Moving From Evidence to Action

The Safe Start Center Series on Children Exposed to Violence

Issue Brief #1

Welcome to the Safe Start 

Center Series on Children 

Exposed to Violence

Over the past several years, significant research has expanded our knowledge about children’s 

exposure to violence and effective 

strategies and interventions to address 

the needs of children at different ages. 

Nevertheless, in many areas, a gap exists between best practices (as determined by scientific evidence or expert 

consensus) and access to information 

about these practices by practitioners in 

the field. 

Moving From Evidence to Action: The 

Safe Start Center Series on Children 

Exposed to Violence was developed 

to respond to this urgent need to translate research-based information and 

disseminate it to practitioners who can 

use it in their work with children and 

families in different settings.

The goal of the series is to build the 

capacity of practitioners in a variety of 

different fields to offer sensitive, timely, 

and appropriate interventions that enhance children’s safety, promote their 

resilience, and ensure their well-being.

Issue Brief #1, Understanding Children’s 

Exposure to Violence, describes core 

concepts—gleaned from research and 

program practice—used in designing 

and implementing programs that 

address children’s exposure to violence. 

The Issue Briefs that follow apply these 

core concepts to different systems that 

interact with vulnerable children and 

their families. (For a complete list of 

Issue Briefs, see the box on page 8.)

Understanding Children’s 

Exposure to Violence

By Elena Cohen, Betsy McAlister Groves, and Kristen Kracke

Children exposed to violence live 

in our neighborhoods, play in 

our parks, and are enrolled in our 

schools. Each year, millions of children are abused or neglected, are 

exposed to some form of domestic 

violence, or witness violence in 

their communities. Exposure to violence cuts across all socioeconomic 

and racial/ethnic backgrounds. 

Most children and youth who are 

exposed to violence are never formally identified, assessed, and/or 

treated. Yet the emotional, social, 

and psychological impact of their 

exposure is observed by families and practitioners in many settings. 

These children may exhibit a range of developmental problems and 

symptoms, both internal (depression or anxiety) and external (aggression or conduct problems). Exposure to violence, particularly multiple 

exposures, can interfere with a child’s ability to think and learn and 

can disrupt the course of healthy physical, emotional, and intellectual 

development. Furthermore, exposure to violence is associated with 

increased use of health and mental health services and increased risk of 

involvement with the child welfare and juvenile justice systems.

Establishing Common Ground for 

Understanding Exposure to Violence: 

Framework

Defining exposure to violence

No universally accepted terminology is used among the various disciplines, agencies, and groups that serve children and youth who are 

exposed to violence. The lack of standard definitions contributes to 

An electronic version of this publication can be found on the Web at 

www.safestartcenter.org.

(continued on page 2)
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Understanding Children’s Exposure to Violence

agencies’ and systems’ failing to identify and serve this 

population. Often, these children and youth are not 

identified until they demonstrate impairments that interfere with their functioning in a particular setting.

The Safe Start initiative defines children’s exposure to 

violence as direct and indirect exposure to violence in 

the home, school, and community.

Research has shown that children have a wide range 

of reactions to exposure to violence. Some children 

are not adversely affected or may show only brief 

and transient reactions. Others may be more affected, 

showing significant symptoms and emotional 

vulnerability. Some develop intense anxiety disorders 

or posttraumatic stress disorder. 

Many factors determine the extent to which a child 

may be affected. Some variables are internal to the child 

and family and their social context (e.g., the child’s 

temperamental and developmental characteristics, the 

protective capacity of the parents and family). Other 

factors are related to the violence itself (e.g., the severity and frequency of violence, whether the child knows 

the victim or perpetrator, and the child’s proximity to 

the event). 

Understanding exposure to violence 

within the stress-to-trauma continuum

Children often are in frightening or stressful situations, whether the situation is being away from home, 

experiencing the death of a beloved grandparent, or 

being hospitalized. These events range from evoking 

mild stress to being severely distressing. When confronted with stressful circumstances, children respond 

by releasing hormones and activating brain circuits 

to cope. The hormones and chemicals of these stress 

responses are essential; they help people protect themselves when threatened. When the stressful event is 

over, the physical response decreases and finally disappears. In most instances, adults can help children learn 

to manage their reactions by helping them develop 

coping skills. 

However, children who are chronically exposed to 

violence (e.g., child abuse and neglect, community or 

family violence) never shut off their stress responses. 

They live constantly in a state of alert and crisis, which 

can produce neurochemical changes and adaptations 

that ultimately damage the child if not addressed. The 

National Scientific Council on the Developing Child 

(2005) has identified three categories of stress:

•	 Positive stress refers to the moderate, short-lived 

response to situations that are usually the normal 

part of life. Frightening events that provoke a 

positive stress response tend to be those that occur 

against the backdrop of safe, warm, and positive 

relationships; children can learn to control and 

manage reactions to these events with the support 

of caring adults. The challenges of meeting new 

people, dealing with frustration, entering a new 

childcare setting, even getting an immunization can 

be positive stressors that develop a sense of mastery. 

•	 Tolerable stress refers to responses that can affect 

brain architecture but generally occur for brief 

periods and allow the brain to recover and therefore reverse potentially harmful effects. One of 

the critical ingredients that make stressful events 

tolerable is the presence of supportive adults who 

create safe environments that help children cope 

with and recover from major adverse experiences 

such as a frightening accident or parental separation 

or divorce. 

•	 Toxic stress—also called traumatic and/or complex 

stress—refers to a strong, frequent, or prolonged 

activation of the body’s stress management system. 
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Issue Brief #1, August 2009

Stressful events that are chronic, uncontrollable, 

and/or experienced without access to support from 

caring adults provoke toxic stress responses. Studies indicate that such stress responses can have an 

adverse impact on brain architecture. In the extreme—such as in cases of severe, chronic abuse—

toxic stress may result in the development of a 

smaller brain. For these types of stressors, intervention is necessary to prevent/reduce negative impact.

These concepts of positive, tolerable, and toxic stress 

carry three important messages: 

1. Not all exposures to violence have a long-term 

negative impact. 

2.The presence of a supportive adult or environment 

provides a powerful buffer to children from the 

intense stress or anxiety that may occur when they 

are exposed to violence.

3.The effects of exposure to violence can be mitigated 

with appropriate supports and interventions.

The role of risk and protective factors

The response of the child or adolescent to exposure to 

violence is governed both by risk factors that increase 

the likelihood of a disruption in the developmental 

trajectories and by protective factors in the environment. These risk and protective factors depend on the 

child’s age and developmental level and the type and 

intensity of challenges present in the environment. 

Risk and protective factors for children exposed to 

violence are typically embedded in one or more of the 

following: 

•	 Biological and psychological characteristics of the 

child (e.g., temperament, age, developmental level, 

disability) 

•	 Quality of the parent/caregiver–child relationship, 

relationships among family members, the parental 

relationship, and relationships with other important 

adults

•	 Stability and responsiveness of systems and staffs 

that interact directly with the child (e.g., school 

personnel, pediatric care staff) 

•	 Social supports and interventions for parents and 

other caregivers (e.g., access to mental health services, drug treatment interventions)

•	 Factors that affect the environment (e.g., poverty, 

racial and ethnic status, community’s attitudes 

about violence). 

Enhancing resilience, decreasing risks, 

and providing specialized treatment 

Exposure to violence often requires interventions that 

range from improving the environment of the child by 

enhancing protective factors, to reducing symptoms, to 

addressing underlying trauma. In addition, early interventions for children who are already exposed (e.g., 

survivors of abuse, neglect, and sexual violence; children 

and youth in the juvenile justice system; children in 

homeless families; children and youth living in neighborhoods with high levels of community violence) enhance 

the children’s capacity to cope with ongoing stressors. 

Research has documented the effectiveness of an array 

of programs to enhance resilience and decrease the 

risks of vulnerable children and their families:

•	 For all children, participation in high-quality early 

care and education programs can enhance physical, 

cognitive, and social development and promote 

readiness and capacity to succeed in school. Effective programs combine small class sizes, high adultto-child ratios, a language-rich environment, an 

age-appropriate curriculum, highly skilled teachers, 
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Understanding Children’s Exposure to Violence

and warm responsive interactions between staff 

members and children (Aos, Lieb, Mayfield, Miller, 

& Pernucci, 2004).

•	 For at-risk families, early identification of and intervention with high-risk children by early education 

programs and schools, pediatric care and mental 

health programs, child welfare systems, and court 

and law enforcement agencies can prevent threats 

to healthy development by detecting and addressing 

emerging problems. There is empirical support for 

the efficacy of early intervention services for children in the general population; children receiving 

early intervention services are more likely to complete high school, maintain jobs, and avoid teenage 

pregnancy and delinquency than those who do not 

receive such services. Such favorable outcomes are 

most profound for children who are significantly at 

risk (Aos et al., 2004; Olds et al., 1998).

•	 For children and families already exposed to violence, intensive intervention programs delivered in the 

home and in the community can improve outcomes 

for children well into the adult years and can generate benefits to society that far exceed program costs. 

Evaluations have shown that effective programs must 

be implemented by highly qualified staff that has 

access to supports (e.g., supervision, consultation, 

training); programs implemented by poorly qualified 

staff have minimal effect on parents and children with 

significant needs (Mihalic, Irwin, Elliott, Fagan, & 

Hansen, 2004). 

•	 Outcomes improve when highly skilled practitioners provide intensive trauma-focused psychotherapeutic interventions to stop the negative chain 

reaction following exposure to traumatic stressors 

(e.g., child abuse and neglect, homelessness, severe 

maternal depression, domestic violence). Treatment 

is an essential component of successful adjustments 

to exposure to violence, especially for children 

who have frequent exposure and who have complicated courses of recovery (Cohen, Mannarino, & 

Deblinger, 2006; Jaycox, 2003; Lieberman & Van 

Horn, 2004).

Barriers to Building a Common 

Agenda 

Several barriers to a coordinated system of service 

delivery for children exposed to violence have been 

identified (Knitzer & Lefkowitz, 2006):

•	 Lack of agreement on a definition of exposure to 

violence. Different systems (e.g., domestic violence, 

child abuse) define exposure to violence in different 

ways, for example, by the type, direct victimization, 

or extent of violence toward the child.

•	 Poor or insufficient identification of children exposed to violence. Many programs do not screen 

children, especially young children, for exposure to 

violence. Programs are likely to identify and refer 

children for evaluation and treatment of physical 

health and educational concerns, but they are less 

likely to identify behaviors that may be related to 

exposure to violence. 

•	 Lack of valid and reliable screening tools, especially 

for use by nonclinical staff. 

•	 Lack of available services or difficulties ensuring 

access to services. Even after a child is identified as 

having behaviors that may be related to exposure 

to violence, it may be difficult to link the child 

to services because of problems unique to each 

system. These problems include poor communication, lack of a clearly identified case coordinator, 

inability to obtain a signed consent, and decreased 

funding for services.
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Issue Brief #1, August 2009

Mandated Reporting

Many children experiencing crises or violence are also 

at risk for child abuse and neglect. All States have 

child welfare systems that receive and respond to 

reports of child abuse and neglect, offer services to 

families, provide foster homes for children who must 

be removed from their parents’ care, and work to find 

permanent placements for children who cannot safely 

return home.

Domestic violence does not equal child abuse and neglect, and therefore not all cases of domestic violence 

must be reported to child protective services. When 

responding to families affected by domestic violence, 

it is critically important for practitioners to consider 

simultaneously the safety of the child and the safety of 

any adult victim.

State-by-State information on reporting requirements 

can be found at www.childwelfare.gov/systemwide/

laws_policies/state. 

•	 Ineffectiveness of intervention services received. Even if 

a child receives an assessment and is linked to services, 

there is no assurance that the child will receive an 

evidence-based intervention or that his or her outcomes will improve. 

•	 Cultural “blindness.” Children at different ages and 

from diverse ethnocultural backgrounds may respond differently to assessments, questionnaires, and 

interviews, as well as to staff members with different 

styles and backgrounds. Many assessment tools are 

available only in English or have not been adapted 

for members of minority ethnic groups. 

Guiding Principles To Support 

Best Practices

The following Safe Start principles serve as guidelines 

for the development of policies, programs and specialized interventions that are effective in responding to 

exposure to violence.

•	 Safety of non-offending parent and of the children 

must be paramount and addressed concurrently in 

cases involving domestic violence. 

•	 Children must be understood in the context of their 

individual traits, families, and community. (a socioecological approach). 

•	 Responsibility for child’s well-being must be owned 

by parents, community agencies and public systems 

together—CEV is everyone’s responsibility. 

•	 Agencies must work together in a coordinated 

manner to expand and enhance service delivery. 

•	 Policies, programs, and services must be developmentally appropriate, culturally competent, and 

offered in the family’s preferred language. 

•	 Programs and services need to be evaluated rigorously for effectiveness—efficacy is key. We must 

commit to learning what works.

Designing an Effective 

Response: Key Elements

Children exposed to violence have a variety of complex needs, and the network of child and family 

interventions must reflect this diversity of needs. It is 

unrealistic to expect that any single program can promote strength and resilience of children and families, 

provide interventions to reduce the negative effects 

of the exposure, and respond to the economic, social, and psychological needs of families. Each system 

should offer services that are based on its function 

and focus, work collaboratively with other agencies, 

and refer families for other services. 

Research and program evaluations, including the crosssite evaluation of the Safe Start Demonstration Sites 

(Kracke, Lamb, & Hyde, 2008), demonstrate that the 

best outcomes are achieved when the following response 

elements are adapted to specific fields of expertise, resources, and constraints: 

•	 Early detection and identification. Communities, 

families, and staff at different entry points should 

recognize and respond immediately to symptoms of 

exposure to violence.

•	 Promoting community awareness and educating 

practitioners. Outreach includes contacting groups 

of people with information and resources and 

educating practitioners on core concepts of vulnerability and exposure to violence. Ongoing outreach 

and education should meet the specific needs of the 

community and program.

•	 Protocols, policies, and procedures. Programs and 

systems should have specific protocols, policies, 

and procedures that detail their response to child 

exposure to violence. These elements should 
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Understanding Children’s Exposure to Violence

be designed with community and consumer 

collaboration.

•	 Referrals. Staff should be aware of services provided 

by other agencies and be able to provide appropriate referrals to these agencies, including mandated 

reporting to child protective services when required 

(see Mandated Reporting box on page 5).

•	 Evidence-based interventions. Research and emerging promising practices should inform service 

delivery.

•	 Comprehensive, coordinated responses. 

Relationships should be developed in the organization and with external organizations to ensure 

that services provide a coordinated continuum of 

care for children and families. Working together is 

cost-effective because it reduces duplication, shares 

expenses, fosters cooperation, and improves outcomes for children and families.

•	 Staff support and supervision. All staff members 

working with children and families who are affected by violence should have access to supervision 

and support. 

•	 Evaluation and continuous improvement. Programs 

and interventions should be regularly evaluated to 

enhance practice and improve the organizational 

response to children exposed to violence.

•	 Expansion of each system’s perspective: A problem 

without a home. Exposure to violence is the responsibility of everyone, but this responsibility is not 

owned by any specific system or program. Systems, 

programs, and staff members need to expand their 

perspectives and adapt or enhance their policies and 

practices to ensure that children who are exposed 

to violence are not invisible. 

Conclusion

Despite the complexity of developing and evaluating 

interventions for children who are at risk of exposure 

or have been exposed to violence, a growing number 

of efforts are currently gaining momentum. 

Coordinated efforts during the last decade are encouraging systems and communities to move beyond individual agencies to respond to the effects of violence on 

children in a more collaborative, comprehensive way. 

These efforts include the Greenbook Initiative communities, National Child Traumatic Stress Network, Safe 

and Bright Futures projects, Domestic Violence Initiative for Child Protective Services at the Massachusetts 

Department of Social Services, Child Development–

Community Policing projects, Miami Model Dependency Court, Safe Start, Child Witness to Violence Project 

at Boston Medical Center, Violence Intervention Program at Louisiana State University, and Child Trauma 

Research Project at San Francisco General Hospital 

(Kracke & Cohen, 2008). 

In the clinical field, data to support the effectiveness of 

different strategies and protocols in diverse environments are being collected across the country. Critical components of successful interventions include a 

developmental perspective that engages the child’s and 

the family’s ecological contexts and service systems to 

screen for, provide early intervention for, and respond 

to the treatment needs of children. Effectiveness is bolstered when treatment is offered in a range of settings, 

such as homes, early care and education programs, and 

schools, incorporating collaboration with health, law 

enforcement, legal, child welfare, and other systems 

(Lieberman & DiMartino, 2005). 
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Issue Brief #1, August 2009

Definition of Terms

Domestic violence. Pattern of coercive behaviors 

including physical, sexual, and psychological abuse, as 

well as economic coercion, used by adults or adolescents against their current or former intimate partners. 

Community violence. Random violence including 

school shootings and use of guns, knives, and drugs 

in the community. It can be an isolated incident or 

frequent and continuous events. 

Exposure to violence. Witnessing, being affected 

by, or being aware of domestic and community violence and/or experiencing violence through child 

abuse and neglect or in a violent incident in the home 

or community.

Impact of exposure to violence. Children react 

to exposure to violence in different ways, and many 

children demonstrate remarkable resiliency. However, 

children’s exposure to violence has been associated with 

difficulties with attachment, regressive behavior, anxiety 

and depression, aggression and conduct problems, dating violence, delinquency, and involvement with child 

welfare and juvenile justice systems. And there is a strong 

likelihood that exposure to violence will affect children’s 

capacity for partnering and parenting later in life, continuing the cycle of violence into the next generation.

Intervention. Purposeful response to address a child’s 

exposure to violence. Intervention can occur when services are provided at the time of the exposure or after 

the event has occurred. The goals of interventions are 

to provide support to children who have been affected 

by the exposure to violence and to find immediate solutions to practical problems that arise from, or gave rise 

to, the traumatic, disruptive, violent experience.

Resilience. The property of a material that enables it 

to resume its original shape or position after being bent, 

stretched, or compressed; in humans, the capacity to 

adapt to and recover from a disruption in functioning 

quickly and effectively (Masten & Gewirtz, 2006). 

Stress. Life event or situation that causes imbalance 

in an individual’s life. Often stress results from something that is beyond the individual’s control. Control 

has a great deal to do with levels of stress. Internal 

sources of stress include hunger, pain, temperature 

change, and fatigue. External stress includes changes 

in family composition, loss of property, unrealistic 

expectations, and disorganization in daily events.

Trauma. An exceptional, sudden, and unexpected 

experience that is perceived as dangerous. It may involve a threat of physical harm leading to intense fear. 

It overwhelms an individual’s ability to cope. Acute 

trauma is generally a one-time event, such as a natural 

disaster or short-term parental illness. Chronic trauma 

(or complex trauma) is experiencing multiple traumatic events over time (physical abuse) or when different 

traumatic events are related to one another (maltreatment followed by separation from caregiver).

Treatment. A form of intervention that may be short 

or long term and is characterized by an ongoing relationship with a particular service provider, most often 

a counselor, mental health clinician, or medical practitioner. The goal of treatment is to provide long-term 

support and remediation of symptoms.

Vulnerability. Susceptibility to distress and 

disturbances during development. 

References

Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pernucci, A. (2004). Benefits and costs of prevention and 

early intervention programs for youth. Olympia, WA: 

Washington State Institute for Public Policy. Retrieved 

September 9, 2008, from www.wsipp.wa.gov/

rptfiles/04-07-3901.pdf 

Cohen, J., Mannarino, A., & Deblinger, E. (2006). 

Treating trauma and traumatic grief in children and 

adolescents. New York: Guilford Press. 

Jaycox, L. (2003). Cognitive-behavioral intervention 

for trauma in schools. Frederick, CO: Sopris West

Education Services. 

Knitzer, J., & Lefkowitz, J. (2006). Helping the most 

vulnerable children and their families. New York: 

National Center for Children in Poverty.

Kracke, K., & Cohen, E. (2008). The Safe Start initiative: Building and disseminating knowledge to support 

children exposed to violence. Journal of Emotional 

Abuse: Interventions, Research, and Theories of Psychological Maltreatment, Trauma, and Nonphysical 

Aggression, 8(12), 155–174.

Kracke, K., Lamb, Y., & Hyde, M. (2008). The Safe 

Start demonstration project: Knowledge building to 

knowledge transfer for children exposed to violence. 

Best Practices in Mental Health, 4(1) 92–98. 
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Understanding Children’s Exposure to Violence

Safe Start Initiative

The Safe Start initiative is funded by the U.S. 

Department of Justice’s Office of Juvenile Justice and 

Delinquency Prevention (OJJDP). The goal of the 

initiative is to increase the knowledge of and promote 

community investment in evidence-based strategies 

for preventing and reducing the impact of children’s 

exposure to violence. Eleven demonstration sites were 

funded from 2000 to 2006 to create a comprehensive 

service delivery system to improve the accessibility, 

delivery, and quality of services for children exposed 

to violence at any point of entry. A national evaluation 

broadened understanding of how communities can 

successfully implement a comprehensive system of care 

with policy and practice interventions to minimize the 

negative consequences of exposure to violence.

Fifteen Promising Approaches pilot sites, funded in 

2005, are focusing on implementing and measuring 

developmentally appropriate services for children 

exposed to violence within the context of the systems 

that serve them. A national evaluation of these sites 

will analyze the impact of specific intervention 

strategies on outcomes for children and families. 

The Safe Start Center is a resource center designed to 

support the Safe Start initiative on a national level and 

to broaden the scope of knowledge and resources for 

responding to the needs of children who are exposed 

to violence and their families. For more information on 

the Safe Start initiative and Safe Start Center, visit www.

safestartcenter.org.

Recommended Citation: Cohen, E., McAlister Groves, 

B., and Kracke, K. (2009). Understanding Children’s 

Exposure to Violence. Moving From Evidence to Action: 

The Safe Start Series on Children Exposed to Violence, 

Issue Brief #1. North Bethesda, MD: Safe Start Center, 

Office of Juvenile Justice and Delinquency Prevention, 

Office of Justice Program, U.S. Department of Justice.

Lieberman, A., & DiMartino, R. (Eds.). (2005). 

Interventions for children exposed to violence (Johnson 

& Johnson Pediatric Series, 6). Key Biscayne, FL: 

Johnson & Johnson, Inc. 

Lieberman, A. F., & Van Horn, P. (2004). Don’t hit my 

mommy! A manual for child-parent psychotherapy for 

young witnesses of family violence. Washington, DC: 

Zero to Three Press. 

Masten, A. S., & Gewirtz, A. H. (2006). Vulnerability 

and resilience. In D. Philips & K. McCartney (Eds.), 

Blackwell handbook of early childhood development. 

Oxford, England: Blackwell Publishing.

Mihalic, S., Irwin, K., Elliott, D., Fagan, A., & 

Hansen, D. (2004). Blueprints for violence prevention. 

Boulder, CO: Center for the Study and Prevention of 

Violence, University of Colorado. 

National Scientific Council on the Developing Child. 

(2005). Excessive stress disrupts the architecture of the 

developing brain (Working Paper 3). Cambridge, MA: 

Author.

Olds, D., Henderson, C. R., Cole, R., Eckenrode, 

J., Kitzman, H., Luckey, D., et al. (1998). Long-term 

effects of nurse home visitation on children’s criminal 

and antisocial behavior: 15-year follow-up of a 

randomized trial. Journal of the American Medical 

Association, 280(14),1238–1244.

Issue Brief #1 was written by Elena Cohen, Director of the 

Safe Start Center, JBS International, Inc.; Betsy McAlister 

Groves, Director of the Child Witness to Violence Project, 

Boston Medical Center; and Kristen Kracke, Safe Start 

Initiative Coordinator, Child Protection Division, Office of 

Juvenile Justice and Delinquency Prevention, U.S. Department of Justice.

Points of view or opinions expressed in this document are 

those of the authors and do not necessarily represent the 

official position or policies of OJJDP or the U.S. Department 

of Justice. 

Moving From Evidence to Action: 

The Safe Start Center Series on 

Children Exposed to Violence

Issue Brief #1: Understanding Children’s 

Exposure to Violence

Issue Brief #2: Pediatric Care Settings 

Issue Brief #3: Schools

Issue Brief #4: Child Welfare Systems

Issue Brief #5: Domestic Violence Agencies 

and Shelters 

Issue Brief #6: Homeless Shelters, Permanent/

Supportive Housing, and 

Transitional Housing

Issue Brief#7: Fatherhood Programs