JOINING FORCES

Joining Families

Volume 16, Issue 2 • Fall 2016

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’s Exposure to Intimate Partner Violence andCanada’s VEGA Project
An interview with Harriet MacMillan, with Contributions by Nadine Wathen andJill McTavish
Biography — Harriet MacMillan

Harriet MacMillan, CM, MD, MSc, FRCPCis Professor in the Departments of Psychiatry
and Behavioural Neurosciences, and Pediatrics at McMaster University, London, Ontario,
Canada, holds the Chedoke Health Chairin Child Psychiatry, and is a member of theOfford Centre for Child Studies. She was the
In This Issue
In this issue, we discuss children’s exposure to intimate partner violence(IPV). We present an interview with Harriet MacMillan with contributions
by her colleagues, Nadine Wathen and Jill McTavish, although neither
could be available at the time of the interview. Such exposure has manyeffects on children and adults and can be considered a distinct type of childmaltreatment. We summarize a recent article by McTavish et al., an overview
of children’s exposure to IPV, and an article on subtypes of exposure. We
also review an article on adult outcomes of children’s exposure and two
articles on the effects of exposure on children’s brains. We have two Building
Bridges to Research articles: one gives an example of a child’s exposure to
IPV and an explanation of risks, rates, and odds. The second describes terms
encountered in descriptions of research using big data. Finally, Websites
describes the VEGA Project and the PreVAil Network, projects in which Drs.
MacMillan and Wathen have key roles.

Contents

Featured Interview: Harriet MacMillan........................................................ 1
Building Bridges to Research: Risks, Rates, and Odds in Children’s
Exposure to Intimate Partner Violence......................................................4Children Exposed to IPV and Adult Outcomes..........................................5
Building Bridges to Research: New Terminology: Big Data.......................6
An Overview of Children’s Exposure to Intimate Partner Violence.............7
Changes in Brains of Children Exposed to IPV..........................................9
Subtypes of Co-Occurring Exposure to Intimate Partner Violence..........10
Website of Interest..................................................................................12

founding Director of the Child Advocacy andAssessment Program (CAAP) at McMaster
Children’s Hospital, a multidisciplinary programcommitted to reducing the burden of suffering
associated with family violence. She conducts
research on the epidemiology of violence againstchildren and women and she has led randomized controlled trials evaluating the effectivenessof approaches to preventing child maltreatment
and intimate partner violence. Dr. MacMillan
is the co-principal investigator of the Canadian
Institute of Health Research-funded Centre for
Research Development in Gender, Mental Healthand Violence across the Lifespan (PreVAiL) andco-leads VEGA: A Public Health Response to
Family Violence.

Dr. McCarroll: Let’s talk about children’s
exposure to intimate partner violence. How
do you talk to practitioners about children
who are being exposed to intimate partner
violence?
Dr. MacMillan: I try to emphasize theimportance of being alert to the signs andsymptoms of any type of exposure to violence
and integrating those questions in a sensitive,
careful, and safe way into the actual assessment
and history-taking rather than attempting universal screening in which the same questions
are asked of everybody in the same way regardless of presentation. In my opinion, there has
been so much emphasis on screening and lessemphasis on how to ask questions in a sensitive
way that is relevant to the clinical assessment.
Some people interpret this as “We should not
Continued on page 2

Interview Contributors

We see the sametypes of problems inchildren who are being
exposed IPV that we
see for children who
have experienced othertypes of maltreatment.

Jill McTavish, PhD, isa postdoctoral fellow,
supervised by Dr. Harriet MacMillan. working
at the Offord Centre forChild Studies, McMaster University, London,
Ontario. Jill is supporting pan-Canadian
guidance development
regarding strategies to best identify andrespond to family violence. Previously, she wasan information professional at a hospital in
London, Ontario, where she supported nurses
and allied health professionals through mediated literature searches (including systematic
reviews) and instruction related to critical appraisal and research methods. She also teaches
in the Facualty of Information and Media
Studies at Western University about consumer
health information sources and services andevidence-based health care for information
professionals.

raise it.” Not at all. It is an essential part of understanding the lives of our patients and theirfamilies, but asking in a way that is sensitive andappropriate.

JOINING FORCES
Joining Families
Editor-in-Chief
James E. McCarroll, PhD
Email:
James.McCarroll.ctr@usuhs.edu
Joining Forces Joining Families
is a publication of the U. S.
Army Installation Management Command and theFamily Violence and Trauma
Project of the Center for the
Study of Traumatic Stress(CSTS), Bethesda, Maryland
20814-4799, tel. 301-2952470. CSTS is part of the
Department of Psychiatry of
Uniformed Services University of the Health Sciences,which is our nation’s federal
medical school.

2 • Joining Forces/Joining Families

Nadine Wathen, PhD,
is Professor at The
University of Western
Ontario, a Research
Scholar at Western’sCentre for Researchand Education on Violence Against Womenand Children, and a
Member of the Collegeof the Royal Society of Canada. Her research
examines the health and social service sector
response to violence against women and children, interventions to reduce health inequities,
and the science of knowledge translation, with afocus on enhancing the use of research in policy
and practice. She co-leads a number of research
initiatives, including: the PreVAiL Research Network (www.prevailresearch.ca), VEGA: A Public Health Response to Family Violence (projectVEGA.ca), EQUIP: Research to Equip Primary
Health Care for Equity (http://equiphealthcare.
ca) and the international Domestic Violence @Work Network (www.dvatworknet.org).

Editorial Advisor
LTC Ricky J. Martinez. PhD, MSC, USA
Family Advocacy Program Manager
Installation Management Command
Department of the Army
Editorial Consultant
Joshua C. Morganstein, MD
Commander, US Public Health Service
Assistant Professor/Assistant Chair andScientist
Center for the Study of Traumatic Stress
Uniformed Services University
Department of Psychiatry

Dr. McCarroll: Rather than attempting
screening, what might a provider encounter inchildren exposed to intimate partner violence(IPV)?
Dr. MacMillan: The important message isthat the same types of problems that we see forchildren who have experienced other types ofmaltreatment are what we see in children whoare being exposed to IPV. It can be one or moreof a number of internalizing or externalizing
symptoms. Conceptualizing children’s exposure
to IPV as a type of child maltreatment is controversial , because some people feel that doing
so implies that one is somehow blaming, typically a mother, who has been victimized. I comefrom a public health model in which we needto understand all the factors that influence theoccurrence of violence, in this case, children’s
exposure to IPV.
Continued on p. 3

Fall 2016

An interview with Harriet
MacMillan, from page 2Children’s emotional
responses to IPV
can arise throughthe awareness thata caregiver is at riskof violence. This isin addition to being a
direct witness.

Dr. McCarroll: Are practitioners in schools andclinics in Canada taking children’s exposure
seriously?
Dr. MacMillan: Within the child protection
system, there is much greater awareness of therange of problems associated with exposure
to IPV than among health care providers. In
the past, there has been emphasis on physical problems arising because of a child being
directly affected by the partner violence. Thatis only one issue. Another is understanding
the potential mental health problems that may
occur. People typically use the word witnessing, but witnessing can be interpreted as only
seeing or hearing. You have to consider a child’s
awareness that one or more of their caregivers
is at risk. That knowledge in and of itself, even
if they never see or hear actual violence, puts
them at risk.
Dr. McCarroll: How do you evaluate children
who might have been exposed?
Dr. MacMillan: One needs to have appropriate training and take care to conduct athorough assessment in which each person isinterviewed separately in order to understandthe extent of the problems in the family. Whenchildren are referred for emotional or behavioral problems some providers might only see
the family together without providing an opportunity where the child and the parents areassessed individually. Doing so is potentiallyharmful, because it does not provide an opportunity to ask about violence in the family safely.
In assessments of children and families, wehave to make sure we are not doing anythingthat does “more harm than good”.
Dr. McCarroll: In the paper by McTavish andyou and your other colleagues, you gavesome examples of how to talk to children
about violence.
Dr. MacMillan: This is one of the areas
where clinicians want and need the most guidance. It is very hard to communicate such approaches through a written article. For example, some reviewers of one of our publications
on emotional maltreatment (Hibbard et al.,2012) asked “Could we have some set questions
to ask children?” But, it depends so much on
age and developmental stage. We were not able
to provide such examples in that article, but
this is a fundamental part of a comprehensive
assessment of children and families.

http://www.CSTSonline.org

Dr. McCarroll: Current brain research hasprovided many new insights about how thetypes of maltreatment actually affect people.
[Editor’s note: For example, see Teicher &Sampson, 2016]. Do you find that talking
about maltreatment affecting children’s brains
is something that parents are paying attention
to?
Dr. MacMillan: I think that emphasizing
the brain science findings is important, but at
the same time, it is also important for people
to have hope. Sometimes, when people hearthat the brain is affected, they ask the question,
given this has occurred, “Is there any reason tobelieve that intervention or various programs
can help?” So, one has to be careful in how it isdiscussed with a patient.
Dr. McCarroll: You and Dr. Nadine Wathen are
the co-leads of an important long-term projectin Canada, the Violence, Evidence, Guidanceand Action (VEGA) Project (https://projectvega.
ca/).
[Editor’s note: See Webpages of Interest for
more information about VEGA and links to its
various programs and activities.]
Dr. MacMillan: This three-year project, supported by 4.47 million dollars from the Public
Health Agency of Canada, is part of a 10-year,
100 million dollar investment to support
research and development of programs for victims who have experienced family violence. The
objectives of VEGA include the development ofpublic health guidance, protocols, curricula andtools for health and social service providers.
The VEGA Project was developed with supportof colleagues involved in our research network
called Preventing Violence across the Lifespan(PreVAiL). PreVAiL is a Centre for Research
Development in Gender, Mental Health andViolence across the Lifespan, which has threemain themes: networking, resilience and knowledge translation — all focused on developing ways of reducing child maltreatment and
IPV. The network brings together researchers,
stakeholders, and policy makers. We have manyorganizations that are partners with researchers.
For VEGA, we are currently conducting
systematic reviews of the global literature to
identify the scientific evidence on responding tofamily violence. We will develop evidence-based
guidance that serves as the basis for a foundational curriculum feasible for use by healthand social service providers across Canadianprovinces and territories.
Continued on p.11
Joining Forces/Joining Families • 3

BUILDING BRIDGES TO RESEARCH

Risks, Rates, and Odds in Children’s Exposure to
Intimate Partner Violence
Danielle R. Bartolanzo, MPH, and Charlotte A. Riggs, MS

The risk of childmaltreatment is higher
in children exposed
to IPV than the risk ofchild maltreatment inchildren not exposed
to IPV.

Introduction

As Mrs. Evergreen walked to her car after
a long day of teaching, she was startled by ascream coming from the opposite side of theparking lot. She rushed toward the sound andfound Mr. and Mrs. Lovett bickering again, but
this time their usual sarcastic quips had escalated to shoving and shrieking insults at one
another. And there was little Timmy Lovett,tears in his eyes, backpack in hand, quietly
standing by the family car waiting for his parents to finish their battle and take him home.
Timmy was a witness to intimate partner
violence (IPV). As MacMillen and Wathen(2014) express, children’s exposure to IPV is
becoming recognized more and more as a typeof child maltreatment and can be strongly
associated with other forms of maltreatment.
Here, we review some common statisticalterms in the context of MacMillen and Wathen’s research including risk, rate, odds, andtheir ratios.

Understanding Risk

MacMillen and Wathen (2014) cite Hamby
et al. (2010) on the overlap of IPV with otherforms of child maltreatment. They noted thatof children sampled for the 2008 National Survey of Children’s Exposure to Violence, 56.8%of those exposed to IPV have also been maltreated in another way. Whereas, only 11.2% of
unexposed children experienced maltreatment.
These values are called risks.
But what exactly is a risk? A risk is the
chance that an individual within a specified
population will experience the outcome ofinterest. To calculate it, simply divide the proportion of individuals with the outcome by the
total study population.
From the example above, the two risks
values reported can be utilized to examine therelationship between exposure and the risk of
the outcome by taking the ratio of the two. Thisratio of risks between exposed children andunexposed children is equal to 5.01. Meaning,children exposed to IPV are at a 5.01 greaterrisk of becoming victims of other forms ofmaltreatment compared to unexposed chil4 • Joining Forces/Joining Families

dren. This result is known as a relative risk, or
RR for short.

Risk and Rates

At times, the terms risk and rate are usedinterchangeably. Mathematically however,unlike risk, rate is not a simple probability. In
order for a rate to be calculated, the additional
component of time has to be considered. Ergo,a rate is equal to the total number of events that
occurred during the study divided by the sumof time all persons at risk during that period (orthe total at risk person-time).
Therefore, if we assume that the population
total is equal to the sum of the at-risk persontime for that study, then it would be true thatrate is equal to risk. Thus, we could revise theinitial statement in the previous section to saythat IPV exposed children are experiencing
other forms of maltreatment at a rate of 56.8%
in the year 2008, whereas unexposed children
are being maltreated at a rate of 11.2%.
To compare the rates of these two separate groups, we simply take their ratio. Thisis referred to as the rate ratio. The rate ratio
indicates how fast or slow the outcome is occurring in the exposed group compared to theunexposed group. The rate ratio can be equal to
the relative risk given the assumption above like
it is in this example, but the two are commonly
not identical.

Understanding Odds

Another term related to the risk of an outcome is known as odds. Like relative risk, odds
can be thought of as a ratio of risks. However,instead of taking the ratio of two similar risks
from two different subpopulations, the odds isequal to the probability of the outcome (e.g.,disease) in a given population relative to theprobability of not having the outcome (nondisease) in that same population.
If we take the risk of non-IPV maltreatment for IPV-exposed children and subtract
it from 100%, we obtain the risk of not being
maltreated in other ways for IPV-exposedchildren, which is 43.2%. Therefore, the odds
of other maltreatment for exposed children isFall 2016

Children Exposed to IPV and Adult Outcomes
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

The authors concluded
that children exposed
to IPV usually live indysfunctional families
where their feelingsof physical andpsychological wellbeing are threatened.

Risks, Rates and Odds…,
from page 4

At times, the terms
risk and rate areused interchangeably.
However, a rate is notsynonymous with risk.

http://www.CSTSonline.org

A retrospective longitudinal survey of
3,023 adults in France in 2005 investigated
the association between exposure to IPV
during childhood prior to age 18 and adultpsychosocial outcomes (Roustit, Renahy,
Guernec, Lesieur, Parizot & Chauvin, 2009).
The outcomes were depression, lifetime suicide attempts, IPV, maltreatment of their own
children, and alcohol dependence. Other datacollected were family-level stressors (parentchild relationships and childhood adversities)
and social-level stressors during childhood(poor parental health, housing problems,parental unemployment, and family financial
problems).
Sixteen percent reported having witnessed IPV during childhood. Exposure wasassociated with numerous adult stressors:parental alcoholism, poor parent-child relationships, adverse parental life events (e.g.,
separation or divorce, incarceration, suicide
attempts, or alcoholism), and physical or sexual abuse. The risk of depression was higher

for women than for men (results not shown).
Men had a 15-times higher risk of committing violence against their own children, while
women double the increase (results not shown).
The risk of IPV was the same for both men andwomen (results not shown). The risk of alcohol
dependence was higher in the men from highconflict families and/or with a parental historyof alcoholism (results not shown). The authors
concluded that children exposed to IPV usually
live in dysfunctional families where their feelings of physical and psychological well-being
are threatened.

(56.8% ÷ 43.2%), or 1.31. Meaning, among IPV
exposed children there are 131 children who
experienced other maltreatment for every 100
children who had not. In a similar manner,among unexposed children there are only 13
children who experienced maltreatment forevery 100 children who had not (odds: 11.2% ÷
88.8% = 0.13).
Comparing exposed children to unexposedchildren, we calculate the ratio of the two odds
(1.31/0.13) and get an odds ratio of 10.08. So
the odds of non-IPV maltreatment in IPV
exposed children is about 10 times greater thanthat of unexposed children.
Conclusion
Perhaps, you have found yourself in asimilar situation as that of Mrs. Evergreen’s
encounter with the Lovett family. You may haveasked yourself, what does this mean for the
future safety and health of this child? Using
MacMillen and Wathen’s reference to calculaterisks, rates, and odds, we have demonstrated
that children exposed to IPV are more likely

to be a victim of other types of maltreatment.
Now both you and Mrs. Evergreen have a few
tangible and evidence-based tools that can beused in the fight for the protection and care of
all children.
For more details on these measures of effectthat are frequently found in scientific and medical literature see Oleckno (2008).

Reference

Roustit C, Renahy E, Guernec G, Lesieur S,
Parizot I,& Chauvin P. (2009). Exposure to interparental violence and psychosocial maladjustment in the adult life course: advocacy forearly prevention. Journal of Epidemiology andCommunity Health; 63: 563–568.

References

Hamby S, Finkelhor D, Turner H, & Ormrod
R. (2010). The overlap of witnessing partner
violence with child maltreatment and othervictimizations in a nationally representative
survey of youth. Child Abuse Neglect; 34(10):734–741.
MacMillen HL, & Wathen NC. (2014). Children’s
exposure to intimate partner violence. Childand Adolescent Psychiatric Clinics of North
America; 23(2): 295–308.
Oleckno, W. A. (2008). Epidemiology: Concepts
and Methods. Long Grove, IL: Waveland Press,
Inc.

Joining Forces/Joining Families • 5

BUILDING BRIDGES TO RESEARCH

New Terminology: Big Data
By Charlotte A. Riggs, MS

In this article, we
present definitionsof several terms
commonly encounteredwhen discussing big
data…data mining,algorithms, predictive
analytics, machinelearning, and datavisualization.

With the rapid progression of computer
technology, big data has become a frequently
encountered term. In general, it refers to large,
often enormous, structured and unstructured
volumes of data that cannot be efficiently
analyzed using traditional data processing
methods, if at all. Therefore, new data analytic
techniques are constantly being developed tohandle huge quantities of data. With such massive amounts of available information, analytic
possibilities are arguably limitless. For example,
companies can use information obtained frompersonal devices like a consumer’s location or
usage habits to achieve targeted advertising.
Today, the use of big data occurs within many
fields, from computer science, to mathematics,
to business, to biological sciences, and others.
In this article, we will present definitionsof several terms commonly encountered when
discussing big data. Among these are: data mining, predictive analytics, algorithms, machinelearning, and data visualization. These terms
represent concepts that are all related to theanalysis of big data.
The term that describes the largest scale
application of data analysis is data mining, theprocess of picking apart large data sets in thehope of finding something new. It is usually accomplished by means of programmer-definedalgorithms. An algorithm is the step-by-stepprocess (set of rules) that the computer must
follow to complete the analysis.
One of the most common methods of data
mining is predictive analytics. Predictive analytics refers to employing statistical techniqueswith the intention of predicting future probabilities and trends like that of contracting a
disease. To accomplish this, predictor variables
are selected to determine what best forecasts a
person’s risk of experiencing the outcome.
But, with all these new advances, there is
still a need to handle big data more efficiently.
Machine learning is a rapidly growing meansof analysis that addresses this concern. The
process uses algorithms to automatically learn
from data without being programmed where to
look. As computer models are exposed to moredata, they adapt independently to produce new
results.

6 • Joining Forces/Joining Families

Data visualization is also not new. It is thepresentation of data in graphical or similar
format that depicts the results of a given data
analysis. This is particularly useful when working with big data as it allows the user to see
relationships that might not otherwise be easily
recognized.
In conclusion, the ability to obtain, store,
and analyze big data provides more advanced
and efficient analytical techniques to give researchers and policy makers additional tools forlearning and decision-making.

References
BIG DATA
http://harvardmagazine.com/2014/03/why-bigdata-is-a-big-deal
https://hbr.org/2012/10/big-data-the-management-revolution
PREDICTIVE ANALYTICS
http://www.sas.com/en_us/insights/analytics/
predictive-analytics.html
MACHINE LEARNING
http://www.sas.com/en_us/insights/analytics/
machine-learning.html
ALGORITHMS
http://whatis.techtarget.com/definition/algorithm
VISUALIZATION
http://www.sas.com/en_us/insights/big-data/
data-visualization.html

Fall 2016

An Overview of Children’s Exposure to Intimate
Partner Violence
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

The term witnessing
IPV is thought to be
too limiting as children
can also be affected by
the awareness of IPV
including the potential
for its occurrence.
The term exposure ismore accurate.
Children’s exposure to
IPV carries increased
risk of emotional andbehavioral problems
such as internalizing
and externalizing
conditions, substanceabuse, posttraumaticstress disorder,
difficulties inrelationships withpeers, school-related
problems, acutephysical injury, anddeath.

http://www.CSTSonline.org

McTavish and colleagues (McTavish, MacGregor, Wathen, & MacMillan, 2016) summarize research evidence on the harmful effects
of children who have been exposed to intimate
partner violence (IPV). The authors’ aim is tohighlight the relevant questions for mental
health providers, but most of the points apply
to other service providers and to policy makers.
The term witnessing IPV is thought to be
too limiting as children can also be affectedby the awareness of IPV including the potential for its occurrence; McTavish et al. suggestthat the term exposure is more accurate. The
definition includes exposure to physical aggression, emotional abuse including intimidation,
controlling, isolating, and financial control of apartner.
There has been awareness about the detrimental effects of children’s exposure to IPV for
decades. A review of the results of individual
studies and meta-analyses found a broad rangeof adverse outcomes associated with such exposures (MacMillan & Wathen, 2014). Amongthese are an increased risk of emotional andbehavioral problems such as internalizing conditions (e.g., withdrawal, depression, and somatic complaints) and externalizing conditions(e.g., aggressive behavior, conduct disorder, anddelinquency), substance abuse, posttraumaticstress disorder, difficulties in relationships withpeers, school-related problems, acute physicalinjury, and death.
Children’s exposure to IPV is difficult to
study. Research should include investigating
ways to identify, assess, treat, and prevent it.
Estimates of the incidence and prevalence of
exposure vary depending on the definition andthe study methods. Determination of exposure
can be attempted through cases submitted tochild protective services, community surveys,
and retrospective reports by adults. The authors
identify self-reports by children and adolescents as the most accurate method, but thesecan be fraught with numerous methodological,
legal, and ethical issues involving research withthese special populations. However, the National Survey of Children’s Exposure to Violence,a cross-sectional national survey of children
who are 17 years of age or younger conductedin the U.S. in 2008 (Finkelhor, Turner, Ormrod,& Hamby, 2009) and 2011 (Finkelhor, Turner,
Ormrod, & Hamby, 2013) collected data onchildren who had witnessed a parent assault
another caregiver in their lifetime. In the 2008
study, 16.3% had witnessed an assault between
their parents in their lifetime. The 2011 study
found that 17.3% of children had witnessed aparent assault another caregiver in their lifetime, 6.1% in the past year.
Risk factors of children’s exposure to IPV
are primarily those that increase the likelihoodof women experiencing IPV and perpetration
by men McTavish et al. (2016). Most of theseidentified to date are at the individual level (e.g.,young age and economic stress) and tend to berelated to biological factors and individual histories, but there are also risk factors at the levelof relationship (e.g., partner’s drinking, druguse, and gender-based beliefs), the community(e.g., supportive relationships outside the family
and resources), and the society (e.g., patriarchal
norms and behaviors).
Protective factors that have been identified
for women include higher levels of education,
healthy parenting as a child, having a supportive family, belonging to an association, andhaving the ability to recognize the risk of sexual
violence (World Health Organization, London
School of Hygiene and Tropical Medicine,2010).
According to McTavish et al. (2016) andin MacMillan and Wathen (2014), there is noevidence that attempting to screen for children’s
exposure for child maltreatment or to IPV
has benefit. However, case finding can be an
important way of uncovering IPV when assessing clinical conditions that are associated withsuch exposure. Case finding involves taking adetailed history in the context of an assessmentin which issues involving safety and well-being
can be inquired about in a sensitive mannerwhereas screening often involves asking thesame questions of each person regardless ofclinical presentation. (Editor’s note: See Joining Forces Joining Families, Volume 14, Issue
2, Summer 2014, for a discussion of screening
and case finding in IPV.) The primary consideration in conducting such assessments is thesafety of the child and parent. Each should be
Joining Forces/Joining Families • 7

Overview of Children’s
Exposure to Intimate
Partner Violence,from page 7

The primaryconsideration in
conducting anassessment of thepresence of IPV is
the safety of thechild or parent.

interviewed separately and in an area where
the conversation cannot be overheard by otherssuch as by an abusive parent. Some generalquestions can be asked of children, tailoredto the child’s age and developmental status(MacMillan & Wathen, 2014). Briefly, theseare (1) how do people in the family get along;(2) inquiry about family members’ safety andspecifically asking about each household member; (3) any worries the child might have about
him/herself or other family members; and (4) ageneral inquiry about how much yelling, pushing, or shoving occurs in the home including
discussion of what happens when someone
gets in trouble. It is important not to assure
patients of complete confidentiality, given thatchildren’s exposure to IPV is subject to mandatory reporting in certain jurisdictions.
The best strategy to prevent children’s
exposure to IPV is to prevent the IPV of adults.
Summaries of research on other approaches
in this area, such as couples’ counseling andrestraining orders, are reviewed, but evidence
to support them is limited. The authors discusssafety issues such as dealing with mandatory
reporting requirements balanced against theneeds of the child, and supporting women
exposed to IPV and their children.
The potential for impairment due toexposure to IPV is significant. McTavish et al.
review a number of strategies to reduce impairment based on clinical trials including psychotherapeutic interventions, parenting skills
education, and advocacy. Since the results ofclinical trials may not be generalizable, basedon inclusion criteria to recruit study participants, it remains to be seen if these interventions are effective in the everyday clinic orhousehold.
Recognizing that IPV is complex, it isimportant in meeting the needs of children
to involve healthcare providers, child and IPV
advocates, and judicial personnel (Wathen& MacMillan, 2013). The authors advise thatmental health providers should be aware ofwhether their child and adolescent patients areexperiencing current maltreatment, as well as
their adult patients’ trauma histories across thelife span including child maltreatment. In addition, the clinician should have knowledge about
the effects of IPV on health as well as skills in
responding to patients who have experienced
IPV, particularly for safety concerns. Finally,
the clinician should know about appropriate
services for persons experiencing IPV suchas shelters, outreach services, and social andlegal resources (Stewart, MacMillan, & Wathen,2013).

References

Finkelhor D, Turner H, Ormrod R, & Hamby SL.
(2009). Violence, abuse, and crime exposurein a national sample of children and youth.
Pediatrics; 124: 1411–1423.
Finkelhor, D., Turner, H., Shattuck, A., & Hamby,
S. (2013). Violence, crime, and abuse exposurein a national sample of children and youth: An
update. JAMA Pediatrics, 167(7), 614–621.
World Health Organization, London School ofHygiene and Tropical Medicine. (2010). Preventing Intimate Partner and Sexual Violence
Against Women: Taking Action and Generating
Evidence. Geneva, Switzerland: World HealthOrganization.
MacMillan HL, & Wathen CN. (2014). Children’s
exposure to intimate partner violence. Childand Adolescent Psychiatric Clinics of North
America; 23: 295–308.
McTavish JR, MacGregor JCD, Wathen CN, &MacMillan HL. (2016). Children’s exposure
to intimate partner violence: An overview.
International Review of Psychiatry; http://dx.doi,org/ 10.1080/09540261.2016.1205001.
Stewart DE, MacMillan HL, & Wathen CN.
(2013). Intimate partner violence. Canadian
Journal of Psychiatry; 58: 1–15.
Wathen CN, & MacMillan HL. (2013). Children’s
exposure to intimate partner violence: Impacts
and interventions. Paediatrics & Child Health;18: 419–422.

Recent estimates found that 17.3% of children had witnessed a parent
assault another caregiver in their lifetime and 6.1% in the past year.

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Changes in Brains of Children Exposed to IPV
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

Recent advances inneurosciences haveshown that childmaltreatment alters
the trajectory of brain
development.

Child maltreatment has long been known
as having deleterious effects on development
and adjustment as well as effects on health andwell-being in adulthood. Recent advances inneurosciences have shown that child maltreatment alters the trajectory of brain development. A study of neuroimaging findings inchildren who witnessed caregiver violence
reported specific changes in neural tracts in thebrain from the left occipital cortex (the visual
processing center of the brain) to the left temporal lobe (an area important for the processing of speech and vision) (Choi, Jeong, Polcari,
Rohan, Teicher, 2012). Subjects of this researchwere 20 persons (average age 22 + 2.5 years)
who had witnessed domestic violence (WDV)
and 27 age-equivalent controls. Persons in the
WDV group reported seeing and hearing years
of intense verbal aggression between their parents, sometimes with acts of physical violence.
Overall, they reported that between the agesof 3-16, they witnessed an average of 4.4 + 2.7
years of exposure to interparental (IP) physical violence plus verbal aggression along with
4.8 + 4.0 years of IP verbal aggression without
physical violence. The total exposure duration
was 9.2 years + 2.8 years. The father was theperpetrator in 55% of subjects, the mother’s
boyfriend in 10%, the mother in 15%, and boththe mother and the father in 10%. Seventyfive percent said that the incidents were veryor extremely upsetting and 80% said that theincidents had a moderate or great effect on
their lives.

Subjects in the WDV group had increased
ratings of anxiety, depression, somatization,
anger-hostility, dissociation and other indicators of irritability in the brain’s limbic system(an area of the brain largely dealing with emotion, memory, behavior and other functions).
The strongest neuroimaging association finding(lower activity in the tract from the left occipital lobe cortex to the left temporal lobe) was
between the duration of exposure to IP verbal
aggression unaccompanied by physical violence.
Subjects were most susceptible to exposure to
IP aggression from ages 7-13. This study suggested that WDV has a strong auditory component and that the worst WDV episodes were
multimodal involving both hearing and vision.
Some subjects were resilient in terms of
their responses to WDV. The authors suggested
that some possible reasons might be genetic aswell as sensitive periods of development when
the brain is maximally sensitive to stress when
WDV did not occur. Study of brain functioning
can shed light on the development of emotion
regulation and other brain pathways mediating
the perception of adverse events.

Reference

Choi J, Jeong B, Polcari A, Rohan ML, Teicher
MH. (2012). Reduced fractional anisotropy
in the visual limbic pathway of young adults
witnessing domestic violence in childhood.
NeuroImage; 59: 1071–1079.

Resources to Build Family Resilience from the
Defense Centers of Excellence
The Defense Centers of Excellence (DCoE)
posted on their website (http://www.dcoe.
mil/blog/16-11-30/Military_Families_Matter_These_Resources_Help_Build_Family_Resilience.aspx) a wide variety of resources formilitary families. These include The Real Warriors Campaign, a public awareness campaignthat encourages service and family memberswith mental health concerns to get help. But, in
addition, these resources are intended to build
resilience through the use of guidelines forindividuals and families. These include creating
http://www.CSTSonline.org

family plans and checklists, adjusting to phasesof deployment, helping with combat stress,
personal care and attentiveness, and building
family resilience.
Additional resources are for helping aservice member at home After Return from
Deployment, Resources for Children, Help for
Preteen and Teens, and Support for Service
Members.
Mobile apps are available from the National
Center for Telehealth and Technology
Continued on p. 12
Joining Forces/Joining Families • 9

Subtypes of Co-Occurring Exposure to Intimate
Partner Violence
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

Rather than beinga unitary type ofmaltreatment, exposureof children to IPV
has subtypes: direct
exposure to physicalviolence, indirect
exposure to physicalviolence, and exposure
to emotional violence

Rather than being a unitary type of maltreatment, exposure of children to intimate
partner violence (IPV) has subtypes (Gonzalez, MacMillan, Tanaka, Jack, & Tomby, 2014).
The Canadian Incidence Study of Child Abuse
and Neglect (CIS-2008) reported three types
as reported by child welfare workers: indirect
exposure to physical violence, direct exposure
to physical violence, and exposure to emotional
violence (PHAC, 2010). The CIS-2008 sampled 112 child welfare sites including 11,807
investigations. Children who were subjects ofinvestigation were those of age 15 and under.
The number of boys and girls was equal, theaverage age was 6 years old, and the sample was
63.9% white. There were five different categories of maltreatment: sexual abuse, physicalabuse, emotional maltreatment, neglect, andexposure to IPV. CIS used a three-tiered classification system for investigations: substantiated, suspected, or unfounded. Child functioning was coded as (1) internalizing problems(e.g., low self-esteem, depression, anxiety, social
withdrawal), (2) externalizing problems (e.g.,aggression, violence and delinquency), and (3)whether mental or emotional harm to the childwas evident in the last six months. Primary
caregiver and household risk factors were also
recorded. The analyses reported here include
only those cases where exposure to IPV was thesole reason for the investigation.
Exposure to IPV as the sole reason wasreported in 18.5% (n=2,184) of investigations. Exposure to direct physical violence wasreported most often (30%, n=656), followed byemotional violence only (25.5%, n=556), andindirect exposure only (18.5%, n=403). Total
co-occurring exposure was 26% (n=569) ofinvestigations. The most common co-occurringexposure was to physical violence and emotional violence (11.6%, n=254). The others wereless than 10% each.
Internalizing and externalizing problems
were noted as approximately equal, 9.8% and9.7%, respectively. Emotional or physical harm
was noted in 18.4% of the children. Children
exposed to co-occurring IPV were at greater
odds of internalizing, externalizing, and mental
or physical harm compared to children indirectly exposed to physical IPV only. Thesemajor outcomes were that (1) there was an
association between co-occurring IPV, caregivermental health, and lack of social support withall three child outcomes; (2) exposure to emotional violence only was significantly associatedwith internalizing problems and the presenceof harm, and (3) caregiver mental health andlack of social support were significantly associated with increased risk of all child functioning
outcomes. The only association with genderand child outcomes was that males were atincreased risk of externalizing problems.
Overcrowded houses increased the odds of
direct exposure to physical violence only and toco-occurring IPV. Also, households that ran out
of money for basic necessities was associatedwith an almost three-fold increase in the odds
of exposure to co-occurring IPV.
This study’s examination of exposure to
IPV subtypes, risk factors, and child outcomessuggests that, in addition to well-establishedrisks, the need for increased awareness amongchild welfare workers as well as health care andservice providers, of the importance of differences in children’s IPV exposure subtypes andchild outcomes.

References

Gonzalez A, MacMillan H, Tanaka M, Jack SM,& Tomby L. (2014). Subtypes of exposure to
intimate partner violence within a Canadian
welfare sample: Associated risks and child
maladjustment. Child Abuse & Neglect; 38:
1934-1944.
Public Health Agency of Canada (PHAC). (2010).
Canadian Incidence Study of Reported Child
Abuse and Neglect 2008: Major findings. Ottawa: PHAC.

Children exposed to co-occurring IPV were at greater odds of internalizing,externalizing, and mental or physical harm compared to children indirectly
exposed to physical IPV only.
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Intimate Partner Violence Can Cause Brain Injuries
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

Alterations inconsciousness
following IPV-related
TBI can include
dizziness, seeingstars and spots, being
stunned or disoriented,
losing consciousness,or post-traumatic
memory loss.

An interview with Harriet
MacMillan, from page 3Children’s emotional
responses to IPV
can arise throughthe awareness thata caregiver is at riskof violence. This isin addition to being a
direct witness.

The neurobiology of such intimate partner
violence (IPV)-related traumatic brain injury(TBI) has not been well investigated. TBI was
studied in 20 women recruited from women’s
shelters, domestic violence programs, and wordof mouth. Seventy-five percent of the womenreported multiple TBIs. Women were given
questionnaires, a neuropsychological battery,
and were interviewed for a history of alterations in consciousness (AIC) following a TBI.
AICs included periods of dizziness, seeing stars
and spots, being stunned or disoriented, losing
consciousness, or post-traumatic memory loss.
Brain imaging (magnetic resonance imaging,fMRI) was used to examine cognitive brainnetwork organization. Cognitive functioning was assessed through a questionnaire of

post-concussive symptoms at the time of theincident and currently.
The severity of injury was negatively associated with functional cognitive connections in
the brain. An average of 5.3 post-concussive
symptoms was reported. The most common
symptom (about 58%) was feeling depressedor tearful, followed by headaches (about 53%),
feeling irritable, easily angered, frustrated, or
impatient (about 47% each), poor concentration(about 42%), sleep disturbance, forgetfulness,poor memory and taking longer to think (about37%). When severe IPV occurs, the possibilityof TBI should be considered and, if presented,
should be referred for further examination andintervention such as neurorehabilitation.

Dr. McCarroll: What do you think the end
product is going to look like?
Dr. MacMillan: That is a good question. A
lot of curricula focus on knowledge and do
not have sufficient emphasis on the development of skills. For example, a curriculum
might include information about how common family violence is, the risk and protective
factors, and similar issues, but health and social
service providers might say, “How do I learn torespond to the patient or client in front of me?”
We want to make sure we are focusing on skills.
There will be some online components, but weare also trying to identify those educational
approaches that are more effective. We want tomake sure that the core knowledge is incorporated into the curriculum, but that there isalso the opportunity for the development ofessential skills. One of the important elementsof knowledge translation is that you involve theknowledge user from the beginning. It is not
simply a matter of doing the work and disseminating the information at the end of the
project. It is involving them from the start andworking collaboratively.

just in Canada, but to others and, hopefully,
they can be adapted to suit the needs of othercountries.

Dr. McCarroll: People who read our newsletter
might ask, “How can I get my hands on this?”
Dr. MacMillan: The website is the bestsource of information. Within the next two to
three years our products will be available, not
http://www.CSTSonline.org

Continued on page 12

Dr. McCarroll: Will there be a link on VEGA toshow current developments and future plans?
Dr. MacMillan:Yes; that’s the plan.
Dr. McCarroll: Thank you for your insights aboutchildren exposed to IPV and for describing yourcurrent work with PreVAiL and VEGA.

References

Hibbard R, Barlow J, MacMillan HL, and theCommittee on Child Abuse and Neglect andthe American Academy of Child and Adolescent Psychiatry, Child Maltreatment andViolence Committee (2012). Psychologicalmaltreatment. Pediatrics; 130(2): 372-378, doi:
10.1542/peds.2012-1552.
McTavish JR, MacGregor JCD, Wathen CN, &MacMillan HL. (2016). Children‘s exposure to
intimate partner violence: an overview. International Review of Psychiatry, doi:10.1080/095
40261.2016.1205001.
Teicher MH, & Samson JA. (2016). Annual
research review: Enduring neurobiologicaleffects of childhood abuse and neglect. Journalof Child Psychology and Psychiatry; 57(3): 241266, doi:10.1111/jcpp.12507.

Joining Forces/Joining Families • 11

Websites of Interest
Dr. MacMillan gave a brief overview of the VEGA
(Violence, Evidence, Guidance and Action) projectin her interview. This website https://projectvega.ca/
gives many details of the project. An extensive description of the VEGA project is given at projectvega.
ca/documents/2016/05/vega-brief-project-summarymay2016.pdf. This includes project objectives andan overview of activities as a flow chart showing thesequence of development of products for knowledge
mobilization strategy development and evaluation.
PreVAiL (Preventing Violence Across the Lifespan) is an international research collaboration of over
60 researchers and partners from Canada, the US,
the UK, Asia, Europe and Australia, funded by the
Canadian Institutes of Health Research’s Institute for
Gender and Health (2009-2017). If you go to (http://prevailresearch.ca/) you will find several reports that
describe updates of the PreVAil project and researchbriefs that are valuable resources on four topics thatare of interest to all members of the family maltreatment community. These are Interventions to (1) Prevent Child Maltreatment, (2) Resilience and Mental
Health Outcomes, (3) Identifying and Responding toChildren’s Exposure to Intimate Partner Violence, and(4) Identifying and Responding to Intimate Partner
Violence.
As Dr. MacMillan explained in her interview,
these projects will continue to produce resources forbuilding knowledge and skills for effective publichealth practices in responding to family violence. We
suggest that service providers and policy makers use
the links provided in the VEGA and PreVail and follow developments as they occur.

IPV Can Cause Brain Injuries, from page 11

DCOE, from p. 9

Reference(http://t2health.dcoe.mil/) such as tips forparenting, mindfulness exercises, and stressmanagement through breath work. For moreresources on building resilience or anything
specific to psychological health or traumaticbrain injury, the DCoE Outreach Center isavailable 24/7 by phone at 866-966-1020, e-mail(resources@dcoeoutreach.org) or live chat (http://
www.realwarriors.net/livechat).

Valera E, & Kucyi A. (2016). Brain injury inwomen experiencing intimate partnerviolence: neural mechanistic evidence of an“invisible” trauma. Brain Imaging and Behavior; doi: 10.1007/s11682-016-9643-1.

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