled trials evaluating
approaches to prevent child maltreatment andintimate partner violence. She was founding
Director of the Child Advocacy and Assessment
Program at McMaster Children’s Hospital, aclinical program which addresses the needs ofchildren who have experienced maltreatment. Dr.
MacMillan was appointed as a member of theOrder of Canada in 2016.

Dr. McCarroll: Children’s exposure to intimate
partner violence (IPV) is increasingly
recognized as a form of child maltreatment.
Why should that be the case and how would
you recognize it?
Continued on page 2

An interview with Melissa
Kimber and Harriet
MacMillan, from page 1

The kinds of problems
that you see in children
who are exposed to IPV
are similar to those seenin children who haveexperienced other typesof maltreatment.

Dr. Kimber: The effects of children’s exposure to IPV can really vary according to its
intensity, its duration, and its frequency. The
kinds of problems that you see in children whoare exposed to IPV are similar to those seen inchildren who have experienced other types ofmaltreatment including physical abuse, sexual
abuse, emotional abuse, and neglect. Somesigns that might alert us to potential exposure
to IPV are major shifts in the child’s emotions
and behavior. For example, some children
display marked increases in aggression. Others
could signal to us their exposure by becoming
quite withdrawn from activities that they usually enjoy.
Dr. MacMillan: As well, children can manifest symptoms of posttraumatic stress disorder(PTSD). Sometimes people are expecting thefull gamut of PTSD symptoms, and children
may exhibit these, but often they have some
symptoms of PTSD (which is separate fromanxiety disorders), as well as symptoms ofanxiety disorders, and/or depressive symptoms.
In addition, there is the whole category of what
we call the externalizing symptoms that you
can see manifested among children exposed to
IPV.
Dr. McCarroll: I have often seen in theliterature that boys have externalizing
symptoms and girls have internalizing
symptoms. How consistent is that? Is that a

JOINING FORCES
Joining Families
Joining Forces Joining
Families is a publication of
the Center for the Study ofTraumatic Stress (CSTS)
and the U.S. Army Installation Management Command. The CSTS is part of
the Department of Psychiatry, Uniformed Services
University (USU), Bethesda,
MD 20814. The USU is the
US national federal military
medical school.

2 • Joining Forces/Joining Families

Editor-in-Chief
James E. McCarroll, PhD
Email: James.McCarroll.ctr@usuhs.edu
Editors
Joshua C. Morganstein, MD
Captain, US Public Health Service
Assistant Director, CSTS
Associate Professor and Assistant Chair
Department of Psychiatry, USU
Ronald J. Whalen, PhD, LMSW
Research Social Worker, CSTS
Research Assistant Professor
Department of Psychiatry, USU
Assistant to the Editors
Alexandra Burris, BA

good guideline for people or should they be on
the lookout for both types of symptoms in bothboys and girls?
Dr. Kimber: I think you are right. That iswhat the literature suggests. In Canada, as wehave become more diverse, we have to think
about gender differences, as well as culturaldifferences. Even though certain symptoms are
more common among a certain gender – forexample, externalizing symptoms among boys girls also demonstrate externalizing symptoms.
It depends on many factors, including the family context. Different types of symptoms may
be exhibited by children depending on a range
of factors, including genetic and environmental factors; an example of the latter would beparental response to certain behaviors.
Dr. MacMillan: It is important to think
about the whole range of symptoms. If I am
taking a history, I ask questions of the child andalso of the parents that address both internalizing and externalizing symptoms regardless ofthe gender of the child.
Dr. McCarroll: How would you inquire about
exposure to IPV when working with a child orfamily?
Dr. Kimber: We need to elicit information ina safe and respectful way. For any health professional interacting with children or adolescentsand their families, I would suggest that theyask open-ended questions around the relationships within that home environment. I would
ask, “Who is in your family?” “Tell me a little bit
about how people get along in your family.” For
younger children, “If someone gets in trouble,
what does that look like?” “What do yourparents do for discipline? “ “How might yourparents let you know that you are in trouble?”“If your parents disagree about something, what
happens?” “How do the other kids in your family [siblings] get along?”
Clinicians are more willing to ask about
physical abuse. People can get behind that
because it is often visible. We know that weare not supposed to hit one another. Where
there is some tension, usually in the context
of children’s exposure to IPV, there is also a
caregiver who is being exposed to violence andthat is usually a mother. Mandatory reportingof children’s exposure to IPV can be particularly
difficult for mothers because they are also experiencing IPV at the same time that the child isbeing exposed to it in the family. The responses
from the child welfare system, while variable,
Continued on p. 3
Spring 2019

An interview with Melissa
Kimber and Harriet
MacMillan, from page 2

Parents tend tounderestimate the extent
to which children areaware of and exposed
to IPV. The behavioral
and emotional effectsof being exposed to
IPV can be reduced bya warm and supportive
relationship with a nonoffending caregiver oranother adult in the childor adolescent’s life.

can potentially end up creating problems forthe mother. That is an important factor that
we have to keep in mind in this form of childmaltreatment.
Dr. McCarroll: How do we keep track ofchildren who have been exposed to IPV?
Dr. Kimber: It is not clear what childprotection process is best for keeping track ofchildren who have been exposed to child maltreatment or who are at risk for child maltreatment. What is most important is developing
evidence-based effective intervention. We havean imperfect system. Mandatory reporting wasrolled out and scaled up very quickly. There
were good reasons for this such as the underidentification of maltreated children and theneed to assess and ensure safety as quickly as
possible. We are in different times now when
there is much stronger recognition about the
impact of reporting on child and family outcomes, and a willingness to question the extent
to which it helps children who have experienced different forms of maltreatment. Entry
into a registry can be stigmatizing. Mandatory
reporting laws have increased the identificationof child maltreatment, but we are unclear about
the extent to which such identification actually
improves child and family outcomes. It is really
important that, once identified, these children
are followed for safety reasons. We know that
how agencies respond to different forms ofchild maltreatment can vary within and acrossjurisdictions. [See text boxes on Army andCanadian policies for children exposed.] This isparticularly the case with children’s exposure to
IPV. We are just really starting to get a sense of
its impact and how to address it, but we needsome method of being able to check in with

Army Policies for Child Emotional Abuse or Neglect in theContext of Intimate Partner Violence

Army guidelines for establishing whether an incident of abuse orneglect meets its criteria are: (1) whether the act occurred and (2) thelevel of impact of the act on the victim. In incidents of intimate partner
violence (IPV) that could involve children, two guidelines apply. First,
child neglect may meet the criteria when the act of IPV is close enoughin proximity to the child to create the risk of injury. In the second case,child emotional abuse may meet the criteria when the child is not exposed to the hazard (i.e., not close enough to the IPV to be harmed), butthere is reasonable potential for psychological harm to the child. Regardless of whether the incident meets criteria for abuse or neglect, the Army
offers treatment for children and families when there are clinical needs.

kids. A key question is: how can we follow up to
make sure children continue to be safe?
Dr. McCarroll: What are interventions forchildren exposed to IPV?
Dr. Kimber: The evidence comes acrossas weak. (See Howarth, Moore, Welton, et al.,2016). There are parenting interventions that
improve family processes, but the extent towhich they prevent or reduce IPV or children’s
exposure to IPV is unclear. If we have good andresponsive parenting from the non-offending
caregiver that will, hopefully, be protective inthe context of IPV. But, we do not have any
interventions yet where, for example, if a couple
has risk factors for IPV and participate in anintervention, we can then expect that the likelihood of IPV in the home will be reduced.
Dr. MacMillan: We put a lot of emphasis on
identification without the associated need forevidence-based intervention and the system
support that is necessary.
Dr. Kimber: Children need caregivers who
can respond to their needs in a safe environment. How we can mitigate these negative
effects? The behavioral and emotional effectsof being exposed to this form of violence canbe reduced by a warm and supportive relationship with a non-offending caregiver or another
adult in the child or adolescent’s life. However, it
is also important to remember that even when
violence happens and the child or adolescentdoes not have a warm and supportive adult intheir life, some kids really demonstrate remarkable resilience in the face of exposure to IPV
and will not go on to develop negative healthoutcomes. We do not know the proportion, butfrom experience in my own clinical work and inresearch, I know there are children and adolescents who have had these experiences, yet do
not go on to have the negative outcomes that we
consistently see in the literature.
Dr. McCarroll: What would you do if you
believe that children are resilient to their
exposure to IPV?
Dr. Kimber: Let’s say I find out a child was
exposed to IPV and I was not seeing any kindof behavioral or emotional indicators that thishas actually been an issue for them. They canbe resilient in the period immediately following
IPV, but I still think that safety trumps how thechild currently is functioning. If someone mademe aware that this child was being exposed
to violence between their parents, even if theContinued on p.4

http://www.CSTSonline.org

Joining Forces/Joining Families • 3

An interview with Melissa
Kimber and Harriet
MacMillan, from page 3

When there is IPVin the home, we cantell parents that they
deserve a healthy andsafe relationship, thatyou want to support
them in a way thatwould be helpful andsafe for them.

child was not demonstrating any emotional or
behavioral problems, I would still have a duty
to report this to child protection services. The
importance of safety for their child is critical tome as a clinician.
Dr. MacMillan: When IPV is identified in
the household, safety is really important. We
need to look at how people are doing generally. A child who is living in a household where
there is IPV deserves the opportunity to beassessed by someone who has experience inassessing mental health problems in children— for example, a family physician or a social
worker — to understand what has happened,
what they have experienced, and what problems they might be experiencing. The safetyissues need to be paramount because we knowthat parents underestimate the extent to which
their children are aware of and exposed to IPV.
Dr. McCarroll: What can you tell parents who
have children about the risks to them fromongoing intimate partner violence?
Dr. Kimber: What we can do is offer validation that they deserve a healthy and safe
relationship, that you want to support them ina way that would be helpful and safe for them.
We can offer referrals for advocacy services,
and assist them with safety planning. And if an
individual is ready to leave an abusive relationship, we can support them to think about thesafest way to do so, for themselves, and fortheir children.
Dr. McCarroll: What would you tell theoffending parent about the potential
involvement of child protection services?
Dr. Kimber: It would depend on the formof maltreatment exposure that has occurred. In
the case of exposure to IPV, I would say something like the following: “Relationships can be

Canadian Policies for Accounting for Child Exposure to IPV

In Canada, legislation for child maltreatment is determined on aprovincial/territorial (PT) basis. Most of the PTs include exposure to
intimate partner violence (IPV) as a type of child maltreatment in theirlegislation, but even when it is not mentioned directly, it falls under the
category of emotional harm (or risk of). The Canadian Incidence Studyon Child Abuse and Neglect, which surveys child protection agencies
about maltreatment approximately every five years, includes exposure to
IPV as a type of child maltreatment. It is overseen by the Public HealthAgency of Canada.

difficult and made even more challenging by
stressors within and outside the home. In what
you have told me, I have become concerned
about the impact of the challenges at homeon your child’s well-being. When I have theseconcerns, I need to talk to child protection
services about how best to support your childand your family. I would like for us to makethe call to child protection together. Would you
like to join me in making that call?” Asking theparent to join me for the call would depend on
the information that I have been provided. For
example, if I had met with the child and theysaid something to me that I felt child protection
would need to know, but would also place thechild at risk of harm, I would not ask the parent
to join me. That would be the only reason that I
would not ask a parent to join me for the phonecall. As much as possible, I would answer any
questions that the parent had, without making
any absolute statements. In some cases, practitioners, to ease the tension that can arise with achild protection call, may tend to inadvertently
say “I need to call child protection, but they
probably won’t do anything,” or “Child protection will probably just talk with you,” or “Don’t
worry, they won’t take your kid away”. Child
protection responses to reports of child exposure to IPV can be variable and it is best not topredict what they will or will not do, but rather,to outline the different possibilities of response.
We know that most of the time, a child is notremoved from the home and child protection
services do as much as they can to preserve thefamily system while ensuring the safety of thechild/children. Finally, it is important to let theparents know about what you have been told
from child protection, what will happen next (ifthey have been clear about this).
Dr. McCarroll: You have emphasized safety.
Are you considering safety from a broader
point than just physical safety? Children
also observe relationships where there isemotional abuse between parents. Is thatsomething that concerns you in addition tophysical abuse between parents?
Dr. Kimber: Yes. We know that emotional
abuse is just as harmful as physical abuse.
For example, if I become aware of emotional
violence between parents, I would take that asa safety concern and I would still contact childprotection services. We know that emotionalsafety is important for healthy emotional andContinued on p. 10

4 • Joining Forces/Joining Families

Spring 2019

Exposure to Intimate Partner Violence:
Effects on and Experiences of Children and Adults
By James E. McCarroll, PhD, Joshua C. Morganstein, MD, and Ronald J. Whalen, PhD

Definitions of Exposures
Exposure to IPV is amore appropriate termthan witnessing as
it includes children’s
presence, awarenessof IPV between
parents or caregivers
and children’s actual
involvement in an
incident.

http://www.CSTSonline.org

Children’s exposure to intimate partner
violence (IPV) is increasingly recognized as aform of child maltreatment (McTavish, MacGregor, Wathen, & MacMillan, 2016; Wathen& MacMillan, 2013). There is no standard definition for clinical or research purposes of what
constitutes children’s exposure. Witnessing isa term that is commonly used to describe theconcept of children’s presence when IPV occurs. However, witnessing is too general a term
as it implies or even specifies that the childmust be present when IPV occurs. Exposure is
the more appropriate term as it includes children’s presence as well as a child’s awareness of
IPV between parents or caregivers and othercircumstances such as children’s actual involvement in an incident (MacMillan & Wathen,2014). More specific definitions have been
proposed including a taxonomy of 10 different
types of exposure (e. g, child observes, participates, or overhears), nine characteristics of
IPV as applied to children (e. g., types of IPV,
nature of acts, and injuries), and six ways inwhich IPV victimizes children (e.g., terrorized,
isolated, and emotionally neglected) (Holden,
2003).
The Canadian Incidence Study of Reported
Child Abuse and Neglect in 2008 (CIS-2008)
provided a profile of families with children 15
years and younger (n=2,184) who were receiving child welfare services in Canada where
exposure to IPV was the sole reason for aninvestigation (Gonzalez, MacMillan, Tanaka,Jack, & Tonmyr, 2014). They found four mutually exclusive and exhaustive categories of child
exposure: (1) indirect (overheard, but did notsee IPV or saw its consequences), (2) emotional
only (emotional violence between parents or
caregivers), (3) direct only (child was present
and witnessed physical IPV), and (4) co-occurring IPV (children were exposed to more than
one type of IPV). The presence of mental oremotional harm was also counted as present or
not present.
Non-violent coercive control is anothertype of exposure to IPV that is increasingly
recognized as a form of child maltreatment.
Research tends to emphasize controlling
behaviors by fathers (or father figures) against

the mother. These controlling behaviors include
verbal abuse, restrictions of finances, isolation, and monitoring of her activities. Coercive control can also extend to the children.
Examples are preventing them from spendingtime with their mother and grandparents, bymonopolizing the mother’s time, from visiting
other children’s houses, and from engaging in
extracurricular activities (Katz, 2016). Threatsof and harm to pets are other methods of coercive control (McDonald et al., 2015).

Epidemiology

Intimate partner violence is a worldwide
tragedy. A review of 11 surveys estimatedthe prevalence of IPV for perpetration andvictimization (Esquivel-Santoveña & Dixon,
2012). The 12-month rate of victimization of
women was between 34.9% (Uganda) and 5.0%
(China). The rate of victimization of men was
between 12.3% (U.S.) and 5.0% (China). The
authors also reported that during a 10-year
period in the U.S., men’s and women’s perpetration and victimization remained relatively
stable and symmetrical with approximately 12%of both engaging in physical violence including 4% severe violence. In addition, intimate
partner homicide accounted for nearly one outof seven (13.5%; 39% females and 6% males) of
all homicides in 66 countries between 19902011 (Stöckl et al., 2013). Global differences in
IPV are important for greater understandingof its risk factors and other social indices of its
origins.
Establishing the incidence and prevalenceof children’ exposure to IPV is difficult as IPV isunderreported (McTavish et al., 2016). Worldwide, there are very limited data on children
exposed to IPV. Studies have reported that
underreporting is common by both parents andchildren. The UNICEF reported the estimatednumber of children exposed to IPV in theAmericas, the UK, Europe, the Middle East,
Africa, and the Asia-Pacific region (UNICEF,
2006). The number varied widely by country—
from a few thousand (Iceland, 2,000 and New
Zealand, 18,000) to several million (Pakistan,
6.1 million).
An estimate of children’s exposure to alltypes of violence in the U.S. is the National
Joining Forces/Joining Families • 5

Exposure to IPV, from page 5

and emotionally

Survey of Children’s Exposure to Violence(NatSCEV) (Finkelhor, Turner, Shattuck, &Hamby, 2015). The NatSCEV began in 2008
and has continued through 2014. It includes arepresentative sample of 4,000 children aged
0-17 years old. The NatSCEV, 2008-2011,
found that a total of 17.3% of children had
witnessed a parent assault another caregiver(e.g., witnessing a parent kick, choke or beatup another parent) in their lifetime and 6.1%
in the past year (Finkelhor, Turner, Shattuck,& Hamby, 2013). Data from 2013-2014 foundthat 5.8% of children witnessed an assault
between parents in the past year (Finkelhor etal., 2015). The percentage of children exposed
was higher for females (7.4%) than for males(4.2%). The highest percentage by child age
was for 2-5-year-olds (9.2%) followed by 0-1(7.1%) and 14-17 (5.9%).

in attempting

Evidence of Harm

Children are notmerely passive
participants when
there is IPV in
the family. They
often are actively
involved physicallyto understandthe causes andconsequences of IPV.

Some negative effects on children exposed
to IPV include disturbances in attachment
and emotion regulation (Carpenter & Stacks,
2009) conduct problems (Jouriles et al., 2018),
internalizing problems such as depression,anxiety, suicidal thoughts, or self-harming
behavior (Gonzalez et al., 2014), animal cruelty
by children (Currie, 2006), and PTSD (Levendosky, Bogat, & Martinez-Torteya, 2013). The
likelihood of traumatic symptoms in childrenchanges across development and increases withchild age and the number of symptoms increases with the frequency of IPV (Levendosky
et al., 2013). The co-occurrence of multiple IPV
subtypes was associated with increased odds
for all child problems (Gonzalez et al., 2014).
Children are not merely passive participants when there is IPV in the family. They
often are actively involved physically andemotionally in attempting to understand thecauses and consequences of IPV. Children
ages 7-12 whose mothers were receiving
services at domestic violence agencies reported their thoughts and feelings on aggression in the home. Children often attempted
to intervene in the violence and to withdraw.
Both parents were seen as playing a role inthe violence although they generally viewed
the mother’s partner as responsible. Lack ofcontrol of anger by the perpetrator was seenas the reason for the violence, but the children also reported that the victims provokedaggression. Sadness and anger were reported
more frequently than anxiety (DeBoard-Lucas& Grych, 2011).

6 • Joining Forces/Joining Families

Effects on adults have included perpetrationof IPV. However, evidence linking children’s
exposure to IPV and adult perpetration of IPV
is limited in scope based on low methodologicalquality and is limited to studies of physical IPV(Kimber, Adham, Gill, McTavish, & MacMillan,2018).
Whether exposed children will have apermanent negative outcome is not clearly
established. In a review of resilience factors of
exposed children, the secure attachment to a
non-violent parent or other caregiver has been
consistently found to be an important protective factor (Holt, Buckley, & Whelan, 2008).
Other protective factors are positive peer andsibling relationships and self-esteem.

Interventions

Interventions for children exposed to IPV
include procedures for (1) identifying and (2)preventing IPV (Wathen & MacMillan, 2013).
However, evidence of effectiveness in preventing and decreasing IPV is limited. Interventions
that have shown promise are addressing conduct problems in exposed children (Jouriles etal., 2009), and trauma-focused cognitive behavior therapy for children with PTSD related to
exposure (Cohen, Mannarino, & Iyengar, 2011).
The question of what are good outcomes for
exposed children (as well as other sources oftrauma and distress) were evaluated in a larger
review of clinical trials to measure the perceived
benefits of interventions and the views of professionals, parents, and young people as to what
constitutes a good outcome. Most trials evaluated symptoms whereas children, parents, andpractitioners had broader concepts of success.
Among these were functional outcomes suchas school attainment, coping with challenge,
self-expression, self-regulation, self-esteem, asense of empowerment, and improvements ininterpersonal contexts such as enhanced qualityof the parent-child relationship (Howarth et al.,2015).

Assessment

There is no evidence to justify universal
screening of children for exposure to IPV (Wathen & MacMillan, 2013) or for screening women for IPV in health care settings (Klevens et al.,2012; MacMillan & Wathen, 2014; MacMillan etal., 2009). Clinicians should, however, be alert
to the signs and symptoms that children might
exhibit as well as risk factors for IPV in theiradult patients. Inquiry should be conducted aspart of a history-taking diagnostic assessment
Spring 2019

Exposure to IPV, from page 6

Addressing children’s
exposure to IPV ischallenging for clinicaland social service
providers as wellas policy-makers.
Negative effects havebeen documented, but
children also show
resilience to negative
outcomes.

using open-ended questions (e.g., “Do you feelsafe at home?”) and should be done individually to avoid putting the patient at risk for future
violence or retribution. Disclosure of IPV requires inquiry into safety, but also support for
the individual and consideration of referral to
medical and community resources for evaluation and intervention. In addition, the clinician
should be aware of local mandatory reporting
policies and procedures.

Summary

Addressing children’s exposure to IPV
is challenging for clinical and social service
providers as well as policy-makers. Negative
effects have been documented, but children
also show resilience to negative outcomes.
Much is required of research to establish effects
of different types of IPV at children’s developmental stages as well as how to support the
non-offending parent and the child. Increasing
the awareness of parents and clinicians to thedetrimental effects of children’s exposure is also
necessary through medical and social channels
as well as public information campaigns.

References

Carpenter GL, & Stacks AM. (2009). Developmental effects of exposure to intimate partner
violence in early childhood: A review of theliterature. Children and Youth Services Review;
31(8): 831-839.
Cohen JA, Mannarino AP, & Iyengar S. (2011).
Community treatment of posttraumatic stressdisorder for children exposed to intimate
partner violence. Archives of Pediatric andAdolescent Medicine; 165(1): 16-21.
Currie CL. (2006). Animal cruelty by children
exposed to domestic violence. Child Abuse &Neglect; 30(4): 425-435.
DeBoard-Lucas RL, & Grych JH. (2011).
Children’s perceptions of intimate partner
violence: Causes, consequences, and coping.
Journal of Family Violence; 26(5): 343-354.

http://www.CSTSonline.org

the National Survey of Children’s Exposure toViolence. JAMA Pediatrics; 169(8): 746-754.
Gonzalez A, MacMillan, HL, Tanaka M, Jack SM,& Tonmyr L. (2014). Subtypes of exposure to
intimate partner violence within a Canadianchild welfare sample: associated risks and child
maladjustment. Child Abuse & Neglect; 38(12):1934-1944.
Holt S, Buckley H, & Whelan S. (2008). The
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Howarth E, Moore THM, Shaw ARG, Welton
NJ, Feder GS, Hester M.,… Stanley N. (2015).
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parents and professionals. Child Abuse Review;24(4): 297-310.
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(2009). Reducing conduct problems amongchildren exposed to intimate partner violence:a randomized clinical trial examining effectsof Project Support. Journal of Consulting andClinical Psychology; 77(4): 705-717.
Jouriles EN, Rosenfield D, McDonald R, Vu NL,
Rancher C, & Muelle, V. (2018). Children
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with the child. Journal of Clinical Child andAdolescent Psychology; 47(3), 397-409.:
Katz, E. (2016). Beyond the physical incident
model: How children living with domestic
violence are harmed by and resist regimes of
coercive control. Child Abuse Review; 25(1):46-59.
Kimber M, Adham S., Gill S, McTavish JR,& MacMillan HL. (2018). The association
between child exposure to intimate partner
violence (IPV) and perpetration of IPV inadulthood-A systematic review. Child Abuse &Neglect; 76: 273-286.

Esquivel-Santoveña E & Dixon L. (2012). Investigating the true rate of physical intimate
partner violence: A review of the literature.
Aggression and Violent Behavior; 17: 208-219.

Klevens J, Kee R, Trick W, Garcia D, Angulo
FR, Jones R, & Sadowski LS. (2012). Effect ofscreening for partner violence on women’squality of life. Journal of the American Medical
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Finkelhor D, Turner HA, Shattuck A, & Hamby
SL. (2013). Violence, crime, and abuse exposure in a national sample of children andyouth. JAMA Pediatrics; 167(7): 614.

Levendosky AA, Bogat GA, & Martinez-Torteya
C. (2013). PTSD symptoms in young children
exposed to intimate partner violence. Violence
Against Women, 19(2), 187-201.

Finkelhor D, Turner, HA, Shattuck A, & Hamby
SL. (2015). Prevalence of childhood exposure
to violence, crime, and abuse: Results from

MacMillan HL, & Wathen CN. (2014). Children’s
exposure to intimate partner violence. Child

Continued on page 10
Joining Forces/Joining Families • 7

What is Qualitative Research and How is it Used?
By James E. McCarroll, PhD, Joshua C. Morganstein, MD, and Ronald J. Whalen, PhD

Qualitative research
is an important
technique for
identifying areas
for future empirical
study. It can identify
subtleties that broaden
our understanding of
the concepts understudy.

Qualitative research is a major analytic
technique employed in many types of research.
There are many strategies for conducting qualitative research either as a unique approach toa question or in combination with or part of alarger study involving mixed research methods. In social research, it is used to understandsuch phenomena such as people’s beliefs,
experiences, attitudes, behavior, and interactions (Pathak, Jena, & Kaira, 2013). Qualitative
research is an important technique for identifying areas for empirical study. It can identify
subtleties that broaden our understanding of
the concepts under study. Examples of qualitative procedures are found in studies involving
interviews, focus groups, observations, anddocumentary material such as transcripts, casehistories, and many other forms of written andspoken material. Applications of qualitative
research can be found in diverse fields. For example, the chaplaincy can explore the meaningof experiences through conversations, written
texts (journal, prayers, or letters), or visualforms (drawings and photographs) (Grossoehme, 2014).
Qualitative research procedures differ fromthose of quantitative research. Quantitative
research is about measurement and its product is numeric; qualitative research generates
non-numeric data such as themes that would
be obtained from focus groups exploring a
topic. For example, in the summary of police
involvement with children exposed to intimate
partner violence, Swerin (2018) suggested thatinterviews with police officers could explore
why they may be less likely to arrest offenders
when a child is present, why they are reluctant
to speak with children, and what steps could betaken to reduce their concern (Swerin, Bostaph, King, & Gillespie, 2018).
Qualitative procedures can add dimensions
that are not possible with numeric data in thatparticipants can have a voice in the researchthat can enhance its quality. They can havean impact on data collection, analysis, andinterpretation of results. Formal and informalinteractions with the investigators can also
have an effect on data collection, analysis, andinterpretation of results as well as their experiences of benefits and harms (Pathak, Jena, &Kalra, 2013).

8 • Joining Forces/Joining Families

Comparison groups are often lacking inqualitative research due to the nature of theresearch. For example, in reviews of textual
materials of homicides (e.g., law enforcement
and medical examiner narratives), comparisons may be difficult to conceptualize (Holland, Brown, Hall, & Logan, 2015). However,in health research, comparisons are frequently
possible and result in better research such as byunderstanding how experiences vary between
groups on key variables. A review of 31 studies
using qualitative research focusing on different
health conditions found five different types ofqualitative comparison groups (Lindsay, 2018).
These were comparing (a) healthy controls, (b)no intervention or treatment, (c) two or more
health conditions, (d) different aspects of ahealth condition, and (e) multiple perspectivesof the same phenomenon. This review indicates that a variety of qualitative comparisonsare possible and the possibility of comparisonsshould be considered when designing qualitative research.
Lindsay (2018) described some key steps
involved in selecting and using a comparisongroup in qualitative research. These included(a) considering why and how having a comparison group would benefit the research,(b) consider matching by sociodemographic
variables and other relevant characteristics,(c) in collecting data use the same design forboth groups, (d) decide how to compare results
within and between groups, and (e) in reporting the findings describe similarities and differences between the groups.

References

Grossoehme D. (2014). Research methodology
overview of qualitative research. Journal of
Health Care Chaplains; 20(3): 109-122.
Holland KM, Brown SV, Hall JE, & Logan JE.
(2018). Circumstances preceding homicidesuicides involving child victims: A qualitative
analysis. Journal of Interpersonal Violence;
33(3): 379-0401.
Lindsay S. (2018). Five approaches to qualitative
comparison groups in health research: A scoping review. Qualitative Health Research; 29(3):455-468.
Continued on p. 9

Spring 2019

Police Respond Differently to Intimate Partner
Violence When Children Are Present
By James E. McCarroll, PhD, Joshua C. Morganstein, MD, and Ronald J. Whalen, PhD

Following an incidentof IPV in whichchildren may be
involved, Army
military police focus
on building rapport
with the children andensuring that they
are physically andmentally OK.

What is Qualitative
Research, from page 8

Police often encounter children when they
respond to an incident of intimate partner
violence (IPV). As reported in the accompanying interview in this edition of JFJF, children
who are exposed to IPV are at risk for emotional and physical problems in childhood andin adult life. A study of police reports from
345 IPV incidents in a Northwestern U.S. city
in 2013 found that children were present in
162 (47%) incidents. The average age of thechildren was 6.6 years and the average numberof children present was 1.8. Most offenders
were males (82%) and 56% were non-spouses.
Thirty-nine percent of children present were
under the age of four years. Police reported
interacting directly with a child in 51% of cases
where a child was four years old or older. That
number increased with increasing child age.
Police-child interaction was recorded if theofficer spoke directly to the child or to moreof the children present. Child presence at anincident was a significant predictor of victimdirected intervention (e.g., referral, victim
witness coordination) and victim-directed follow-up. However, victim follow-up decreased
by 71% in cases of a female offender. Child
presence decreased the likelihood of arrest by
50% due to officer discretion in not making theevent more traumatic for the child.
The authors suggested that improvements
to police responses to IPV incidents whenchildren are present include increased training for officers in talking with children to help
reestablish a sense of safety, to facilitate thehealing process, and to improve children’s attitude toward police. Strategies needed for police
training could include increasing officers’

willingness, comfort, and ability in talking withchildren after an IPV incident. Such approaches
may help to reduce the trauma children sufferwhen they are exposed to IPV. Other suggestions as best practices were to identify anddocument the children in the home and theirlevel of exposure to the incident, to speak withchildren at the child’s eye level about what happened and what will happen next, and to assist
with comforting the child.
Additional research needs are to determine
the factors taken into consideration when responding to children exposed to IPV, and why
officers are reluctant to speak with children.
The authors suggested that collaboration is the
key to an effective and comprehensive responseto children exposed. In addition to the police
response and to better police-community coordination, those who work with police might
consider enhancing police education and training on responding to children exposed to IPV.
The Army trains military police personnel
in methods to help children on the scene of
an incident of IPV. Similar to the procedures
suggested by Swerin (2018), the military police
focus on building rapport with the children,
asking what they were exposed to, and asking
if they are physically and mentally ok. If they
believe the children need a more thoroughinterview, they will refer the case for further
investigation.

Reference

Swerin DD, Bostaph LG, King lL, & Gillespie LK.
(2018). Police response to children present atdomestic violence incidents. Child Maltreatment; 223(4): 417-425.

Pathak V, Jena B, & Kalra S. (2013). Qualitative
research. Perspectives in Clinical Research; JulSep; 4(3): 192-3.
Swerin DD, Bostaph LG, King lL, & Gillespie LK.
(2018). Police response to children present atdomestic violence incidents. Child Maltreatment; 223(4): 417-425.

http://www.CSTSonline.org

Joining Forces/Joining Families • 9

An interview with Melissa
Kimber and Harriet
MacMillan, from page 4

An emotionally unsafe
environment is one inwhich a child may feel
unloved, unwanted,
or serving only
instrumental purposes
for their caregivers.

behavioral adjustment in children and a healthyemotional environment is essential for theirdevelopment. We know that if a home is not
emotionally safe, it has negative consequences
just as in homes that are not physically safe.
Health and social service providers may
find it really challenging to identify andrespond to emotional abuse and emotional
neglect in children. If I were to extrapolate thatto children’s exposure to IPV, I think it is evenharder to wrap one’s head around the idea ofchildren’s exposure to emotional abuse between
their parents or caregivers. How does one
characterize that, and make a report to childprotection services so that they would takeseriously that there is a potential for harm?
Dr. McCarroll: Do you have a definition
for emotional safety? I might think of it
as freedom from threats, from coercion,from being exposed to yelling or harmful
arguments.
Dr. Kimber: That is right. An environment
where children are not emotionally safe is one
where they may be feeling unloved, unwanted,
or serving only instrumental purposes for theircaregivers. A safe environment is one wherea child is not living in the context of fearful,threatening, or controlling behavior that serves
the purposes of the parent or the caregiver.
Dr. McCarroll: What would you say to parents
when you fear for children’s emotional safety?
Dr. Kimber: I would take a similar approachthat I outlined above. I would not say, “I think
you are emotionally abusing your child.” Rather, I would say, “I have heard things from you
and your child that make me concerned about

Exposure to IPV, from page 7

and Adolescent Psychiatric Clinics of North
America; 23(2): 295-308.
MacMillan HL, Wathen CN, Jamieson E, Boyle
MH, Shannon HS, Ford-Gilboe, M, . . .
McNutt L.-A. (2009). Screening for intimate
partner violence in health care settings.
JAMA; 302(5): 493-501.
McDonald SE, Collins EA, Nicotera N, Hageman
TO, Ascione FR, Williams JH., & GrahamBermann SA. (2015). Children’s experiences of companion animal maltreatment inhouseholds characterized by intimate partner
violence. Child Abuse & Neglect; 50: 116-127.

10 • Joining Forces/Joining Families

your child’s emotional well-being.” I would
then provide some examples of what I haveheard. For example, “I have heard that there
is frequent name calling, yelling, or a lot of
ignoring.” We know that if a child experiencesa pattern of inconsistent or harsh responses totheir emotions, or overhears harsh communication between other family members, that thiscan lead to emotional and behavioral problems
in children and adolescents. For this reason, I
would then say something to the parent, like,“In meeting with you and your family, I havebecome concerned about the impact of theseexperiences on your child’s well-being. WhenI have these concerns, I need to talk to childprotection services about how best to support
your child. I would like to make the call to childprotection services together.” Then I would
continue with a similar process that I outlined
previously.
Dr. McCarroll: This has been a pleasure.
Thank you for your time and your work on this.
Dr. Kimber: You are welcome. Thank you for
asking.

References

Howarth E, Moore THM, Welton NJ, Lewis N,
Stanley N, MacMillan H, … Feder G. (2016).
IMPVoving Outcomes for children exposed todomestic ViolencE (IMPROVE): an evidence
synthesis. Public Health Research; 4(10): 337.
Kimber M, Adham S, Gill S, McTavish J, & MacMillan HL. (2018). The association between
child exposure to intimate partner violence(IPV) and perpetration of IPV in adulthood—A systematic review. Child Abuse & Neglect.
doi:10.1016/j.chiabu.2017.11.007.

McTavish JR, MacGregor JCD, Wathen CN, &MacMillan HL. (2016). Children’s exposure to
intimate partner violence: an overview. International Review of Psychiatry; 28(5): 504-518.
Stöckl H, Devries K, Rotstein A, Abraham, N,
Campbell J, Watts C, & Moreno CG. (2013).
The global prevalence of intimate partner
homicide: a systematic review. The Lancet;
382(9895): 859-865.
Wathen CN, & MacMillan HL. (2013). Children’s
exposure to intimate partner violence: Impacts
and interventions. Paediatrics and Child
Health; 18(8): 419-422.

Spring 2019

Emotional Safety: An Important Human Need 		at Home and at Work
By James E. McCarroll, PhD, Joshua C. Morganstein, MD, and Ronald J. Whalen, PhD

Clinicians and otherservice providers areadvised to consider
emotional safety fromtheir own perspective
in terms of how
they work with theirfamily, clients, andstaff within theirorganization.

http://www.CSTSonline.org

In her interview in this issue or Joining
Forces Joining Families, Dr. Kimber discussed
emotional safety as part of a safe home environment for children. Emotional abuse of children
may be considered an emotional injury leading
to a lack of emotional safety. While physicalabuse is easier to recognize and is more likely toreceive the attention of child protective services,emotional abuse is more nuanced and difficult to detect. Lack of a standard definition ofemotional abuse further complicates detection
efforts. Emotional injuries can occur throughcoercion, threats, and belittling, as well as otherforms of maltreatment. Results of emotional
injury may include internalizing and externalizing symptoms, poor self-esteem, and guilt(Evans, Davies, & DiLillo, 2008; MacMillan,
Wathen, & Varcoe, 2013).
Recognizing and providing emotional safety
is also important in other human relationships.
In addition to being an essential componentof a child’s home environment, emotionalsafety also can apply to other circumstances inwhich conflict may occur including nursing(de Castro, 2004), the workplace (Wang, Wu,& Huang, 2018), in intimate relationships suchas in psychotherapy (Cathedral, 2012), andin research (Bowtell, Sawyer, Aroni, Green, &Duncan, 2013).
Physical safety is emphasized in organizations. However, emotional safety has been lessrecognized or fostered. Improved workplacesafety has been related to emotional safety.
Individuals can improve safety by taking responsibility for attention to safety issues and regulating their behavior accordingly and motivatingothers to do the same (Wang, Wu, and Huang,2018). Proposed strategies for achieving an emotional safety culture were safety education andrespecting and caring for organization members.
Organizational and personal considerations ofemotional safety are important to ensuring thestaff that it is safe to practice and work.
Intimate relationships require emotionalsafety to be successful. In psychotherapy involving couples, emotional safety has been considered a key component of the therapeutic process. When couples feel emotionally safe, theycan explore issues of conflict with the therapist.
In this model, emotional safety is establishedthrough identifying emotional concerns underlying the couple’s problems and then throughmaintaining esteem for each other and throughsecure attachment (Catherall, 2012).
In a more specialized psychotherapy, trauma-informed care, emotional safety has been
included in addressing domestic violence services (Wilson, Fauci, & Goodman, 2015). Threecomponents contributing to emotional safety
in the provision of trauma-informed care are
the physical environment, staff behaviors, andorganizational policies. The physical space should
help to establish emotional safety through having
a home-like atmosphere, good security including
good exterior lighting, and having quiet spaces tohelp establish calm. Staff should be accepting ofsurvivor responses and be non-judgmental. Organizational policies should be clear and explicit
about transparency and predictability about interactions with survivors. The climate of promoting
emotional safety is a key element of establishingan overall sense of safety and the possibility ofhealing.
Qualitative health research can pose risks ofharm to participants and to researchers throughthe emotional impact of in-depth interviews
involving sensitive topics. Reflexivity and ethicalmindfulness are strategies proposed for enhancing emotional safety (Bowtell, Sawyer, Aroni,
Green, & Duncan, 2013). Reflexivity consists ofidentifying and considering the interactions between the researcher and the participant. Ethicalmindfulness is having a non-judgmental attitude
and open-mindedness to the present moment.
There are also ethical challenges such as the blurring of boundaries when establishing rapport,
confidentiality, and relationships with supervisors.
Children’s exposure to intimate partner
violence as well as other settings reviewed here illustrate that safety planning should include much
more than physical safety (MacMillan, Wathen, &Varcoe, 2013). The similarities and differences inemotional safety and physical safety are important concepts for prevention and interventions
involving risks as well as personal well-being.
Clinicians and other service providers are advised
to consider emotional safety from their own
perspective in terms of how they work with theirfamily, clients, and staff within their organization.
Continued on page 12
Joining Forces/Joining Families • 11

Websites of Interest
There are many websites that give information about
how families can get help when intimate partner
violence (IPV)/ domestic violence (DV) occurs. The
Change a Life program teaches caring adults how to
support a child. It is a free program consisting of four
modules: learn, connect, support, and help. It features
statements by noted researchers and extensive explanations of the concepts involved in children exposed toDV.
(See http://cdv.org/the-change-a-life-program)

The National Child Traumatic Stress Network
provides a wide variety of resources including definitions and descriptions of the many types of childtrauma and the effects of IPV/DV. There are resources
for counseling and mental health interventions forfamilies as well as information on how to help children
in a family in which abuse is currently occurring or has
occurred.
https://www.nctsn.org/what-is-child-trauma/traumatypes/domestic-violence

The National Council of Juvenile and Family Court
Judges and the Office of Juvenile Justice and Delinquency Prevention provide a manual for resources
and research on children exposed to DV. This lengthy
manual describes the impact of DV on children,
legal issues and system responses (legal system, childprotection, law enforcement) for children exposed,
and additional information on national organizations,informational websites, and recommended reading onchildren exposed.
http://www.ncjfcj.org/sites/default/files/Childrens%20Exposure%20to%20Violence.pdf

Emotional Safety References (from page 11)
Bowtell EC, Sawyer SM, Aroni RA, Green JB, & Duncan RE.
(2013). “Should I send a condolence card?” Promoting emotional safety in qualitative health research through reflexivity
and ethical mindfulness. Qualitative Inquiry; 19(9): 652-663.
Catherall DR. (2012). Emotional Safety: Viewing the Couple
through the Lens of Affect. Binghamton, NY: The Hawthorne
Press.
de Castro (2004). Emotional vs. physical labor. American Journalof Nursing; 104(3): 120.
Evans S, Davies C, & DiLillo D. (2008). Exposure to domestic
12 • Joining Forces/Joining Families

violence: A meta-analysis of child and adolescent outcomes.
Aggression and Violent Behavior; 13: 131-140.
MacMillan HL, Wathen CN, & Varcoe CM. (2013). Intimate
partner violence in the family: Considerations for children’ssafety. Child Abuse & Neglect; 37: 1186-1191.
Wang B, Wu C, & Huang L. (2018). Emotional safety culture: A
new and key element of safety culture. Process Safety Progress;
37(2): 134-139.
Wilson JM, Fauci JE, & Goodman LA. (2015). Bringing traumainformed practice to domestic violence programs: A qualitative analysis of current approaches. American Journal of
Orthopsychiatry; 85(6): 586-599.
Spring 2019