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--> 6 Health Care Interventions In the last three decades, knowledge about the short- and long-term health effects associated with abuse and neglect, combined with the advocacy efforts on behalf of victims of family violence, have stimulated health professionals to focus attention on its causes, consequences, treatment, and prevention (Alexander, 1990; Chadwick, 1994). This enhanced interest has been accompanied by an increase in the number and variety of health intervention programs (Kolko, 1996a; Infante-Rivard et al., 1989). Although individual clinicians may respond to the needs of individual patients, clinical settings and public health agencies often do not address family violence as a health and social problem (Journal of the American Medical Association, 1990; Hamberger and Saunders, 1991; Kurz, 1987; McLeer et al., 1989). Several professional associations have recommended diagnostic and treatment guidelines for family violence, but health care interventions for family violence are generally not incorporated into standard medical care, health data reporting systems, or health care reimbursement practices. In their direct contact with individual patients, who may include past, present, and future victims of family violence, health care providers have daily opportunities to screen for, diagnose, treat, and prevent individual cases of child abuse and neglect, domestic violence, and elder abuse. Estimates of the impact of family violence on the public health and the health care system indicate that family violence accounts for 39,000 physician visits each year; 28,700 emergency room visits, 21,000 hospitalizations, and 99,800 hospital days Rosenberg and Mercy, 1991). They can provide important linkages between individual health services, social support networks, community resources, and more comprehensive preventive efforts; in their roles as researchers and advocates, they can integrate their
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--> expertise in direct patient care with efforts to expand the range of health and social services available to their patients and the general population. Health care professionals interact with the legal system and the social service system as mandated reporters, forensic examiners, and expert witnesses. The health care system consists of two broad sectors: the medical care sector is focused on services for individuals, and the public health sector is concerned with community-based efforts to improve the quality of care for special groups, including the poor and persons with infectious diseases and chronic or debilitating health problems. The interventions described in this chapter are primarily medical interventions; they focus on individuals and the treatment of patients for injuries or illnesses, including mental illnesses, that may or may not be reported as consequences of family violence. The medical model includes interventions such as screening, diagnostic and therapeutic services, referrals for specialized services, and follow-up care to maintain the patient's health and prevent the recurrence of health disorders. Current violence prevention efforts in the medical care system generally focus on particular populations defined by gender, age group, or type of violence. Some efforts involve system-wide approaches that include interactions between health care providers and representatives of community agencies, advocacy groups, and the media to address family violence in the general population. Prevention efforts have usually targeted individuals rather than the family unit, with the exception of services based in family practice and some mental health settings. In contrast, prevention efforts in the public health system include programs and interventions to improve the health of the public or special populations within a community. In the last decade, the field has embraced violence as a subject within its mandate, and proponents have contributed new tools and perspectives to changing abusive and violent behavior and preventing its injurious consequences (Mercy et al., 1993). The formulation of violence as a public health issue dates to the 1985 surgeon general's Workshop on Violence and Public Health, convened by Surgeon General C. Everett Koop to encourage health professionals to begin to respond to the consequences of interpersonal violence (U.S. Department of Health and Human Services, 1986). Modeled on historical successes in controlling infectious diseases, the public health approach aims to reveal underlying patterns of violence in communities, to identify individuals and groups at risk, and to highlight and control the risk factors and behaviors that are associated with child abuse, domestic violence, and elder abuse (Rosenberg and Fenley, 1992) (Figure 6-1, Table 6-1). Oriented toward communities and prevention rather than the treatment of individuals and consequences, the public health perspective is not prominent in most of the interventions described in this book. The emphasis on proactive responses to social problems that have major health consequences has the potential to engage the public health system and individual health care providers in a
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--> FIGURE 6-1 Public health scientific method and its role in family violence research. SOURCE: Mercy et al. (1993). Copyright 1993, The People-to-People Health Foundation, Inc., Project HOPE, http://www.projhope.org/HA/. Reprinted by permission of Health Affairs. broad network designed to provide not only health care services but also referrals to others who can address the legal and social dimensions of family violence before harmful effects have occurred. The public health perspective also promotes the use of scientific knowledge and quality assurance and performance measures to achieve community health goals (see Box 6.A). The committee sees real value in a strong commitment to public health approaches to the prevention of family violence, although work in this area has a long way to go to establish viable prevention strategies and demonstrate evidence of their effectiveness. The existing research on health care interventions focuses primarily on the incidence and prevalence of abuse in specific populations, the characteristics of victims and perpetrators, and the health consequences of victimization. Although attention is most often given to the immediate impact of family violence on victim use of health services and resources, the health impact of family violence can affect different stages of development over the life course, including pregnancy outcomes and fetal development, infancy, early and middle childhood,
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--> TABLE 6-1 Public Health Strategies for Preventing Violence and Its Consequences Strategy Description Intervention Examples Change individual knowledge, skills, or attitudes Deliver information to individuals to: —Develop prosocial attitudes and beliefs; —Increase knowledge —Impart social, marketable, or professional skills —Deter criminal actions —Conflict resolution education; —Social skills training —Job skills training —Public information and education campaigns —Training of health care professionals in identification and referral of family violence victims —Parenting education —Home visitation programs for young, poor, single mothers —Family therapy Change social environment Alter the way people interact by improving their social or economic circumstances —Adult mentoring of youth —Job creation programs —Respite day care —Battered women's shelters —Economic incentives for family stability Change physical environment Modify the design, use, or availability of: — Dangerous commodities —Structures or space —Control of alcohol sales at local events; —Gun laws and restrictions (e.g., in schools) SOURCE: Modified from Mercy et al. (1993). Copyright 1993, The People-to-People Health Foundation, Inc., Project HOPE, http://www.projhope.org/HA/. Reprinted by permission of Health Affairs. adolescence, adult stages, and the latter stages of life. Family violence has been identified as a contributing factor for a broad array of fatal and nonfatal injuries and health disorders, including pregnancy and birth complications, sudden infant death syndrome, brain trauma, fractures, sexually transmitted diseases, HIV infection, depression, dissociation, psychosis, and other stress-related physical and mental disorders (Journal of the American Medical Association, 1990). Family violence has also been associated with numerous major social problems, including aggressive, violent, self-injurious, and suicidal behavior; teen pregnancy; runaway and homeless youth and adults; substance abuse; and delinquency and crime (Malinosky-Rummell and Hansen, 1993; National Research Council, 1993a; Widom, 1989a,b,c). Family violence has been identified as the causal
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--> BOX 6.A In 1991, one of the priority areas identified in the Public Health Service report Healthy People 2000 is the need for information to guide public health policy at the state, local, and national levels and to develop common health goals that can help change social norms that may contribute toward a health problem. Among its 300 goals, Healthy People 2000, in its revised form (U.S. Department of Health and Human Services, 1995), includes the following objectives related to family violence: Reverse to less than 22.6 per 1,000 children the rising incidence of maltreatment of children younger than age 18 (Baseline: 22.6 per 1,000 in 1986). Reduce rape and attempted rape of women age 12 and older to no more than 108 per 100,000 women (Baseline: 120 per 100,000 in 1986). Reduce physical abuse directed at women by male partners to no more than 27 per 1,000 couples (Baseline: 30 per 1,000 couples in 1985). Extend protocols for routinely identifying, treating, and properly referring suicide attempters, victims of sexual assault, and victims of spouse, elder, and child abuse to at least 90 percent of hospital emergency departments (Baseline data unavailable). Extend to at least 45 states implementation of unexplained child death review systems (Baseline: 33 states in 1991). Increase to at least 30 the number of states in which at least 50 percent of children identified as physically or sexually abused receive physical and mental evaluation with appropriate follow-up as a means of breaking the intergenerational cycle of abuse (Baseline data unavailable). Reduce to less than 10 percent the proportion of battered women and their children turned away from emergency housing due to the lack of space (Baseline: 40 percent in 1987). Increase to at least 50 percent the proportion of elementary and secondary schools that teach nonviolent conflict resolution skills, preferably as a part of comprehensive school health education (Baseline data unavailable). Extend coordinated, comprehensive violence prevention programs to at least 80 percent of local jurisdictions with populations over 100,000 (Baseline data unavailable). As with many of the national objectives, however, baseline and follow-up data were not available at the national level and data constraints were even more severe at state and local levels (Stoto, 1992; U.S. Department of Health and Human Services, 1995). An Institute of Medicine report has recently proposed a community health improvement process to integrate various perspectives on the determinants of health and performance monitoring and to marshal collective resources in a community to improve the health of its members (Institute of Medicine, 1997). The process includes 12 recommended prototype indicators, including the prevalence of physical abuse of women by male partners; the number of confirmed child abuse cases reported to authorities and the percentage receiving child protective services and appropriate medical care; and the existence of protocols for health care professionals to identify, treat, and properly refer suicide attempts, victims of sexual assault, and victims of spouse, elder, and child abuse.
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--> link in some health and social problems resulting from cases that involve physical injuries, withholding medication, complications of forced sex, or inability to use barrier protection. Although linkages in many other areas are uncertain and often highly individualistic, the presence of family violence as a risk factor in such an expansive range of health disorders has created strong interest in identifying medical interventions to address family violence. Evaluations of family violence treatment and prevention interventions in health care settings are not well developed in the research literature. Child maltreatment interventions are the most commonly studied services, especially mental health services and home visitation programs. Evaluations of health care provider training, identification, and screening programs are extremely rare in all three areas of family violence. Documentation of histories or reports of family violence, for either children and adults, are generally not part of medical practice. As a result, the impact of interventions on an individual's health history or on the general health of a community often is unknown. As in social service and the legal interventions, progress in evaluating the effectiveness of health care interventions is hampered by numerous methodological and design constraints. There are very few quasi-experimental or experimental studies; those that exist do not use control groups or other hallmarks of rigorous design. Rather, they are essentially individual program descriptions, with information about patient demographics and characteristics and caseload and process measures. One important exception to this observation is the set of studies that have been conducted on home visitation interventions, which are usually based in a community public health agency. These studies are some of the few evaluations of family violence interventions to use randomized assignment, rigorous assessment measures for maternal and child well-being, and lengthy follow-up periods (15 years in one study). This chapter reviews health care interventions and the available evaluations of them, first for child maltreatment, then for domestic violence, and finally for elder abuse. As discussed in Chapter 1, our decision to treat interventions according to their institutional settings necessitated somewhat arbitrary categorizations. The discussion of certain interventions would be equally appropriate in the chapters on social services or the legal system, but we have categorized as health related all interventions that occur primarily in a health care setting. The chapter includes brief descriptions of some interventions of great interest in the field that are in the early stages of development but have not been evaluated. Child Maltreatment Interventions Evidence of child maltreatment appears to health care providers as multiple and recurrent injuries, injury histories inconsistent with physical findings, and injuries inconsistent with children's developmental capability to sustain them on their own (examples of the latter are a 2-month-old infant with a fractured arm
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--> and a prepubertal child with a sexually transmitted disease). Health care providers are required under state law to report suspicions of child maltreatment to child protective service officials. The response of the health care system to child abuse and neglect involves identification of maltreatment and referral of victims and perpetrators for associated health care, social, and legal services; treatment for the immediate and long-term medical and psychological consequences; and the reporting of abuse and neglect to the appropriate investigatory authorities in order to initiate protective intervention on behalf of the child. Although all children who come to the attention of the health care system and who require medical care are treated, identification and reporting of maltreatment are inconsistent and are influenced by health care providers' awareness, training, and judgment (see the discussion of mandatory reporting in Chapter 5). As a result, some (possibly many) children do not receive appropriate services and may not be viewed as at risk for future maltreatment. Six interventions are reviewed in this section: (1) identification and screening, including the use of hospital multidisciplinary teams and the role of health care professionals as expert witnesses, (2) mental health services for child victims of physical abuse and neglect, (3) mental health services for child victims of sexual abuse, (4) mental health services for children who witness domestic violence, (5) mental health services for adult survivors of child abuse, and (6) home visitation and family support programs. The sections are keyed to the appendix tables that appear at the end of the chapter. 6A-1: Identification and Screening of Child Maltreatment1 Organizations for health care professionals have initiated training programs designed to increase knowledge for recognizing, diagnosing, documenting, and treating child abuse. The range of efforts includes integrating health care professionals into interdisciplinary multiagency teams and interventions (American Academy of Pediatrics, 1991; American Medical Association, 1992a,b, 1995); issuing guidelines for interview techniques, behavior observations, and physical examinations; and providing health care providers with information about reporting requirements and community resources for social and legal assistance to patients. Physician guides and visual diagnosis kits have been designed to assist health professionals in establishing the causes of injuries in both obvious and obscure cases of child maltreatment. Local community-based programs that unite public health and clinical settings also serve an educational and awareness-raising role. The Preventing Abuse and Neglect Through Dental Awareness (PANDA) Coalition in Missouri, for 1 See also the discussion of mandatory reporting procedures in Chapter 5.
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--> example, includes state medical, public health, and social service representatives committed to educating dental professionals about how to identify and report child abuse and neglect (Missouri Department of Health, 1995). Although evaluations have examined the impact of training about child maltreatment on the knowledge and behavior of health care providers, they have not examined links between training experiences, provider practices, service referrals, and patient outcomes. Nor have they examined the possibility that increased detection may provide diminishing returns for both child and adult victims if additional remedies are not available. As a result, the ability of health care providers and institutions to recommend appropriate care for recognized victims of family violence, monitor treatment implementation and success, and influence eventual health outcomes for children and families has yet to be adequately documented. Table 6A-1 lists the only evaluation of an identification and screening program that meets the committee's criteria for inclusion. It compared child health and rates of reported maltreatment outcomes for two groups of high-risk mothers using a screening device and a comprehensive health services program for one group and routine services for the other (Brayden et al., 1993). Although infant health improved in the treatment intervention, the comprehensive program did not alter the rates of reported abuse for high-risk mothers and was associated with an increased number of neglect reports, possibly a result of surveillance bias. The authors attribute the failure of this intervention to demonstrate reduced rates of maltreatment in part to the possibility that the psychosocial treatment of the mothers may not have been intensive enough to offset past adverse environmental influences, even though the medical aspect of the intervention improved infant health. The authors also observe that group discussions for high-risk mothers may have been a poor choice, since it may have unintentionally facilitated poor parenting practices. This evaluation suggests that improving health care provider knowledge or behavior alone may not be sufficient to influence maltreatment outcomes if the availability and efficacy of other intervention services are not considered. Hospital Multidisciplinary Teams Many health care facilities use multidisciplinary teams to improve identification and case management for victims of child maltreatment identified in hospitals. These teams are generally composed of hospital administrators, social workers, physicians, nurses, and mental health professionals who perform several roles: providing medical consultation on individual cases; assisting with the psychosocial management of the family while in crisis; initiating and coordinating outpatient care and follow-up; conducting integrated case reviews with representatives from social services and legal agencies; and educating other health care providers.
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--> The use of multidisciplinary teams has not been evaluated to assess child health outcomes. Several hospitals have now disbanded their teams because of lack of resources and smaller populations of pediatric patients. The Health Professional as Expert Witness In cases of physical or sexual abuse, the medical record that documents the history and physical examination of the victim may be the most important piece of evidence heard by the court. Physician statements and medical records can justify important exceptions to hearsay rules (which vary from state to state), thereby allowing the child to speak about the nature of the event, the circumstances, and the identifies of the persons involved (see also the discussion of improving child witnessing in Chapter 5). The health professional can collect, document, and present evidence of abuse; discuss the likelihood of maltreatment and possible perpetrators; and if necessary advocate for the child's safety and best interests. In theory, the preparation and training of health care professionals regarding expert testimony can improve their effectiveness and willingness to appear in court on behalf of patients and enhance the use of the victim's medical records as evidence (Stern, 1997). Such training may also make them better witnesses for the defense as well as better prosecution witnesses. No studies have evaluated the impact of such training programs, however, and uncertainty exists as to whether they improve collaborative efforts between health professionals and the law enforcement officials, improve the prosecution of offenders and the protection of victims, or alter long-term health outcomes for children. In addition, the absence of compensation for the time and diagnostic tests that may be involved in preparing such testimony may discourage many health professionals from participating in law enforcement actions. 6A-2: Mental Health Services for Child Victims of Physical Abuse and Neglect No consistent set of mental health consequences has been identified for children who have been maltreated (Goldson, 1987; Malinosky-Rummell and Hansen, 1993; Kolko, 1996a), although they have been reported to be developmentally delayed, have behavior disorders, and be recognizably different from their age peers in ways than cannot be attributed to physical injuries alone (Cicchetti and Carlson, 1989; Wolfe, 1987). (Note that victims of child sexual abuse are discussed in the next section.) Some children show many symptoms immediately; some show symptoms some time after the abuse; and some seem to show no visible effects of their experiences at all. Different factors may account for this variation in the emotional and mental health impact of maltreatment, including the level of parental support, cognitive-attributional perspectives, and
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--> the presence or absence of other stressful factors in the child's environment. More research is required to investigate the variability in children's responses to their experiences in order to develop effective intervention programs (Salzinger et al., 1993). Children who have been maltreated are typically referred to psychotherapy or counseling for a range of problems, including hyperactivity, impulsiveness, delinquency, aggressive or undisciplined behavior, noncompliance, social withdrawal, isolation, anxiety, phobias, and depression. They may receive any one or a combination of services (individual/group/family therapy and psychodynamic/cognitive-behavioral/psychoanalytic). Table 6A-2 lists five evaluations in this area that meet the committee's criteria for inclusion. Two of the studies involved evaluations of the impact of treating social withdrawal in preschool children who had experienced or were assessed to be at high risk for physical abuse or neglect (Fantuzzo et al., 1987, 1988). The interventions were designed to enhance positive peer social interactions in a community-based day treatment center for maltreated children that integrates comprehensive counseling and education services for parents (the Mt. Hope Family Center in Rochester, New York, provided the site for each of the studies). The evaluations indicated that the treatment group in each study achieved developmental gains, enhancement of self-concept, and positive oral and motor skills that enhanced the social behavior of the maltreated children. Although the studies included a small number of participants (in one case, only four children each in the treatment and comparison groups), they are noteworthy in their assessment of the impact of the intervention across multiple domains of child functioning and their efforts to isolate critical components of the intervention strategy (for example, experimenting with adult versus peer-initiated social interactions). Two studies by Kolko (1996a,b) involved a comparison of treatment conditions for children who had experienced physical abuse. In a comparison of two primary treatment conditions (cognitive-behavioral therapy and family therapy), both treatments appeared to reduce parental anger and force, but cognitive-behavioral therapy showed a significantly larger reduction than family therapy on these measures (Kolko, 1996a). An important observation in this study indicated that one-fifth of the cases showed heightened parental force in both the early and the late phases of treatment, suggesting a subgroup of families who were less responsive to services. In a second study, 55 cases of physically abused, school-age children were randomly assigned to one of three groups: (1) individual child and parent cognitive-behavioral therapy, (2) family therapy, or (3) routine community services (Kolko, 1996b). Relative to routine community services, both individual cognitive-behavioral and family therapy were associated with greater reductions in child-to-parent violence and children's externalizing behavior, parental distress and risk of abuse, and family conflict and cohesion, although the three conditions
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--> reported improvements across time on several of these measures. Although not statistically different, abuse recidivism rates in the three intervention conditions for children in this study were 10 percent (cognitive-behavioral therapy), 12 percent (family therapy), and 30 percent (routine community services); the rates for the participating adult caretakers were 5 percent (cognitive-behavioral therapy), 6 percent (family therapy), and 30 percent (routine community services). No significant differences between cognitive-behavioral and family therapy were observed on consumer satisfaction or maltreatment risk ratings at termination. 6A-3: Mental Health Services for Child Victims of Sexual Abuse In 1994, McCurdy and Daro estimated that 150,000 sexual abuse cases were substantiated by child protective services. Interventions in these cases include counseling programs for the child victims, treatment programs for the offenders (discussed in Chapter 5), and family therapy programs (often comparable to those discussed in section 4A-1 in Chapter 4). Prior studies indicate that between 44 and 73 percent of children who are reported as victims of sexual abuse receive some form of counseling or psychotherapy related to their victimization (Finkelhor and Berliner, 1995; Chapman and Smith, 1987; Finkelhor, 1983; Lynn et al., 1988). Other studies show that between 20 and 50 percent of victims are asymptomatic at the time of disclosure (Kendall-Tackett et al., 1993). Some children remain symptom free, others develop problems at a later developmental stage (Gomes-Schwartz et al., 1990). Furthermore, for those children who do develop symptoms, the effects vary widely (Kendall-Tackett et al., 1993). Traditional treatment of sexually abused children includes three service approaches: the lay or paraprofessional approach, which utilizes peer counseling and support groups; the group approach, which emphasizes group therapy and education; and individual counseling, which may be provided by social workers or mental health professionals (Keller et al., 1989). Treatment types include individual, family, and group interventions and what is offered depends on the child's age, level of functioning, gender, type of victimization, availability of resources in a geographic area, and the orientation of the treatment provider (Pogge and Stone, 1990; Lanyon, 1986; Keller et al., 1989). Treatment programs reflect a variety of intervention goals: to address a child's response to the abuse, to destigmatize the experience, to increase the child's self-esteem, to prevent the onset of short or long-term adverse effects, and to prevent future abuse (Kolko, 1987; James and Masjleti, 1983; Calhoun and Atkenson, 1991; Beutler et al., 1994; O'Donohue and Elliott, 1992). Outcome measures are typically comparative measures of the victim's mental health or externalizing behaviors (sexual play with other children, self-stimulation) relative to untreated victims. Several behavioral inventories and checklists are available, although other methods, such as observations of the child at
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Complete table on previous page.
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--> Intervention Citation Initial/Final Sample Size Duration of Intervention Follow-up Data Collection Results Home visits by nurses providing education about child development and nutrition compared with a prenatal-only condition and a no-visit condition; free well-child visits and transportation to clinic were provided for single, primiparous mothers of low socioeconomic status in rural New York. Olds, 1992 Olds et al., 1986, 1988, 1994, 1995 N(transportation, well-child care) = 94 N(prenatal visits) = 100 N(pre/postnatal visits) = 94 N(O) = 90; N(high-risk nurse-visited infancy) = 18 N(comparison high-risk nurse-visited pregnancy) = 22 Interviews, infant assessment, medical records, Bayley Scales, Cattel Scales, Infant Temperament Q-Sort procedure, Caldwell and Bradley Home Environment Scales, records of abuse and neglect reports Nurse-visited children lived in homes with fewer hazards for children, had 40% fewer injuries and ingestions, 45% fewer behavioral and parental coping problems noted in the physician record, and 35% fewer visits to the emergency room than the nonvisited children. Beneficial effects for visited mothers were noted in their efforts to pursue their education, employment, and reductions in subsequent unintended pregnancies. High-risk mothers (described as young, adolescent, and poor) visited during their child's infancy were less likely to be reported for child abuse and neglect (0.04) than high-risk mothers who received visits only during pregnancy (0.18). Treatment contrasts for groups at lower risk did not reach statistical significance. Home visits biweekly during the 10-month school year for 2 years. The home visitor brings a gift of a toy or book to the family each week and demonstrates how verbal interaction between children and adults can be encouraged. Provided to parents of children aged 2 years in Bermuda. Scarr and McCartney, 1988 N(X) = 78 N(O) = 39 Stanford-Binet Test of Intelligence, Bayley Scale of Mental Development, achievement test designed to assess the curriculum of the program, delay of gratification test, Infant Behavior Record, Cain-Levine Social Competence Scale, Childhood Personality Scale, parent report, Parent as Educator review, discipline techniques interview, maternal teaching test The program had few demonstrable effects on any segment of the sample, even for the socioeconomically disadvantaged. 2 years SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
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Complete table on previous page.
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--> TABLE 6B-1 Quasi-Experimental Evaluations of Domestic Violence Screening, Identification, and Medical Care Responses Intervention Citation Initial/Final Sample Size Duration of Intervention Follow-up Data Collection Results Emergency room protocol for obtaining trauma history. McLeer et al., 1989 N (female trauma patients identified as being battered preprotocol) = 5.6% Review of hospital records to measure number of women identified as battered The percentage of women identified positive for battering increased from 5.6% to 30% following staff training and institution of the protocol in the emergency room. McLeer and Anwar, 1989 N (female trauma patients identified as being battered immediately after protocol introduction) = 30% N (female trauma patients identified as being battered 8 years after the protocol was introduced, with no formal effort to continue its use in the emergency department) = 7.7% 8-year follow-up to measure rates of identification Emergency department protocol to identify battered women. Olson et al., 1996 N (female trauma patients identified as battered preprotocol) = 2.0% Review of hospital records to measure number of women identified as battered Twenty-five (2%) cases were identified as domestic violence in the baseline month, 49 (3.4%) in the chart modification month, and 49 (3.6%) in the education month. N (female trauma patients identified as battered after emergency department chart was modified to ask questions about domestic violence) = 3.4% N (female trauma patients identified as being battered after 30-day domestic violence education for emergency department staff) = 3.6%
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Complete table on previous page.
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--> Intervention Citation Initial/Final Sample Size Duration of Intervention Follow-up Data Collection Results Emergency department protocol to identify battered women. Tilden and Shepherd, 1987 N (female trauma patients identified as being battered preprotocol) = 9.72% Hospital records Enhanced knowledge and interviewing skills of nurses can lead to increased identification of battered women. N (female trauma patients identified as being battered postprotocol) = 22.97% SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
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Complete table on previous page.
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--> TABLE 6B-2 Quasi-Experimental Evaluations of Mental Health Services for Domestic Violence Victims Intervention Citation Initial/Final Sample Size Duration of Intervention Follow-up Data Collection Results Emergency room counseling by a social worker, overnight hospital stay even if not warranted by injuries, counseling after release, referrals to social services, legal services offered to women self-identified as battered. Bergman and Brismar, 1991 N(X) = 58 N(O) = 59 Use of somatic and psychiatric hospital care during 10 years before to 5 years after presentation in the emergency room The use of somatic hospital care was dramatically higher among the battered women than among the control women. No decrease in use of care by the women who entered the program during the 5-year follow-up period. 5-year follow-up Personal and vocational counseling provided to abused women in a shelter. Second treatment group received same counseling and also used a personality factors instrument. Cox and Stoltenberg, 1991 N (counseling only) = 9 N (counseling + personality instrument) = 7 N(O) = 6 Rosenberg Scale, Rotter Internal-External Locus of Control Scale, Adult Self-Expression Scale, Multiple Affect Adjective Checklist, Career Maturity Inventory The group with the personality factors instrument administration and interpretation showed significant improvement in measures of anxiety, depression, hostility, assertiveness, and self-esteem. The group with the COPS System Interest Inventory and Sixteen Personality Factors Questionnaire utilization showed no significant improvement on any of the measures. Five 2-hour modules over 2 weeks Group counseling (partly single sex and partly coed) and couples counseling formats for battered women and their spouses. Harris et al., 1988 N(group) = 23 N(couples) = 35 N(O) = 10 Profile of Mood States, Texas Social Behavior Inventory, Social Support Questionnaire, Reid-Ware Three Factor Locus of Control Scale, Conflict Tactics Scales The group program was not significantly more effective than individual couple counseling in reducing physical violence or improving the participants' level of psychological well-being. Those who received couple counseling were four times more likely to drop out of treatment than those who participated in the group program. Includes group counseling, couples counseling, and no-treatment control group; Ten weekly 3-hour sessions for groups; length of couples counseling determined by therapist on an individual basis; 6-month to 1-year posttreatment follow-up
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Complete table on previous page.
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--> Intervention Citation Initial/Final Sample Size Duration of Intervention Follow-up Data Collection Results Therapy groups for violent couples and for battering men and abused women separately, provided to couples in which the man had used violence at least two times within the past year, but where the violence did not result in injuries for which the wife sought medical attention. O'Leary et al., 1994 N = 70/37 Modified Conflict Tactics Scales, Psychological Maltreatment of Women Scale, Dyadic Adjustment Scale, Positive Feelings Questionnaire, Beck Depression Inventory, fear of husband scale, attribution of responsibility scale Participants in both forms of treatment for wife abuse reported a significant reduction in both psychological and physical aggression at posttreatment and at 1-year follow-up. No significant differences between treatments on any dependent variable. Both treatments evidenced improvement in marital quality at both posttreatment and 1-year follow-up. 14 weeks 1-year follow-up SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
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Complete table on previous page.
Representative terms from entire chapter: