Victims

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Violence and Victims

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Violence and Victims, Volume 26, Number 6, 2011

Victim of and Witness to Violence: An Interactional Perspective on Mothers’ Perceptions of Children Exposed to Intimate Partner Violence Solveig Karin Bø Vatnar, PhD Oslo University Hospital, Norway

Stål Bjørkly Molde University College and Oslo University Hospital, Norway This article reports a study of how mothers perceive the effects of intimate partner violence (IPV) during pregnancy and children’s exposure to IPV: (a) Do interactional aspects of IPV have a negative impact on the fetus during pregnancy or on the newborn baby? and (b) Is there a relationship between interactional aspects of IPV and (a) children’s risk of being exposed to IPV and (b) the age of the child when at risk for exposure to IPV? A representative sample of 137 IPV help-seeking mothers in Norway was interviewed. Severity of physical IPV and injury from sexual IPV increased the risk of consequences to the fetus. Frequency of physical and psychological IPV increased the likelihood of children’s exposure. Duration of the partnership increased the risk of children’s exposure to physical and sexual IPV. Finally, there was a negative linear association between children’s age when exposed for the first time and frequency of physical and psychological IPV.

Keywords: intimate partner violence; pregnancy; child exposed/witness; child age; interactional aspect

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esearch has examined the adverse effects of intimate partner violence (IPV) on children’s range of ages, including fetuses, newborns, and older children (Chambliss, 2008; Graham-Bermann & Perkins, 2010; Lévesque, Clément, & Chamberland, 2007; Straus, 2001; Taillieu & Brownridge, 2010).

Consequences to Fetus and Newborn Recent reviews indicate that the prevalence of IPV during pregnancy is consistently lower than IPV before pregnancy (Bacchus, Mezey, & Bewley, 2006; Chambliss, 2008; Taillieu & Brownridge, 2010). Nonetheless, the prevalence of IPV during pregnancy (3.9%–8.3%) is more common than many other disruptive interactions that cause negative consequences for which routine screens are done (Bacchus et al., 2006; Chambliss, 2008; Taillieu & Brownridge, 2010). IPV has also been associated with unwanted and unplanned pregnancy (Campbell, Garcia-Moreno, & Sharps, 2007). Physical IPV dur830

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Children’s Exposure to Intimate Partner Violence

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ing pregnancy may result in placental separation, antepartum hemorrhage, fetal fractures, rupture of the uterus, liver, or spleen, low birth weight, and premature delivery (Campbell et al., 2007; McFarlane, Campbell, Sharps, & Watson, 2002; Morland, Leskin, Block, Campbell, & Friedman, 2008; Murphy, Schei, Myhr, & Du Mont, 2001; Schei, Guthrie, Dennerstein, & Alford, 2006; Taillieu & Brownridge, 2010). The severity of physical IPV has been found to be a predictor of consequences to the fetus and miscarriage (Campbell et al., 2007; Morland et al., 2008). Although prevalence rates vary among studies, it is clear that a substantial minority of pregnant women experience violence during pregnancy and that this violence often continues into the postpartum period (Taillieu & Brownridge, 2010).

Children’s Exposure to Intimate Partner Violence Recent studies indicate that the prevalence of IPV is higher and the duration of IPV is longer among couples with children than among couples without children (Bair-Merritt, Holmes, Holmes, Feinstein, & Feudtner, 2008; McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006; Vatnar & Bjørkly, 2010). Women who have children often report that their reasons for staying in, leaving, or returning to an IPV relationship is their children (Brownridge, 2006; Vatnar & Bjørkly, 2010). It is recognized that children living in families characterized by IPV are victimized, even if the mothers try to compensate for exposure to IPV in their parenting interactions (Graham-Bermann & Edleson, 2001; Graham-Bermann, Gruber, Howell, & Girz, 2009; Letourneau, Fredrick, & Willms, 2007; Mullender, 1996; Renner, 2009; Timmer, Ware, Urquiza, & Zebell, 2010; Vatnar & Bjørkly, 2010). Recent reviews indicate that the prevalence of children exposed to IPV (about 50%) is underestimated because studies were conducted on families with children between the ages of 2 and 17 years, and younger children were not included in the analysis (Bourassa, 2007; Chambliss, 2008; Letourneau et al., 2007; Levendosky & Graham-Bermann, 2001; Levendosky, Huth-Bocks, Semel, & Shapiro, 2002; Lévesque et al., 2007). Some studies suggest that the number of children in the family, children’s age, and children’s sex are risk factors; others do not find these factors to be significant (Chambliss, 2008; Graham-Bermann & Perkins, 2010; Lévesque et al., 2007; Moylan et al., 2010; Straus, 2001).

Interactional Perspectives on Intimate Partner Violence Studies of IPV during pregnancy and research on children brought up in IPV partnerships appear to have limited theoretical grounding (Taillieu & Brownridge, 2010). An interactional perspective on IPV may add theoretical understanding of some of the mechanisms involved in these adverse phenomena (Arriaga & Capezza, 2005; Bell & Naugle, 2008; Briere & Jordan, 2004; Cano & Vivian, 2001; Heckert & Gondolf, 2004; LanghinrichsenRohling, 2005; Mears & Visher, 2005; Messman-Moore & Long, 2003; Schwartz, 2005; Winstok, 2007). In recent years, a number of researchers have advanced views about ways new theoretical frameworks can improve upon former IPV theories (e.g., Bell & Naugle, 2008; Jasinski, 2005; Wilkinson & Hamerschlag, 2005; Winstok, 2007). First, it has been argued that new IPV theories should be more comprehensive, taking into consideration the perspectives of both victims and perpetrators and integrating views from multiple academic disciplines, including psychology, sociology, and criminal justice (Rhatigan, Moore, & Street, 2005). Additionally, it is argued that newly formed IPV theories should be more ideographic in


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nature, accounting for the significant heterogeneity of IPV (Bell & Naugle, 2008; Winstok, 2007). Correspondingly, theoretical IPV perspectives and related IPV research should address the context and proximal events associated with IPV episodes (Bell & Naugle, 2008; Wilkinson & Hamerschlag, 2005; Winstok, 2007). These authors have encouraged IPV researchers to investigate the “violence process,” examining the nature of the violent relationship, the events and conditions preceding an IPV episode, motivations for engaging in violent acts, and outcomes following IPV episodes (Bell & Naugle, 2008; Jasinski, 2005; Wilkinson & Hamerschlag, 2005; Winstok, 2007). The change toward an interactional approach to IPV has also become evident in the empirical IPV literature. Several studies have examined proximal antecedents or precipitants thought to be associated with the onset of IPV, including substance use, verbal arguments, partner’s physical aggression, relationship factors, and chronic and acute stress (e.g., Belfrage & Strand, 2008; Frye, Manganello, Campbell, Walton-Moss, & Wilt, 2006; Moore et al., 2008; O’Leary, Smith Slep, & O’Leary, 2007; Simmons, Lehmann, & Collier-Tenison, 2008). Although initial steps have been taken to conceptualize and investigate the context and interactions surrounding IPV episodes, the impact of interactional perspectives on empirical research is still not very strong (Bell & Naugle, 2008; Eisikovits & Bailey, 2011; Winstok, 2011). In an interactional approach, the significance of person–situation interactions is emphasized in efforts to analyze both personality and behavior. This approach has also been used in other fields of research on interpersonal violence such as violence committed by persons with major mental disorders (e.g., Bjørkly, 1993; Monahan, 1988). The main idea is that aggression involves an influential and continuous interaction between individuals and the various situations they encounter. Each episode is defined as it is perceived, interpreted, and assigned meaning by the one experiencing it (Magnusson, 1981). From an interactional perspective, then, it is understood, for example, that should a woman be subjected to physical, psychological, and sexual IPV on several different occasions, she would probably have experienced and perceived each of these interactions differently. Even if the aggressor is the same person on each occasion, different dynamics of aggression may have been involved. Accordingly, the escalations leading to physical, psychological, and sexual IPV reported by the same woman are treated as three separate analytical units because the focus is on person–situation interaction rather than on treating three different interactional IPV situations as if they were identical because the same victim and perpetrator were involved. Bell and Naugle (2008) introduced a description of interactional units (e.g., target behavior, motivating factors, reinforcing consequences) applied to IPV episodes. Naturally, these proximal variables are not exhaustive, and a more advanced set of interactional units is needed to generate hypotheses and to help identify relevant IPV variables. Examples of interactional units in this model include the following: Target behavior is the dependent variable or the problematic behavior of interest. Within the IPV literature, the problematic behavior of interest involves three primary forms of abuse: physical, psychological, and sexual IPV (Bell & Naugle, 2008; Dutton & Nicholls, 2005; HoltzworthMunroe, Smultzler, & Sandin, 1997; Saunders, 2003; Walker, 1984). Operationally, target behavior specifications typically include IPV type, severity, frequency, duration, injury, and mortal danger (e.g., Bell & Naugle, 2008; Winstok, 2007). Antecedents refer to setting components or setting events and are stimuli or events that precede the target behavior and impact the likelihood of its occurrence (Bell & Naugle, 2008; Winstok,



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2007). Antecedents may be distal (e.g., childhood abuse, exposed to parents IPV during childhood) or proximal (e.g., pregnancy, immigration, or economic dependency). Discriminative stimuli denotes a distinct class of antecedents involving stimuli, events, warning signals, or conditions whose presence preceding the target behavior signals that the target behavior might be more likely to be reinforced. The presence of a discriminative stimulus (e.g., restless walking, change in complexion, shouting at someone, blaming someone for all his or her problems, considering he or she is the victim, or staring hard at someone) can momentarily increase the likelihood that the target behavior will occur. Motivating factors are antecedent stimuli, events, or conditions that can temporarily change the risk and characteristics of IPV, such as alcohol and drug intoxication (Bell & Naugle, 2008; Moore et al., 2008; Testa, 2004). Motivating factors are estimated to be mediators or moderators, and they are usually closely linked to the perpetrators’ intentions (e.g., to regain control over a woman) and the perpetrators’ motives (e.g., jealousy). Motivating factors might also include the victim’s expressing dissatisfaction with the relationship or the desire for a divorce. Behavioral repertoire refers to socially adaptive skill sets that a person can perform competently under appropriate conditions to successfully attain a desired consequence, for example, coping strategies (give in and obey, escape, try to reason with, cry, call for help, or counterattack). Behavioral repertoire deficits can result in an increase in maladaptive behavior to attain the same desired consequence. Verbal rules are attitudes that can be used to trigger, justify, and influence target behavior and its outcomes, for example, “sometimes you have to use violence to make people understand,” “some women want to be beaten,” “I only beat her when she deserves it,” or “I have never beaten her in front of the children.” Reinforcing consequences are outcomes following the target behavior that increase the likelihood that the target behavior will occur under similar conditions in the future. Reinforcing consequences can include the addition or subtraction of various stimuli, events, or conditions, with the overall effect being an increase in the future occurrence of the target behavior, for example, the woman gave in and obeyed him, she did not go to the party after all, she moved back home and cancelled the divorce application, she ensured him that she loves him, the police/marriage counselor/therapist almost confirmed that being betrayed like he was justified his beating her. Punishing consequences are outcomes that follow the target behavior and reduce the likelihood that the target behavior will occur under similar circumstances in the future, for example, reporting to the police, informing relatives and friends of the abused woman and/or the perpetrator, moving with the children to a shelter, applying for an emergency alarm, or requesting the prosecution authority to issue a restraining order against the perpetrator.

In line with this interactional approach, it is crucial to investigate mothers’ perceptions of the possible impact of different facets of IPV on their children. Does the severity, predictability, or frequency of the IPV represent different consequences to the child witnessing such episodes? Are the consequences to the child the same whether she is exposed to psychological or physical IPV? The focus on such situational characteristics is of paramount significance in an interactional analysis of IPV. It has been suggested that to develop a better understanding of IPV during pregnancy and children’s exposure to IPV, research must differentiate between the various forms of


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IPV (Renner, 2009; Taillieu & Brownridge, 2010). A recent review concludes that most studies focus on physical IPV and do not assess either sexual or psychological IPV in their analyses (Taillieu & Brownridge, 2010). Research indicates that the consequences of IPV during pregnancy and being exposed to IPV in childhood vary according to the type of IPV the mother has been subjected to. It is likely that physical, psychological, and sexual IPV have unique and independent impacts (Renner, 2009; Taillieu & Brownridge, 2010). The failure to differentiate between types of IPV and to do separate analyses of each type may explain the inconsistent findings concerning pregnancy outcomes and childhood exposure. There are also some indications that women who are victims of sexual IPV may not consider themselves physically abused (McFarlane et al., 2002). In addition, many of the findings on consequences to the fetus or baby of IPV during pregnancy and children’s exposure to IPV are hampered by the fact that they are based mainly on studies with convenience samples, that is, on women living in shelters or only including women whose pregnancies resulted in live births (Graham-Bermann & Edleson, 2001; Martin, Mackie, Kupper, Buescher, & Moracco, 2001). By interviewing women recruited from the police, family counseling, and shelters in Norway, we searched for a heterogeneous sample of women concerning sociodemographic variables. This was done to optimize control of the impact of such variables in the analyses of our data. We wanted to investigate mothers’ perceptions of (a) consequences for fetuses and babies and (b) children’s exposure to IPV. Applying a research design based on an interactional perspective on IPV allowed us to control for the possible impact of IPV severity, frequency, duration, injury, regularity, predictability, and mortal danger when we scrutinized the consequences of IPV for fetuses and babies and for children’s exposure to IPV (Arriaga & Capezza, 2005; Grauwiler, 2008; Sartin, Hansen, & Huss, 2006; Vatnar & Bjørkly, 2010). The main scope of this research was to develop a better understanding of the consequences for the offspring of women subjected to IPV during pregnancy and of childhood exposure to IPV. This was done within an interactional perspective and with a design geared to explore mothers’ perceptions of the possible impact of various types (physical, psychological, sexual IPV) and aspects (severity, injury, duration, frequency, predictability, etc.) of IPV. To accomplish this, we addressed two research questions: 1. Is there an association between interactional aspects (physical IPV, sexual IPV, severity, injury, duration, frequency, regularity, and predictability) of IPV during pregnancy and mothers’ perceptions of negative consequences to the fetus or the newborn baby? 2. Is there an association between interactional aspects (physical IPV, psychological IPV, sexual IPV, severity, injury, duration, frequency, regularity, predictability) of IPV a. Mothers’ perceptions of children’s risk of being exposed to IPV? b. Mothers’ reports of age of the children when at risk for exposure to IPV?

METHOD This study was approved by the Regional Norwegian Ethics Committee. Written informed consent was obtained from the participants. The interviews were carried out between April 2005 and April 2006 in eight Norwegian counties. A more detailed presentation of the study is presented elsewhere (Vatnar & Bjørkly, 2008).



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Sampling and Recruitment One of the authors (SV) contacted shelters, police, and family counseling offices. These were selected to secure recruitment from the capital of Norway, towns, and the countryside. The agencies that participated asked every woman who made contact after exposure to IPV if she would volunteer to participate in the study. Inclusion criteria for the women were as follows: (a) a minimum age of 18, (b) had contacted a shelter, the police, or a family counseling office after being subjected to IPV, and (c) had experienced IPV within 6 months preceding involvement in the study. Between April 2005 and April 2006, 214 women were invited to participate in this study. A great majority of those invited (192 or 92.9%) volunteered to take part. Among these, we were unable to establish contact with 5 women (2.6%). A further 7 (3.6%) had to cancel because of somatic illness or because they had moved to other parts of the country. Ten (5.2%) did not show up after the appointment had been made, and 13 (6.8%) had changed their minds. This resulted in a final sample of 157 participants, corresponding to 73.4% of the 214 women who initially were approached to participate. The sample was recruited from 10 shelters (n 5 73), 5 police districts (n 5 41), and 6 family counseling agencies (n 5 43). According to official records, shelters, police, and family counseling agencies cover about 85% of IPV help-seeking women in Norway (Norwegian Ministry of Justice, 2005). The latest official records were used to recruit a representative sample of help-seeking women in Norway, which included a proportional number of immigrant women and a proportional number of women who contacted the recruitment agencies (police, shelters, and family counseling). Until each subgroup related to immigration and recruitment agencies was filled up, every woman who had made contact after exposure to IPV was asked if she would volunteer to participate in the study. Once a subgroup was complete, a message was sent to the recruitment agencies to stop further recruitment of women belonging to that particular subgroup. After the recruitment was completed, the sample was statistically controlled concerning available sociodemographic variables such as age, marital status, employment, and having children. There were no significant differences between the sample and the population it was drawn from.

Subjects Eighty-seven percent (N 5 137) of the 157 women in the final sample who volunteered to participate in the study were mothers; only the mothers (N 5 137) were included in the current study. Twenty of the 157 women did not have any children. Eighty-five percent (n 5 117) of the mothers had children who were younger than 18 years old when the interview took place. Fifteen percent (n 5 20) of the mothers had children who were older than 18 years old when the interview took place. About half (45.7%) of the mothers (n 5 63) had been pregnant within the last 3 years. Mean age of the participants was 37 years (SD 5 8.96; range 5 20–74 years). High school graduation was the median education level. Mean income level of the women was identical to that of the general female population in Norway. Thirty-two percent were married or cohabitating, 26% were separated, 32% were divorced or no longer cohabitating, and 10% were unmarried or widows. Sixty percent perceived their general health as “good” or better. Ethnic Norwegians accounted for 98% of the women; the remaining 39% were born in other countries and had a non-Norwegian ethnic origin. Fifty percent


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of immigrant women came from Asia, 16% from Africa, 15% from Eastern Europe, 11% from Nordic countries, 6% from America/Oceania, and 2% from Western Europe. There was a significant correlation between country of origin in the sample and the distribution of country of origin among immigrant women in Norway in general (Kendall’s tau-b 5 .69, p , .001; Vatnar & Bjørkly, 2008). Eighty-nine percent (n 5 122) of the women had been targets of physical violence, 97.1% (n 5 133) of psychological violence, and 23.3% (n 5 32) of sexual violence.

Procedure Data were gathered in semistructured, face-to-face interviews that one of the authors (SV), a female clinical psychologist, carried out. The interviews lasted from 1 to 3 hours. A professional interpreter was used in 12 of the interviews. Because each woman had already been in contact with the actual recruitment agency, none disclosed the IPV for the first time in the research interview.

Interview Questionnaires Structured Sociodemographic Questionnaire. This 93-item questionnaire covers information about age, education, employment, income level, marital status (concerning the IPV partner), current relationship (if the woman has a new partner), housing standard, religious belief, substance abuse, mental health treatment, and social support. This questionnaire was based on the National Statistics Bureau, Statistics Norway’s Survey Level of Living (1995). Semistructured Intimate Parental Violence Questionnaire. A 229-item, multidimensional interview questionnaire for asking women about IPV was designed by the authors (Vatnar & Bjørkly, 2008). Before the interview started, each woman was informed that her information should be limited to “the partner who caused your most recent contact with a shelter, the police, or a family counseling agency.” This information was primarily aimed at the 36 women who had experienced more than one IPV relationship. Most of the interactional IPV items were developed especially for this research, but items addressing definitions and types of physical, psychological, and sexual IPV were drawn from the Conflict Tactics Scales (CTS2; Straus, 1979; Straus, Hamby, BoneyMcCoy, & Sugarman, 1996). Items addressing the last IPV incident the women had been involved in were drawn from the British Crime Survey (Mirrlees-Black, 1999). The questionnaire covered the three main categories of IPV, physical, psychological, and sexual, and each of these main categories was divided into two parts: during pregnancy and during nonchildbearing times. Every woman was interviewed about each of the categories. If she did not report any experience with any of the types of IPV in the main category, the interview moved on to the next one. The questionnaire was designed to obtain detailed information about interactional factors such as severity, injury, duration, frequency, and mortal danger for each of the types of IPV (physical, psychological, and sexual). Injuries and types of IPV were recoded by the interviewer from a range of different predefined options in the interview record form and into different score scales. These scales were based on recommendations in other published research (Bjørkly, 1993; Fottrell, 1980), and detailed operational classifications of each score of the scales were obtained by consensus between the authors before the coding started. Each fixed option in the interview record form was defined to correspond to a specific score on the relevant scale.



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Severity level was coded on a 5-point scale from no abuse, moderately severe abuse, severe abuse, very severe abuse, to extremely severe abuse. Recoding was performed separately for physical, psychological, and sexual IPV. The following are examples of each level of abuse: • Moderately severe abuse: being scratched, lied to, forced to watch pornographic films • Severe abuse: being shaken, not allowed to work, forced to put on certain clothes, objects, or substances • Very severe abuse: being hit with objects, isolated from family and friends, forced to have intercourse • Extremely severe abuse: being stabbed, threatened with being killed, forced to have intercourse with animals

Severity of injury was measured on a 5-point scale from no consequence, moderately severe consequence, severe consequence, very severe consequence, to extremely severe consequence. Examples of levels of injury include the following: • Moderately severe consequences: wounds, consumption of alcohol • Severe consequences: bruises, consumption of tablets, depression • Very severe consequences: broken bones, physical self-harm, hospitalization • Extremely severe consequences: internal hemorrhages, suicidal attempts, surgery

If the participant had been subjected to one or more of the IPV categories that was preclassified as extremely severe, she got a score of 5 on the severity scale. If no category was coded as extremely severe, but at least one category was coded as very severe, a score of 4 was given, and so on. Duration of IPV was measured on an 8-point scale from less than 6 months, between 6 and 12 months, between 1 and 2 years, between 2 and 4 years, between 4 and 6 years, between 6 and 8 years, between 8 and 10 years, to more than 10 years. Duration of IPV during pregnancy was measured on a 4-point scale: during the first trimester, during the second trimester, during the third trimester, and during all three semesters. Frequency of IPV measured on a 7-point scale from only once, occasionally but less than 4 times per year, almost every month, about 2 times a month, about once a week, twice or more a week, to daily exposure. Reports of the participant’s perception of having been in mortal danger were recorded as yes or no. Able to predict was scored on a 3-point Likert scale: never, sometimes, and always. Regularity was measured as yes or no (e.g., every week, every month, or there could be long periods of months without IPV, followed by periods with multiple episodes of IPV). Consequences to the fetus were measured as none, pregnancy complications, fetal death, and other. Consequences to the baby were measured none, stillborn, preterm baby, low birth weight, harm during delivery, and other. Data were obtained about the incidence of each woman’s child or children witnessing IPV against her by her last partner. Optional answers were never, occasionally, and frequently. Other separate questions addressed the following aspects: age of each child the first time he or she witnessed/was exposed to (a) physical, (b) psychological, and (c) sexual IPV. Another question addressed each child’s behavioral responses when he or she was exposed to each of the three main categories of IPV. Optional answers were cried, shouted, tried to defend you by attacking the aggressor, tried to defend you by getting between you and your partner, defended you verbally, called for help, and other kind of behavior. Women were also asked about their partners’ physical, psychological, and sexual victimization of children living in the family. The questions were restricted to children as subjects of violence.


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Statistical Analysis Because most of the continuous variables were not normally distributed, the Friedman test for related groups was conducted to test for possible differences in variables with more than two related samples. The chi-square test was used for nominal data and unrelated groups. Univariate and multivariate logistic regression analyses were conducted. Dependent variable for the logistic regression analysis were negative consequences to the fetus or not, negative consequences to the baby or not, and children exposed to IPV or not. Sociodemographic and IPV variables giving p values 1 .2 in univariate analyses were included in the multivariate models (Altman, 1991). The goodness-of-fit of the multivariate models was tested by the Hosmer-Lemeshow test. Linear regression analyses were conducted for children’s age compared to interactional IPV variables. All statistical analyses were performed using the statistical program package SPSS, version 17.0.

RESULTS Consequences to Fetus and Newborn For percentage distributions of pregnancy and mothers’ perceptions of negative consequences of physical and sexual IPV to the fetus and newborn baby, see Table 1. Multivariate logistic regression analysis of a possible association between interactional aspects of IPV during pregnancy and mothers’ reports of negative consequences to fetus showed that severity of physical IPV and injury of sexual IPV increased the risk of negative consequences to the fetus (Table 2). There were no significant associations between mothers’ reports of negative consequences to the newborn baby and interactional aspects of IPV during pregnancy, neither for severity, injury, duration of IPV, frequency, mortal danger, regularity nor sociodemographic variables (univariate logistic regression).

Children Exposed to Intimate Parental Violence Eighty-one percent of the mothers (n 5 137) reported that children had been exposed to physical IPV, 90.2% to psychological IPV, and 30.4% to sexual IPV. For mothers reporting children exposed to all three IPV categories, the frequency of children’s exposure was significantly different for physical, psychological, and sexual IPV (Friedman test, [43] 5 58.78, p # .001). The exposure to psychological IPV was more frequent than exposure to physical IPV. Sexual IPV was the least frequent IPV category that the children were exposed to. High frequency of IPV between parents increased the risk of their children being exposed to physical and psychological IPV even when controlling for sociodemographic and other interactional IPV variables. In addition, the duration of partnership increased the risk of children being exposed to physical and sexual IPV (multivariate logistic regression; Table 3). According to the mothers who had been subjected to physical IPV, 25.5% of the children had been exposed before they were 1 year old, and 40% before the age of 5. Forty-one percent had been exposed to psychological IPV before they were 1 year old, and 62.2% before the age of 5. For sexual IPV, 21.4% of the children had been exposed before 1 year old and 33.3% before the age of 5. According to the mothers, the age of exposure was significantly different for first, second, and third child for physical (Friedman test, [31] 5 36.18, p # .001) and psychological IPV (Friedman test, [36] 5 32.82, p # .001). For sexual IPV, there was no such difference (Table 4). The third child was exposed earlier to physical and to psychological IPV



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TABLE 1. Percentage Distributions of Pregnancy and Mothers’ Reports of Negative Consequences of Physical and Sexual Intimate Partner Violence (IPV) to the Fetus and Newborn Baby Physical IPV During Pregnancy (n 5 54)

Sexual IPV During Pregnancy (n 5 20)

None

59.3

75.0

Fetal death

11.1

5.0

Pregnancy complications

11.1

10.0

Other

16.7

10.0

None

49.0

75.0

Stillborn

11.3

5.0

15.1

10.0

9.4

5.0

9.4

0

Mothers (N 5 137)

Pregnancy Pregnant last 3 years

45.7

Desired pregnancy

43.7

Realized pregnant 1 month

79.7

2 months

11.6

3 months

2.9

4 months

5.8

Consequences fetus

Consequences baby

Preterma Low birth

weightb

Harm during delivery Otherc Number of children

2.17 (61.08)

Note. aPreterm 5 less than 36 weeks of bLow birth weight 5 less than 2.5 kg. cOther physical abnormalities such as

dysfunction, and so forth.

22.6

5.0

2.43 (6.90)

2.71 (61.11)

gestation. child born without anus opening, serious heart


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TABLE 2. Univariate and Multivariate Associations Between Interactional Aspects of Intimate Partner Violence (IPV) and Mothers’ Reports of Negative Consequences or Not (Baseline) to Fetus During Pregnancy Physical IPV (n 5 54)

Sexual IPV (n 5 20)

OR (95% CI)

p

OR (95% CI)

Severitya

1.80 (1.13–2.88)

.01

*

Injuryb

1.73 (0.94–3.17)

.08

2.36 (1.00–5.62)

.05

Duration of

0.88 (0.56–1.38)

.57

1.50 (0.46–4.88)

.50

0.97 (0.64–1.48)

.89

1.19 (0.71–2.00)

.52

1.20 (0.40–3.56)

.74

*

0.86 (0.28–2.58)

.78

*

0.91 (0.50–1.66)

.77

1.45 (0.42–4.94)

.56

Age

0.96 (0.88–1.04)

.31

1.03 (0.91–1.16)

.69

Education

1.0 (0.85–1.17)

.96

1.09 (0.83–1.42)

.55

Income

0.81 (0.49–1.36)

.42

0.51 (0.18–1.40)

.19

Health

1.05 (0.64–1.74)

.84

1.05 (0.43–2.59)

.91

Alcoholh

0.98 (0.69–1.39)

.91

2.15 (0.67–6.89)

.20

1.80 (1.13–2.88)

.01 2.36 (1.00–5.62)

.05

p

Univariate

IPVc Frequencyd Mortal

dangere

Regularlyf Able to

predictg

Univariate

Multivariate Severitya Injuryb

-

-

Income level

-

-

Alcoholh

-

-

Note. Univariate and multivariate logistic regression. - 5 significant variables in univariate logistic regression, but not in the multivariate logistic regression; OR 5 odds ratio; CI 5 confidence interval; * 5 same score for each woman for this variable. aSeverity level measured on a five-point scale from no abuse to extremely severe abuse. bInjury measured on a five-point scale from no consequence to extremely severe consequence. cDuration of IPV measured on a four-point scale during the first trimester, during the second trimester, during the third trimester, and during all three semesters. dFrequency of IPV measured on a seven-point scale from only once to daily. eMortal danger measured as yes or no. fRegularity measured as yes or no. gAble to predict IPV measured on a three-point scale: never, sometimes, and always. hPartner’s alcohol use, mother’s alcohol use, partner’s and mother’s use of other substances were also analysed. No substance use variables yielded significant ORs. Partner’s alcohol use was included in this table because it was within recommended limits for inclusion in multivariate models.


1.71 (0.98–2.99)

Able to


.06

Categorical 1.42 (0.99–2.04) 0.89 (0.77–1.03) 0.88 (0.59–1.32) 3.04 (0.84–10.99) 1.39 (1.06–1.81)

Marital status

Duration of partnershipf

Education

Income

Immigrant

Alcoholh .02

.09

.54

.12

.21

0.96 (0.92–1.01)

.10

.06

.06

.005

.09

.77

.24

p

Mother’s age

Univariate

2.54 (0.96–6.70)

predictf

Mortal

1.76 (1.18–2.61)

1.20 (0.97–1.49)

dangere

Frequencyd

Duration of

1.05 (0.76–1.46)

Injuryb

IPVc

1.41 (0.80–2.48)

Severitya

Univariate

OR (95% CI)

Physical IPV (n 5 122)

1.24 (0.90–1.72)

1.32 (0.34–5.08)

1.11 (0.68–1.80)

0.91 (0.76–1.10)

1.07 (0.68–1.70)

Categorical

0.93 (0.88–0.99)

0.69 (0.35–1.37)

1.38 (0.44–4.36)

1.72 (1.23–2.41)

1.23 (0.93–1.63)

1.31 (0.91–1.89)

2.83 (0.84–9.49)

OR (95% CI)

.20

.69

.68

.32

.74

.72

.02

.29

.58

.002

.15

.15

.09

p

Psychological IPV (n 5 133)

1.48 (0.92–2.37)

33.10 (0.73–113.21)

0.71 (0.40–1.27)

0.92 (0.76–1.10)

1.99 (1.01–3.93)

Categorical

0.99 (0.91–1.07)

1.33 (0.64–2.79)

0.73 (0.18–2.94)

1.22 (0.86–1.72)

1.04 (0.77–1.41)

1.06 (0.70–1.60)

*

OR (95% CI)

p

(Continued)

.10

.13

.25

.36

.05

.93

.75

.45

.66

.27

.80

.79

Sexual IPV (n 5 32)

TABLE 3. Univariate and Multivariate Associations Between Interactional Aspects of IPV and Mothers’ Reports of Children’s Exposure to Intimate Partner Violence (IPV) or Not (Baseline)

Children’s Exposure to Intimate Partner Violence 841

.01

-

.01

.05

-

-

1.85 (1.27–2.69)

.001

p

-

-

1.99 (1.01–3.93)

OR (95% CI)

p

.05

Sexual IPV (n 5 32)

Note. Univariate and multivariate logistic regression. - 5 significant variables in univariate logistic regression, but not in the multivariate logistic regression; OR 5 odds ratio; CI 5 confidence interval; * 5 same score for each woman for this variable. aSeverity level measured on a five-point scale from no abuse to extremely severe abuse. bInjury measured on a five-point scale from no consequence to extremely severe consequence. cDuration of IPV measured on a eight-point scale from less than 6 months to more than 10 years. dFrequency of IPV measured on a seven-point scale from only once to daily. eMortal danger measured as yes or no. fAble to predict IPV measured on a three-point scale: never, sometimes, and always. gDuration of partnership measured on a eight-point scale from less than 6 months to more than 10 years. hPartner’s alcohol use, mother’s alcohol use, and partner’s and mother’s use of other substances were also analysed. No substance use variables yielded significant ORs. Partner’s alcohol use was included in this table because it was within recommended limits for inclusion in multivariate models.

-

Alcoholh

1.79 (1.16–2.77)

Duration of partnershipg

Immigrant

0.94 (0.89–0.99)

Mother’s age

-

-

Able to predictf

Education

-

1.69 (1.13–2.54)

Mortal dangere

Frequencyd

-

-

Duration of

-

OR (95% CI)

Injuryb

IPVc

p

Psychological IPV (n 5 133)

Severitya

Multivariate

OR (95% CI)

Physical IPV (n 5 122)

TABLE 3. Univariate and Multivariate Associations Between Interactional Aspects of IPV and Mothers’ Reports of Children’s Exposure to Intimate Partner Violence (IPV) or Not (Baseline) (Continued)

842 Vatnar



843

TABLE 4. Percentage Distributions of Mothers’ Reports of the Age of Children When Exposed to Intimate Partner Violence (IPV) for the First Time Physical IPV

Psychological IPV

Sexual IPV

First child

19.8

35.3

18.2

Second child

16.7

40.0

0

Third child

36.6

61.1

33.3

First child

52.1

53.8

36.4

Second child

59.1

66.3

25.0

Third child

75.8

80.6

33.3

Age ,1 year

Age ,5 years

Note. Women with more than one child reported age of first time of exposure for each child.

than the first and second child. This applied to both children who were less than 1 year old when exposed for the first time, and for children who were less than 5 years old when first exposed. According to the mothers, the association between children’s ages the first time they were exposed to IPV and dimensions of IPV indicated a significant negative linear association between children’s age and the frequency of physical and psychological IPV (Table 5). According to the mothers, children used different coping strategies when exposed to IPV. Crying was the most common response. Less than 20% used any of the following coping strategies: shouted, tried to defend the mother by attacking the aggressor, tried to defend the mother by getting between the mother and her partner, defended the mother verbally, called for help, or other. We did not find any gender differences concerning coping strategies when exposed to IPV (Pearson’s chi-square) for physical, psychological, or sexual IPV nor for being first, second, or third child. Twenty-seven percent of the women who had mutual children with the perpetrator reported that the children also had been targets of his physical violence and that 37.1% had been targets of psychological IPV. None reported sexual abuse of shared children. Corresponding figures for perpetrator abuse of a child whom the woman had with another father were 12.4% for physical victimization, 21.2% for psychological victimization, and 4.1% for sexual abuse. Four percent of the women reported that the perpetrator had physically abused a child he had with another woman. The corresponding figures for psychological and sexual abuse were 5.3% and 2.2%, respectively.

DISCUSSION Main Findings Severity of physical IPV and injury of sexual IPV increased the risk of negative consequences to the fetus as reported by the mothers. There were no significant associations between interactional aspects of IPV during pregnancy and negative consequences to the


844

Vatnar

TABLE 5. The Association Between Interactional Aspects of Intimate Partner violence (IPV) and Mothers’ Reports of Children’s Age First Time Exposed to IPV Physical IPV b (SE) First child

Psychological IPV p

n 5 96

Severitya

b (SE)

p

n 5 94

Sexual IPV b (SE)

p

n 5 10

2.27 (.99)

.02

2.08 (2.62)

.46

*

.10 (.52)

.35

.16 (0.43)

.11

2.42 (1.19)

.32

Duration of IPVc

2.06 (.31)

.59

2.11 (0.34)

.27

.18 (0.98)

.71

Frequencyd

2.10 (.40)

.34

2.36 (0.47)

.001

2.25 (1.58)

.72

2.09 (.76)

.37

.03 (0.80)

.74

2.30 (2.69)

.54

Injuryb

Able to

predicte

Second child

n 5 66

Severitya

2.17 (.83)

.17

.03 (3.12)

.78

.24 (.38)

.07

.06 (0.33)

.61

Duration of IPVc

2.70 (.25)

.48

2.04 (0.29)

.72

Frequencyd

2.26 (.31)

.04

2.41 (0.37)

.001

Able to predicte

2.05 (.62)

.72

2.01 (0.74)

.95

Injuryb

Third child Severitya

n 5 66

n 5 33

-

n 5 29

-

2.25 (.90)

.20

.05 (2.70)

.79

Injuryb

.21 (.43)

.31

2.06 (0.44)

.73

Duration of IPVc

.04 (.31)

.83

2.29 (0.41)

.11

Frequencyd

2.37 (.32)

.04

2.46 (0.48)

.01

2.03 (.63)

.99

2.17 (0.83)

.33

Able to

predicte

Note. Linear regression. SE 5 standard error; * 5 same score for each woman for this variable; - 5 no age difference within this group. aSeverity level measured on a five-point scale from no abuse to extremely severe abuse. bInjury measured on a five-point scale from no consequence to extremely severe consequence. cDuration of IPV measured on an eight-point scale from less than 6 months to more than 10 years. dFrequency of IPV measured on a seven-point scale from only once to daily. eAble to predict IPV measured on a three-point scale: never, sometimes, always.



845

newborn baby. Mothers’ reports of children’s exposure to psychological IPV were more frequent than exposure to physical IPV, and sexual IPV was the least frequent IPV category cited. When sociodemographic and interactional IPV variables were controlled for, results from the analysis of the association between mothers’ reports of children being exposed or not to IPV indicated that IPV frequency increased the risk of children being exposed to physical and psychological IPV. Moreover, the longer the partnership had lasted, the higher the risk of children being exposed to physical and sexual IPV. The analysis of possible relationships between children’s age when exposed to IPV for the first time and the presence of particular interactional aspects of IPV indicated a negative linear association between children’s ages and the frequency of physical and psychological IPV. According to the mothers, low age did not protect against being exposed to severe types of IPV or injury.

Consequences to Fetus and Newborn Less than half (43.7 %) of the pregnancies in the sample were wanted pregnancies. This finding concurs with large-scale studies indicating that unintended or unplanned pregnancy is associated with IPV during pregnancy (Taillieu & Brownridge, 2010). Our finding of an association between severity of physical IPV and mothers’ perceptions of negative consequences to fetus have also been found in other studies that have focused on the relationship between severity of physical IPV and miscarriage (Bacchus et al., 2006; Campbell et al., 2007; Morland et al., 2008; Taillieu & Brownridge, 2010). Our finding of an association between injury after sexual IPV and mother’s reports of negative consequences to the fetus supports claims in other studies suggesting that research must differentiate between the various forms of IPV (Taillieu & Brownridge, 2010). Every woman reporting sexual IPV during pregnancy reported to have been subjected to the highest severity level. However, a recent review concludes that pregnant women’s reports of increased severity (of physical IPV) did not correspond to their scores on severity scales (Taillieu & Brownridge, 2010). It was suggested that because of the risk of injury to their unborn child, pregnant women may rate experiences of IPV as more severe than IPV that occurred when they were not pregnant (Taillieu & Brownridge, 2010). The finding of an association between interactional aspects of IPV and mothers’ reports of negative outcomes for the fetus in contrast to no relationship found of negative outcomes for the newborn baby emphasize the importance of not restricting research on this topic to women whose pregnancies resulted in live births (Graham-Bermann & Edleson, 2001; Martin et al., 2001). Our findings concur with several studies reporting no significant association between educational attainment and income level and the risk of IPV during pregnancy (Campbell & Lewandowski, 1997; Taillieu & Brownridge, 2010). However, pregnancy is associated with increased financial pressures and may increase a woman’s financial dependency on her male partner (Bacchus et al., 2006; Taillieu & Brownridge, 2010). We also did not find any significant associations between the use of alcohol and consequences to the fetus. Studies that have found the use of alcohol as an explanatory variable may have been biased by the selected measurement method and design. A recent review of this possible relationship found that studies reporting significant findings addressed whether partners had a “drinking problem” in general, whereas studies reporting no association asked about any drinking during the preceding months (Taillieu & Brownridge, 2010). In our sample, the women reported low rates of alcohol


846

Vatnar

use in both parties of the intimate relationship (Vatnar & Bjørkly, 2008). The use of potentially teratogenic substances that may have affected fetal outcomes was also measured. However, in this sample, the prevalence of other substance abuse was extremely low. Less than 2% of the women and less than 16% of the IPV partners were substance abusers (Vatnar & Bjørkly, 2008).

Children Exposed to Intimate Parental Violence Rates of mothers that reported children’s exposure to IPV in our study are higher than findings from other studies that have found a prevalence of children exposed to IPV of about 50% (Bourassa, 2007; Chambliss, 2008; Letourneau et al., 2007; Levendosky & GrahamBermann, 2001; Levendosky et al., 2002; Lévesque et al., 2007). Our results were more similar to studies indicating that up to 90% of children living in violent homes have witnessed violence at least once a year (Graham-Bermann et al., 2009; Graham-Bermann & Perkins, 2010). Our finding of different proportions of exposure to physical, psychological, and sexual IPV concurs with findings from other research that have reported different proportions of exposure to different severity levels and categories of IPV. Graham-Bermann et al. (2009) found that children were reported to have been present during 100% of the incidents of threats and mild IPV and 78% of incidents of severe IPV. Our inclusion of children younger than 2 years of age may also have increased the reported rates of children exposed to IPV (Bourassa, 2007; Chambliss, 2008; Letourneau et al., 2007; Levendosky & Graham-Bermann, 2001; Levendosky et al., 2002; Lévesque et al., 2007). Our results indicate that there is an association between interactional aspects of IPV and children’s risk of exposure to IPV (Arriaga & Capezza, 2005; Bell & Naugle, 2008; Briere & Jordan 2004; Cano & Vivian, 2001; Heckert & Gondolf, 2004; LanghinrichsenRohling, 2005; Mears & Visher, 2005; Messman-Moore & Long, 2003; Schwartz, 2005; Winstok, 2007). First, the frequency of physical and psychological IPV increased the risk of child exposure. Second, the duration of partnership increased the risk of child exposure to physical and sexual IPV. There was also a negative linear association between age when exposed the first time to IPV and frequency of physical and psychological IPV. Mothers reported that high proportions (40.0% physical, 62.2% psychological, and 33.3% sexual IPV) of children had been exposed to IPV before they were 5 years old. Unfortunately, low age did not protect against exposure to severe IPV or injury. Other studies indicate that the amount of IPV that children have been exposed to is related to children’s maladjustment (Graham-Bermann et al., 2009; Graham-Bermann & Perkins, 2010; Kilpatrick, 2004; Williams, 2003). Results from meta-analyses suggest that children who witness less severe forms of IPV evidence less severe symptoms than children who witness severe IPV (Graham-Bermann et al., 2009; Kilpatrick, 2004; Williams, 2003). In other studies, the history of IPV exposure and number of violent partners have been found to increase the risk of negative effects later in life (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006). Yet one characteristic of the child that was consistently associated with lower risk of negative outcome is first-time exposure after the age of 5 (Graham-Bermann et al., 2009). Studies seeking to find differences in adjustment for boys and girls exposed to IPV are not conclusive (Chan & Yeung, 2009; Evans, Davies, & DiLillo 2008). More recent reports find no gender difference in this regard (Graham-Bermann et al., 2009). This is supported by our findings of no significant gender differences concerning coping strategies. Conflicting results have been reported from research on the possible co-occurrence of IPV and parental violence against children (Lévesque et al., 2007). Studies from the 1990s



847

indicate that children in IPV families were two to three times more likely to be victims of parental violence. Later studies found a co-occurrence of 63% for physical abuse and 19% for severe physical violence (Lévesque et al., 2007). Some investigations have found physical child abuse in at least 50% of the families with recurrent IPV (Chambliss, 2008; Lévesque et al., 2007; Straus, 2001). Different designs, different assessments of IPV, and different definitions of parental violence against children such as “parental violence,” “physical abuse,” “physical child abuse,” and “severe physical violence” might explain some of the discrepancies between the results. However, compared to these studies, our results indicate lower co-occurrence for physical, psychological, and sexual violence against children, both for the couple’s children and for stepchildren. However, our results are based on self-reports from the mothers, and this may have caused underreporting. On the other hand, any kind of violence against children is forbidden by law in Norway, even forms of punishment such as being smacked or controlled slapping. This may increase parents’ awareness of avoiding violence against children. However, it might also increase the likelihood of underreporting violence against them.

Clinical, Legal, and Policy Implications Although prevalence rates vary among studies, it is clear that a substantial number of pregnant women experience IPV. In a study of women’s views of screening for IPV during pregnancy, 97% of the women screened reported that they were not embarrassed, angry, or offended when screened for the occurrence of IPV during pregnancy (Taillieu & Brownridge, 2010). When using an interactional approach, it is crucial that this kind of screening encompasses specific measurements pertaining to different categories of IPV, as well as different levels of severity and frequency. Recent studies indicate that being exposed to parents’ IPV is a stronger predictor of revictimization than being a childhood victim of physical violence (Filipas & Ullman, 2006; Kogan, 2005; Macy, 2007; Messman-Moore & Long, 2003; Vatnar & Bjørkly, 2008). Our results concur with Graham-Bermann et al.’s (2009) finding that up to 90% of children living in IPV homes have been exposed to parents’ IPV. Accordingly, children’s exposure to IPV should be an important issue when IPV help-seeking women get in contact with the support and treatment systems. Even the law and legal system should take this into consideration in custody judgments.

Methodological Limitations Findings from our sample of help-seeking women do not necessarily generalize to IPV victims outside Norway because of cultural and social differences. Even if official Norwegian records of help seeking after domestic violence may have some shortcomings, this information was used in our research because it was the closest we could get to finding adequate criteria for selecting a representative sample (Norwegian Ministry of Justice, 2005). Nonetheless, this calls for careful interpretation of the representativity of our sample. This investigation was based on women’s retrospective self-reports of IPV experiences. Only half of the women had been pregnant within the last 3 years, and this might indicate some recall bias. This limitation might be of extra concern for those 20 women who had children who were older than 18 years old when the interview took place. However, in other studies, recall bias has been associated with underreporting of IPV (Schwartz, 2005). In addition, the taboo of sexual IPV and IPV during pregnancy may be even higher than


848

Vatnar

for IPV in general. One of the women put it this way, “I didn’t seek help when I was pregnant because it would be more serious then in a way. Due to the pregnancy, I was in many respects more dependent on him, and what would it say about me if I told anyone that the guy I was pregnant with beat me up?” There are also methodological limitations connected to only interviewing the victims and not others involved in or exposed to IPV encounters, such as the partner and the children. Concerning exposure to IPV, interviewing the children may add important knowledge and different outcomes (Hungerford, Ogle, & Clements, 2010). However, this approach will exclude the youngest children, and there are also ethical obstacles in interviewing children about IPV encounters. Self-report surveys involving both partners tend to reveal higher rates of IPV and to disclose consistent differences between men and women’s perceptions of IPV (Archer, 2000; Hicks, 2006; Moore et al., 2008). Nevertheless, for ethical and safety reasons, only the women were interviewed in this study. In our opinion, the inclusion of the women’s perpetrators would have increased the risk of obtaining a biased and nonrepresentative sample of help-seeking women. If we had only included women in an IPV study who had partners willing to participate, we likely would have lost willing female participants because they feared the consequences if the researcher contacted the IPV partner. This would also raise ethical questions concerning women with partners who denied the IPV and participants living on unlisted address or under protection by the police. The fact that one researcher did all the interviews may have increased the risk of systematic measurement error. Still, analyses of the score variances yielded no indications of systematic measurement error. It is also likely that the semistructured interview with fixed response options modified this risk. Moreover, a recent review reported that higher disclosure rates were found in studies using in-person interviews conducted by a “skilled and trained” clinician and studies that included specific questions about the different types of IPV (Taillieu & Brownridge, 2010). The reliability of our investigation was also secured by the use of only one interviewer. Nonetheless, the small sample size calls for cautious interpretation and generalization because of the limited statistical power of our study. Finally, the cross-sectional design of our study has limitations concerning the measurement of the causality between variables.

Further Research Findings from this study speak to the need for additional investigation into pregnancy and IPV, as well as into children exposed to IPV. Large-scale studies with an emphasis on women’s perspectives of IPV, pregnancy, and children’s exposure are needed. To understand the complexities of IPV, research efforts must expand beyond subgroups like shelter residents to include samples of women who represent different ethnic and sociodemographic groups, have different marital status, and have been subjected to different IPV categories and interactional aspects of IPV. The evolving nature of IPV, pregnancy, and children’s exposure require longitudinal studies with opportunities to investigate chronologies and patterns of IPV before having children during pregnancy and during motherhood. Longitudinal data is fundamental for examining the interaction of individual, situational, and contextual variables. Although this design would be costly and time-consuming, it has the potential to substantially improve theory development and measurement and to contribute to new suggestions for the development of more effective prevention and support strategies.



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