Clinical Challenges in Addressing Intimate Partner ... - Springer Link

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Aug 21, 2011 - C. M. Lewis. School of Social Work, University of Texas at Austin,. Austin, TX, USA ... research received approval from the University Institutional.
J Fam Viol (2011) 26:565–574 DOI 10.1007/s10896-011-9393-1

ORIGINAL ARTICLE

Clinical Challenges in Addressing Intimate Partner Violence (IPV) with Pregnant and Parenting Adolescents Shanti J. Kulkarni & Carol M. Lewis & Diane M. Rhodes

Published online: 21 August 2011 # Springer Science+Business Media, LLC 2011

Abstract Intimate partner violence (IPV) has been identified as a significant issue for pregnant and parenting adolescents. This study thematically analyzed data from focus groups with service providers (n=43) who work with pregnant and parenting adolescents to learn about barriers and strategies for addressing IPV. Service providers described four primary barriers to addressing IPV with their adolescent clients: adolescent clients’ definitions of love, intergenerational relationship patterns, cultural norms about gender and violence, and developmental-contextual considerations. Service providers also indicated that they respond to adolescents’ IPV related concerns by taking steps to identify IPV, building working relationships, and taking appropriate follow-up action. Results suggest that providers can benefit from increased training and skill development in working with IPV, as well as working in interdisciplinary, collaborative

S. J. Kulkarni Department of Social Work, University of North Carolina at Charlotte, Charlotte, NC, USA C. M. Lewis School of Social Work, University of Texas at Austin, Austin, TX, USA D. M. Rhodes School of Social Work, University of Texas at Austin, Austin, TX, USA S. J. Kulkarni (*) Department of Social Work, CHHS, 9201 University City Blvd., Charlotte, NC 28223, USA e-mail: [email protected]

teams to increase effectiveness with challenging cases. Programs should consider integrating IPV prevention initiatives that target broader social norms. Future research should pilot and test the effectiveness of targeted IPV training and programmatic interventions with service providers who work with this population. Keywords Intimate partner violence . Pregnant and parenting adolescents . Intervention . Service barriers

Introduction Pregnant and parenting adolescents appear to be at heightened risk for experiencing intimate partner violence (IPV)—the physical, sexual or psychological harm inflicted by a current or former partner or spouse (Saltzman et al. 2002). Epidemiological studies report IPV rates for adolescents seeking prenatal care range from 16% to 37%, exceeding the range for adult pregnant women of between 12% and 22% (Wiemann et al. 2000; Curry et al. 1998; Gessner and Perham-Hester 1998; Covington et al. 2001). Variability in IPV rates is typically influenced by sample sources, definitions, and methods used to assess IPV (Jasinski 2004). Nevertheless, these estimated rates for parenting adolescents are considered conservative since IPV is often underreported because of the associated stigma (Chang et al. 2005). Indeed qualitative studies and program evaluations in which researchers have had the opportunity for prolonged engagement have revealed higher rates of IPV ranging from 41% (Leadbeater et al. 2001) to over 50% (Larson 2004). A significant proportion (40%) of non-pregnant adolescents attending health clinics indicate they’ve experienced IPV (Silverman et al. 2001).

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IPV has a negative impact on abused women’s physical (Campbell et al. 2002) and mental health (Dutton et al. 2006) and can undermine efforts towards economic self sufficiency (Tolman and Rafael 2000). In addition, IPV often interferes with safer sex compliance and contraceptive behaviors which places pregnant and parenting adolescents at even higher risk for unwanted pregnancies and sexually transmitted infections (Campbell et al. 2000; Miller et al. 2010). IPV may be experienced by adolescents in developmentally distinct ways, and thus have different consequences for adolescents than for adult women (Leaman and Gee 2008). For example, adolescents tend to have more rigid gender stereotypes within their relationships and be more influenced by cultural norms (Ismail et al. 2010; Kulkarni 2007). Over the course of adolescence, youth decrease their involvement in parental relationship investing more heavily in romantic and peer relationships (del Valle et al. 2010), thus increasing the potential isolation of pregnant and parenting adolescents who may already be marginalized within their social contexts. Further for those adolescents who already have a history of trauma, IPV can be an even more complex and devastating experience (Kennedy and Bennett 2006). Programs that serve pregnant and parenting adolescents are now encouraged to consider IPV while addressing the adolescents’ inter-related physical, emotional, educational, and economic needs (Kulkarni 2006; Office of Adolescent Pregnancy Programs 2006; Rowlands 2010). Despite efforts to incorporate IPV screening into existing services, significant program barriers remain to addressing this issue. For example, provider attitudes, time limitations, inadequate training, and lack of resources were all cited as barriers to screening with a family planning clinic (Colarossi et al. 2010). To date, there is scant information about how service providers work with pregnant and parenting adolescents around IPV issues (Lewis et al. 2005; Weisz and Black 2009). This study addressed that gap by querying service providers about barriers encountered in identifying and addressing IPV, as well as strategies employed to overcome obstacles and successfully address IPV among pregnant and parenting adolescents. Because service providers work with adolescents within a variety of settings, we used a focus group method that allowed us to engage providers within their workgroups.

Methods

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services to pregnant and parenting adolescents in an urban teen health clinic (n=7), an urban public school district (n= 11; school nurses), a rural county health department (n= 8), and a residential facility for pregnant adolescents and adult women (n=8). The fifth focus group was convened at a wrap-around program for pregnant and parenting adolescents and conducted in a southwestern state (n=9). Participants were all recruited through their workplace. Participation was voluntary and all participants provided informed consent. Each participant received a $25 gift card. The research received approval from the University Institutional Review Board. Focus Groups This project utilized focus group interviewing, a qualitative data collection method that involves bringing a group of homogenous participants together with a moderator to discuss a particular topic or issue (Berg 2004). Focus groups are “particularly useful for exploring people’s knowledge and experiences” (Kitzinger 1995). Through facilitated discussion with one another, participants are able to explore and clarify their experiences in ways they may be less likely to do in one-on-one interviews. Data collection was guided by two primary research questions: RQ 1) What barriers do service providers encounter in addressing IPV with pregnant and parenting adolescents? and RQ 2) What strategies do they employ in addressing IPV? A semi-structured focus group interview guide was developed by the first author and included openended questions that explored what providers knew about IPV services, policies, and research, how they addressed IPV in their work, what their adolescent clients told them about their IPV experiences, what barriers they encountered in addressing IPV, and what recommendations they offered towards improving IPV services for pregnant and parenting adolescents. Focus groups were conducted at participants’ work sites between August 2007 and May 2009. Each focus group lasted from 60 to 90 min, and was facilitated by the first author. Participants were encouraged and prompted to discuss a range of experiences. The facilitator attempted to elicit outlier as well as shared experiences. Participants were recruited through email invitation and through flyers posted at their workplace. A majority of the participants were female, between the ages of 30–49, Caucasian, and college graduates who had worked in their current position for 1–5 years (See Table 1 for detail).

Sample Analysis This study used purposive sampling, to ensure variation in service delivery settings between focus groups. The first four focus groups included personnel who provided

All focus groups were digitally recorded and later transcribed verbatim by graduate research assistants. Transcriptions

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Table 1 Participant demographics Description Gender (n=43) Female Male Age (n=41) 20–29 years 30–39 years 40–49 years 50–59 years Ethnicity (n=42) African American Caucasian Hispanic Education (n=43) Less than high school diploma Some College Completed College Post-college Position (n=43) Nurse Director/Coordinator Case Manager/Social Worker Other (MD and Psychologist) Years in Current Position (n=42) Less than 1 1–5 6–10 11–15 16–20

Frequency (%)

42 (98%) 1 (2%) 9 13 13 6

(21%) (32%) (32%) (15%)

15 (36%) 24 (57%) 3 (7%) 1 1 27 14

(2%) (2%) (63%) (33%)

21 11 9 2

(49%) (25%) (21%) (5%)

5 23 10 3

(12%) (55%) (24%) (7%)

1 (2%)

were reviewed by all three authors using a modified grounded theory approach (Charmaz 2006) to generate initial thematic codes. Transcription files were entered into Atlas-ti, a qualitative research software program, for data management and were coded line by line. Three research team members independently coded separate focus group transcripts to generate an exhaustive list of codes for each research question. Codes were then compared, revised, and consolidated themes by the team. Reports and tables were then generated to compare themes within and across settings to in order to examine relationships (see Table 2).

violence, and the developmental-contextual realties of their clients’ lives. Service providers also described how they responded to their adolescent clients’ IPV related concerns by taking steps to identify IPV, building a working relationship with their clients, and taking appropriate follow-up action. Research Question 1: Barriers to Youth Identifying IPV as a Problem As long as they’re in the ‘I’m in love’ mode they can’t see it Service providers gave numerous examples of relationship abuse that was unrecognized by the adolescents experiencing it. Youth viewed behaviors such as jealousy and control as expressions of love. They overlooked or minimized violence in their relationships because of strong positive feelings for their partners. Service providers said that some youth “don’t see it necessarily as a problem,” instead viewing abuse as “just a normal relationship.” One service provider noted that some youth had very narrow definitions about what constituted abuse and did not “equate what’s going on necessarily to violence; if he didn’t ball up his fist, then he didn’t really hit her.” One provider commented that youth formed their definitions of love and healthy relationships without much input from trusted adults, though she saw adults as responsible for educating youth about healthy and unhealthy aspects of relationships, such as “what really being in love looks like in a healthy relationship.” Service providers believed youths’ lack of perspective about their relationships was frequently related to the intensity of their attachments. According to one participant, “When the relationship is declining, that’s when they can see what everyone else was able to see a long time ago, but as long as they are in that ‘I’m in love’ mode they can’t see it.” Sometimes overlooking abusive behavior was connected to perceptions of dependency. One service provider described the situation from the perspective of her adolescent client: “He’s taking care of me and that’s all I need to take care of my baby. Everything else I can overlook and that’s it.” Other providers noted that self-blame sometimes prevented adolescents from taking the violence in their relationships more seriously. Because adolescents were sometimes reluctant to discuss their relationships, providers were often left to speculate about youths’ reasoning. As one service provider pondered, “I always wonder if it’s because of the shame that’s associated with it, or if it’s because they really believe it isn’t a big deal.”

Results It’s that cycle… Service providers described four primary barriers to addressing IPV with their adolescent clients. These included their adolescent clients’ definitions of love, intergenerational relationship patterns, cultural norms about gender and

Participants in most focus groups referred to the intergenerational cycle of abuse when explaining adolescent IPV. Service providers believed that families had a formative

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Table 2 Themes by focus groups Research Question

Theme

Focus Groups

RQ 1: Barriers to Youth Identifying IPV as a Problem

“As long as they’re in the ‘I’m in love’ mode they can’t see it.” It’s that cycle “In some cultures, it (abuse) is not (viewed as) an issue.” “they haven’t outgrown it.” Identifying IPV Building relationships/rapport Following up/taking action

All 1, 2,3, 4 All 2, 3, 4 All All All

RQ 2: Provider Efforts to Engage Adolescents

influence on adolescent children’s relationships. They saw some parents as exhibiting or accepting abusive behavior in their own relationships, and hindering their children’s ability to seek help for IPV in their own relationships. A number of service providers described adolescents’ perceptions of abuse in their relationships as normal because they “grew up in an environment where that’s what they see people do.” As one service provider explained, So if he pushed her, that’s just kind of normal. They’ve seen their brother do it or their dad…So, sometimes it’s like it’s going on, but unless there is something that really brings it up to them, in their mind it’s not really violence. Service providers often struggled to help adolescents recognize that they were being abused in their relationships. Adolescents who had been abused or had grown up witnessing domestic violence often had trouble seeing themselves as victims. Even when they were able to identify abuse in their families, they might not see abuse in their own romantic relationships. A service provider illustrated this with her client: She wasn’t able to connect between the two, so I would talk with her about the qualities that she doesn’t like in mom’s boyfriend and then compare those to the same things that her boyfriend was displaying to help her see that the same things you don’t like in mom’s boyfriend—you are saying he’s controlling and abusive—are some of the same things that your boyfriend is doing. Other service providers described the struggle of some adolescent females to break the cycle of abuse while remaining connected with their families. One provider resolved this by intentionally supporting clients’ relationships with their mothers, by assuring them that “their mothers were doing the best they could.” Some providers saw their work undermined by unconcerned parents and believed that they needed to attend to the relationship issues of parents before they could make significant progress with adolescents.

Finally, service providers also saw adolescent mothers as potentially perpetuating the cycle of abuse with their own children. They expressed concerns about clients whose young children were “mean to them” or were “hitting them” or “saying bad words to them.” Service providers worried that these children would grow up to become abusers or victims. In some cultures, it (abuse) is not (viewed as) an issue Most service providers spoke of abuse as a learned behavior in which cultural norms played an important role. Often parental acceptance or minimization of adolescent IPV was attributed to cultural beliefs that supported traditional gender roles and permissive attitudes toward violence. Though youth might observe violence in the home, they also looked to the larger community to teach them about healthy relationships. As one service provider explained, “if the child is brought up in an environment where abuse is normal and the community says the abuse is within what they consider normal, then we have a problem.” Service providers also identified abuse as an artifact of the “culture of poverty”, as well as “Southern culture” and “religion and how people interpret it.” One provider noted that male victims were often overlooked because of cultural assumptions about the gendered nature of aggression. Most cultural explanations involved descriptions of Latino and African American cultures. As an African American service provider remarked, I think that it happens more across specific cultures like I can speak about African-American culture, various (sic) Latino cultures, a lot of times, you know, it’s very male-dominated, patriarchal, whatever, the guy is significantly older than the woman, he’s in control of the situation, there are high levels of physical and domestic violence, and control issues. And that’s maybe a little more accepted in that culture than another. According to another service provider, Your Hispanic man is the ruler. That’s all it is to it. It’s done like I say or else. You’re going to find that

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they’re going to be more apt to be abusive…I find that, for me, a bigger percentage of the violent cases are from the Hispanic population. In one focus group, service providers highlighted the cultural struggles that African American females faced in terms of being ‘strong’ and how this led them to not identify themselves as victims. However, even as AfricanAmerican girls claimed to be the aggressors, service providers saw a more complicated pattern, where “it was more you know ‘I said this’, or ‘I did this to him and that’s why he did this’, you know, that kind of justifying kind of an attitude.” Providers were particularly perplexed by what they saw as family approval and even encouragement of relationships between young adolescent girls and much older men, and then reported seeing these more often in the Latino community. Service providers attributed this to differences in American and Latino cultural norms. Service providers were equally critical of the Latino community and law enforcement for not taking allegations of sexual assault more seriously. They were also concerned about incidents of early teen pregnancy in the Latino community: Especially with the Hispanic students, it seems like right around that age of 14 [verbal agreement from the group] it was mind boggling to me when I had about 4 to 5 of them at one time all pregnant, all were 14, 14 seems to be that ripe age, especially in the Hispanic culture where they start having children and evidently are considered to be mature, and ready to take on motherhood. However, some service providers, particularly those from the southwestern state focus group, shared a more complex understanding of Latino culture. As one participant noted, “Not all (Latinas) were raised with the macho male… because even in Mexico there’s different populations.” She cautioned that providers should not to over generalize based on ethnicity or language. Hoping they outgrow it Interestingly, developmental explanations of IPV were mentioned in only three of the five focus groups. These explanations highlighted the role of teens’ age and developmental capabilities in IPV dynamics. One service provider described adolescents as being in developmental transition in both their thinking and their expectations: Sometimes when we get them and they’re here for 6 months you can, you can watch them learn and grow and…kind of gauge from right and wrong. I want to believe that when they outgrow it. I think they may outgrow each other. Yeah they get tired of it.

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Other service providers suggested that the adolescents they worked with had not developed adequate emotional regulation to manage the intensity of the feelings in their relationships. Another service provider remarked that her young clients might feel as though “I want to control my anger, but I don’t know how to do it.” According to these providers, young mothers faced particular challenges establishing an independent ‘adult’ identity at a time when most were still quite dependent upon parents and other adults. When significant adults modeled unhealthy relationships, adolescent mothers had a more difficult time creating healthy relationships of their own despite their desire to do so. When relationships in the home were very poor, providers saw adolescents in abusive relationships as having more limited options. For some, living with an abusive partner might be preferable, since “living with mom could be worse.” Research Question 2: Providers Efforts to Engage Adolescents Identifying IPV Service providers learned about patients’ IPV experiences in a variety of ways. A number of providers used standardized screening protocols in intakes and regular visits. For example, school nurses were required to ask the question, ‘Have you ever been abused?” to all of their student patients. At the adolescent health clinic, patients were not only asked about violence during their examination, but were asked about family history of violence on pre-exam paperwork given to them and their parents. Despite standardized screening intake questions, service providers commented that many youth with IPV experiences screened negative. They noted that service providers’ definition of abuse differed from adolescents’ definitions. As one service provider explained, “They may not even realize that ‘Oh my boyfriend pushed me around’ is abuse.” In order to get more accurate responses, some providers adapted the standard questions, asking more descriptive or behaviorally oriented questions. One provider recommended that, “Instead of asking ‘Have you been abused?,’ ask the question ‘Has anyone hit you?’, or ‘Has anyone kept you from your friends or your family? And get really specific.” Some providers used educational tools, such as the ‘power and control wheel’ to facilitate assessment of IPV. They noted that education of patients was a nonthreatening approach that normalized the experience of IPV in a way that was de-stigmatizing. According to one service provider, There’s all kinds of information and brochures that are out there that, if you want, you can just packet some

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information to share with them and we can just stick it in the packet like this and just give one to everybody sort of thing. Other service providers spent time preparing adolescents for sensitive questions and creating a safe environment for them to talk about IPV. For example, a school nurse described her approach this way: “The framing of the questions takes a good chunk of time and it also takes a setting where you can…give the questions the privacy and the attention that they deserve. “A service provider in a residential setting viewed screening as a conversation rather than a question: “We ask everybody about it, kind of as a starting point, you know the open ended questions and saying ‘can you talk a little bit more about that’ and clarifying.” A case manager highlighted the need to individualize the approach: “I think you just kind of assess it for what might work because everything is not going to work, the same thing will not work for every client.” A residential service provider utilized the same client-directed approach: “whatever they present is kind of how you know the direction that we would go in with the conversation and the information that we would provide for them.” When service providers had the opportunity to observe couples together, suspicions of IPV were sometimes raised. For example, one service provider recounted a number of red flags from her own work: Like “why she doesn’t want him in the room during delivery”…and lactation stuff where…they don’t want him to see their breast…(or) he’s not supportive physically in an affectionate way when she’s just had a baby and you can tell there’s something missing there. A rural public health service provider described actually witnessing domestic violence on a home visit. On rare occasions, adolescents came to service providers specifically because of IPV concerns. A school nurse related such an example: I had a girl this past year who came to me because she had gotten into an altercation with her boyfriend and to protect herself she grabbed a box cutter and he actually put charges on her. He had pushed her when she had the baby, she had took the baby to ED (emergency department), and by the time she got there Social Services were there and she lost custody for a good 6 months. She couldn’t get her own baby back; they actually gave him and his family the baby. So she came to school and came to me every single day so we could…see if they had a warrant out on her. Sometimes, adolescents were referred for services because of IPV. A service provider at a rural health clinic noted that adolescents might be referred to the clinic for follow up after seeking treatment for an injury.

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Service providers were ambivalent about broaching the subject of IPV with their patients. One clinic provider noted her preference for bringing up IPV later in the healthcare appointment and her discomfort when IPV came up unexpectedly. Another clinic provider described being unsettled when IPV came up as she asked a patient about the age when she began having sex: “She told me she started when she was 6 years old, and right off the bat I’m like no 6 year old is going to consent to have sex and I was like I didn’t know where to take it from there, so I just said, ‘Okay.’” Other service providers raised concerns about the relevance of exploring past IPV if there was not an immediate safety issue. As one service provider questioned: “I wonder how beneficial it is to them, when it is something that they’ve already dealt with and they have moved on and it’s actually more traumatic to revisit it.” Other service providers felt discomfort about their reporting obligations, especially given the lack of responsiveness from the system. That is, reporting to protective authorities typically damaged the patient-service provider relationship and protective action was rarely taken. As one provider noted: When I have reported to the police department… given big long lists of everything the child has said and some of these things are like horrendous and then they go out and I have not had a single case substantiated. Another service provider related a hostile interaction with law enforcement when she reported a sexual assault on a minor: “The police told her that…“she better make darn sure that she’s telling the truth or she could be put in jail,” so now she’s saying well, it really didn’t happen.” Building relationships/rapport Service providers often spoke of disclosure in the context of their relationships with adolescent clients. They said that when they had the opportunity to develop relationships with clients over time, they were more likely to learn about IPV. One service provider described her strategy, which included careful listening, noting subtle cues in the adolescent’s stories, and holding back—allowing the adolescent to tell her story in her own time: Just kind of keying into how they answer certain questions and stuff, and, usually, you think there will be more to be revealed. And, sure enough, there’s more to be revealed. It’s just they’re building up trust, you know, with us or the clinic, and once that kind of happens they are more likely to start sharing more. When service providers demonstrated that they cared, youths felt safer to share more sensitive information, including the details of their important relationships. As a

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rural public health service provider explained, “I like to build a relationship with them so that if they do decide to listen to what I’m saying, they may feel like they might agree or that what I’m saying has meaning to them.” Service providers also commented on observed cultural differences in how adolescents dealt with IPV. One provider noted that Caucasian clients presented in a more “straightforward” manner. Although there was “minimizing,” they tended to more readily disclose IPV. At the opposite end of the spectrum, another service provider experienced Native American clients as “more reserved,” requiring her to work harder with them than she did with African American or Caucasian clients. Service providers viewed cultural differences between themselves and their clients as creating barriers to disclosure of IPV. Hesitancy to discuss sensitive issues by both the service provider and client was noted. On one hand, service providers noted that sometimes clients’ ability to trust had been negatively impacted by IPV experiences. One service provider described helping her adolescent clients connect their tendency to mistrust with previous abusive experiences. Another service provider acknowledged her discomfort in raising the topic of IPV too soon in the clinical encounter: The reason why I ask those questions kind of towards the end is not only for their comfort but for mine too, you know, because it’s easier for me to ask people those types of things once I’ve been talking to them about other stuff. In summary, these service providers nurtured relationships by listening, spending time, and providing individual attention to adolescent clients. One service provider used a gardening metaphor to describe her nurturing relationships with adolescent clients: “You can’t just plant a seed and then expect it to grow.” Following up/taking action Service providers responded to adolescent IPV in a variety of ways, depending on the client situation, the organizational features of their practice settings, and the resources available in their communities. Service providers working as part of an interdisciplinary team spoke positively about collaborative interactions and support in their work. For example, one member of such a team commented, We meet weekly for staffing. These kinds of issues come up all the time. And the case manager will kind of present and we have a therapist at the table and a medical person at the table and so there is a lot of consulting about, you know, kind of where to go from here. And, they’ve each seen a little different piece I think, of the case.

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According to one service provider, an advantage to the team care approach was that an adolescent could choose to confide in the person with whom she had the strongest relationship. Consistent with this view, a school nurse felt she could respond to adolescent IPV in only a limited manner working alone. Many service providers expressed frustration with the limited free or low-cost resources that were available to clients. Even when resources could be identified, adolescents often encountered barriers to accessing services. Often they could not access services because of transportation barriers; school health staff who advocated for communitybased services said: “Half the people, you know, they can’t get there, they don’t have the time, they’re watching little baby brothers or sisters, or whatever it may be, and they can’t leave their communities to go somewhere else.” Also, some services were contingent on the permission or participation of a parent or legal guardian. Service providers were critical of the adequacy of community resources. They blamed a lack of public will to tackle social problems such as teen pregnancy, or to invest in youth prevention. Also, they sometimes found that resources were overly specialized and did not meet clients’ needs. One service provider shared her unsuccessful attempts to get an adolescent client into a battered women’s shelter: The shelter wouldn’t take her and she was like ‘He is emotionally violent to me. He’s psychologically violent. It’s only a matter of time before it turns physical and they won’t take me. What do I do?’ And, I hadn’t, I mean I was at a loss. I was like where do I go, what do I do, where do I refer her?

Discussion According to service providers in this study, adolescent IPV was a common concern in their practice. They viewed IPV as a complex and often difficult phenomenon to address with pregnant and parenting adolescents. Providers felt hampered in addressing IPV in numerous ways. They believed they needed to overcome key barriers associated with adolescents’ definitions of love, intergenerational relationship patterns, cultural norms about gender and violence, and developmental-contextual realities. Adolescents’ minimization or misidentification of abuse within their relationships interfered with providers’ attempts to engage youth in conversations about IPV. In addition, providers implicated cultural norms that support IPV as an additional barrier to problem identification and helpseeking. Finally, both family dysfunction and adolescents’ stage of development were viewed as interfering adolescents’ ability to confront IPV.

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To address IPV, providers actively engaged adolescent clients—laying the groundwork by identifying the issue (IPV) and building a working relationship, and then following up in some manner. Wide variation in service providers’ implementation of these strategies emerged. At one end of the spectrum, their responses were limited to asking IPV screening questions and providing referral information for community resources. At the other end of the continuum, providers formed ongoing relationships with adolescent clients and provided direct counseling and advocacy. The level and depth of intervention were influenced by many factors, including service providers’ views of their role, service delivery setting, and knowledge and comfort in working with IPV. For example, service providers who shared clients as part of an interdisciplinary team, particularly a team that included social workers and counselors, appeared to have more opportunity for consultation and dialogue about their cases. Cultivating relationships with adolescents and taking a longer view of change seemed to be an effective strategy even in the face structural barriers and resource limitations. Overall providers tended to locate IPV barriers within the adolescents’ environment or within the adolescent herself—rather than viewing the service provider or practice setting as creating barriers. In addition, although these providers identified barriers at the individual, relationship, family, community, and cultural levels, it was less clear how they viewed these influences as interacting and competing with one another. For example, when youths perceived relationship abuse as 'normal', service providers might attribute this perception to family experiences, cultural norms, or perhaps some interaction between the two. Service providers did not explore how they reasoned to their conclusions in this study however this may be an interesting avenue for future research. Service providers appeared to struggle in their work with Latino populations, especially providers in the southeast, a region without a long history of serving immigrant populations. Some research estimates that Latinas may experience slightly higher rates of abuse (Caetano et al. 2008), however other research suggests that cultural factors have less influence on prevalence and severity of IPV than on potential IPV consequences, such as depression, PTSD, and lowered selfesteem (Edelson et al. 2007). Acculturative stress in particular may play a role in Latinas’ experience of IPV (Hokoda et al. 2007), as well as potential influences of poverty (Goodman and Epstein 2009), and neighborhood disadvantage (Benson et al. 2003). Service providers should be aware of the cumulative and intersecting nature of these influences for both white and non-white adolescents seeking services. Training can also help providers to identify their personal biases, stereotypes, and attitudes about IPV that impact their effectiveness in working with adolescent clients.

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Training has been identified as an important avenue for increasing IPV screening and disclosure in healthcare settings, especially combined with tools such as protocols (Waalen et al. 2000; Brown et al. 2007). Providers should be aware of available community resources and their service limitations (Kulkarni et al. 2010). Adolescents are typically seen as less vulnerable than children when it comes to their victimization (Coble et al. 1993) and in addition are more likely to fall outside of the scope of adult services. Service providers can help document needs and advocate for services for this vulnerable population. Study findings suggest that in order to surmount identified barriers, provider training needs to be comprehensive in nature. Expanding the scope of intervention and providing professionals with a integrated conceptual framework for addressing IPV may also be helpful (Burton et al. 2010). For example, though providers spoke extensively about socio-cultural norms contributing to adolescent IPV, interventions were almost exclusively delivered at an individual or family level. Universal prevention strategies may support direct intervention with pregnant and parenting adolescents and support changes beyond the individual level. These findings vary somewhat from the barriers providers identify when asked about the narrower practice of IPV screening. Those studies have tended to emphasize barriers within medical practice settings, such as lack of privacy, time, training, and resources (Waalen et al. 2000). This study highlights what happens in the broader context of addressing IPV with pregnant and parenting adolescents. All focus group practice settings included questions about IPV in their intakes and assessment. However some providers noted their discomfort asking about IPV or addressing it when it came up unexpectedly. Their experiences underscore that screening protocols alone may reinforce IPV as a segmented health concern rather than a critical life stressor that can have complex, far-reaching, and long term effects on many aspects of health and wellbeing (Campbell et al. 2002; Dutton et al. 2006; Tolman and Rafael 2000).

Conclusions The feedback provided by these participants reflects the unique voices of service providers. In addition, the issues raised in these discussions are meaningful for developing strategies for best serving this population. Given the extremely high rates of IPV among pregnant and parenting adolescents, service providers working with these populations must be armed with the knowledge and skills to address IPV. These findings suggest that providers have identified effective intervention strategies, as well as common concerns and training needs across settings. Some

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providers seemed to feel overwhelmed especially when confronted with intergenerational patterns of abuse and persistent gender and cultural norms. These findings reinforce calls for the development of IPV interventions that address adolescents’ developmental stage issues while also taking into account complex individual, familial, and societal influences of gender, culture, and class (Milan et al. 2005; CDC 2000; Newman and Campbell 2010). Future research should pilot and test the effectiveness of targeted IPV training and programmatic interventions with this population.

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