Family Violence and Other Potentially Traumatic Interpersonal Events Among 9- to 17-Year-Old Children Attending an Outpatient Psychiatric Clinic

Abstract

Among children visiting child and adolescent mental health care (CAM), the prevalence of exposure to family violence (FV) is reported to exceed prevalence in community samples, as are potentially traumatic interpersonal events (IPE) outside the family. The aim of the study was to relate CAM patients’ self-reported experiences of violence exposure to their current psychiatric symptoms and to compare patients exposed to violence with patients who reported no exposure. We asked 305 consecutive 9- to 17-year-old patients in CAM about their current and previous exposure to violence in and outside of the family. Prevalence of exposure to any kind of violence was 67%. Reported exposures were 19% to IPE, 21% to FV, and 27% to both. Children exposed to both FV and IPE were more negatively affected by the events than children exposed to FV or IPE only. Children in the FV + IPE group reported more mental health symptoms than those in the no violence (33%) group. In general, IPE was related to the outcome measures only in combination with FV. Degree of violence exposure seemed to have a dose–response relationship with the diagnosis of post-traumatic stress disorder.

Keywords

child abuse children exposed to domestic violence domestic violence disclosure of domestic violence

Introduction

Many studies have shown the negative psychological and social consequences for children who are exposed to Family Violence (FV; intimate partner violence [IPV] or child abuse [CA]). Victims of CA and IPV are at a similar risk of developing externalizing and internalizing symptoms (Sternberg, Baradaran, Abbott, Lamb, & Guterman, 2006). The negative effects on children in the general population of exposure to IPV have been documented in a meta-analysis (Evans, Davies, & DiLillo, 2008), and similar effects have been shown in three meta-analyses in children who had also been subjected to CA (Chan & Yeung, 2009; Kitzman, Gaylord, Holt, & Kenny, 2003; Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003). The prevalence of exposure to violence among patients attending child and adolescent mental health care (CAM) is largely unknown, as is the relation between violence exposure (within or outside the family) and child symptomatology. For children to receive proper care and treatment, it is important that violence be identified in CAMs. Because only a few studies have been conducted on clinically referred children exposed to FV, we need to know more about the background of these children, how and where they are identified, and their clinical situation. To understand the consequences of FV, it is important to take into consideration the victimization children may also face in other domains (e.g., at school or in the neighborhood; Turner, Finkelhor, & Ormrod, 2010).

The aim of the study was, therefore, to investigate the kinds of violence CAM patients had been subjected or exposed to and whether their psychiatric symptoms were related to exposure to violence. Data were collected at intake, using a structured self-report questionnaire answered by 9- to 17-year-old patients. The data were collected by clinicians under supervision of the research team.

Definitions

IPV is defined as both acts and threats of physical or sexual violence, including psychological and emotional violence (Saltzman, Fanslow, McMahon, & Shelley, 2002) perpetrated by a current or former spouse or an intimate partner. This definition was used in the present study to express the phenomenon of IPV, regardless of the perpetrator’s sex. Following Leeb, Paulozzi, Melanson, Simon, and Arias (2008, p. 15), we defined CA (acts of commission) as “words or overt actions that cause harm, potential harm, or threat of harm to a child. Acts of commission are deliberate and intentional . . . ” The concept of domestic violence has typically referred to IPV, but has sometimes included all types of violence that can occur in families. In this study, the concept of FV is used to cover children’s exposure to IPV, CA, or a combination of the two. Although FV sometimes includes violence from strangers visiting the home, violence from older siblings toward parents or younger siblings, and violence occurring in other relationships at home, only violence between parents and their partners or perpetrated by adult caregivers against their children was included in this study. The term potentially traumatic interpersonal events (IPE) is used for the subjection of a child to violence by someone outside the family, regardless of the perpetrator’s age (Greenwald & Rubin, 1999).

Prevalence

In general populations

A recent study of physical abuse in U.S. children from birth to 17 years indicated an 8.9% lifetime prevalence and an estimated 4% past-year prevalence (Finkelhor, Vanderminden, Turner, Hamby, & Shattuck, 2014). The prevalence of sexual abuse by a caregiver was 0.1% (past year) and 0.7% (lifetime) in the same study. The prevalence of children’s exposure to IPV has been estimated to be 10% to 20% in the United States (Carlson, 2000). A majority of children subjected to child maltreatment suffer neglect (71%), followed by physical abuse (16%) and sexual abuse (9%; Myers, 2010). Children are at a greater risk of exposure to IPV during their mother’s pregnancy, and young children run a higher risk of exposure than older children (Myers, 2010). In Sweden and other Scandinavian countries, the reported exposure to CA and IPV is generally lower than in the United States. Single exposure to physical CA or IPV in Sweden is around 10%, and repeated exposure to CA is around 3% to 6% (Annerbäck, Wingren, Svedin, & Gustafsson, 2010; Janson, Jernbro, & Långberg, 2011). The anti-spanking law enacted in Sweden 1979 could partly explain the relatively low level of violence against children. According to the Swedish National Board of Health and Welfare (NBHW; 2000), the prevalence of child sexual abuse in Sweden has been reported to be 7% to 8% for girls and 1% to 3% for boys. A study on teenagers’ exposure to potentially traumatic IPEs in Sweden found a prevalence similar to IPV (11.5%; D. Nilsson, Gustafsson, & Svedin, 2010). In a Swedish population study on teenagers’ exposure to IPEs and non-IPEs, 13.6% reported that they had been beaten or wounded by an adult in the family and 11% reported that they had witnessed one family member being beaten or wounded by another (D. K. Nilsson, Gustafsson, & Svedin, 2012). Fewer than 10% of the exposed children had reported their exposure to the child protection authority (Annerbäck et al., 2010). Also internationally only few children who have experienced IPV or CA are reported to receive official attention from child protection services, and thus many children in need of CAM treatment because of traumatic experiences will probably not receive this (Gilbert et al., 2009).

CAM

Some children who have been subjected to FV will, however, be referred to CAM because of their psychiatric symptoms. Only a few studies have documented the prevalence of exposure to IPV among CAM patients. Two studies from the United States (McDonald, Jouriles, Norwood, Shinn, & Ezell, 2000; Stewart, deBlois, Meardon, & Cummings, 1980) reported a high prevalence of IPV among families of patients in CAM: 43% and 47% among children with conduct disorders and approximately 20% in general CAM populations (Ford, Gagnon, Connor, & Pearson, 2011; Olaya, Ezpeleta, de la Osa, Granero, & Doménech, 2010). In Sweden, one explorative study reported a prevalence of 21% among CAM patients (Hedtjärn, Hultmann, & Broberg, 2009), and a study in Norway found that 39% of a general CAM population was subjected to IPV (Ormhaug, Jensen, Hukkelberg, Holt, & Egeland, 2012). Taken together, the studies indicate a substantially higher prevalence of IPV exposure in CAM patients compared with children in the general population. We have found no prevalence figures for CA in CAM population.

Asking about IPV is fraught with difficulties, which have been studied in adult health care settings (Todahl & Walters, 2009). One difficulty, for example, is clinicians’ low confidence in their ability to effectively intervene with IPV. Only one study of IPV in CAM has been published, and it showed similar interviewing problems as found earlier in adult care (Hultmann, Möller, Ormhaug, & Broberg, 2014).

Consequences of Violence

Children in general

Approximately two thirds of children subjected to FV will develop symptoms, but these will be highly diverse (Kitzman et al., 2003). Three meta-analyses found small to moderate associations between exposure to FV and psychological symptoms (Chan & Yeung, 2009; Kitzman et al., 2003; Wolfe et al., 2003), and one meta-analysis found similar effects for children exposed to IPV (Evans et al., 2008). Conclusions from the meta-analyses, however, are weakened by methodological problems regarding study populations, definitions of violence, and report biases. No clear pattern emerged regarding the effects of gender or age. Schoolchildren may have school, peer, and cognitive problems and suffer from anxiety or depression (Sternberg et al., 2006). In a national sample, adolescents aged 13 to 17 years are at risk of developing post-traumatic stress disorder (PTSD) after exposure to IPV or being subjected to CA. The prevalence of PTSD was 16% after exposure to IPV and 25% after subjection to CA (McLaughlin et al., 2013).

Consequences of FV are found in the domains of internalizing (e.g., depression and anxiety) and externalizing (e.g., peer problems and aggression) problems. Associations have been found between childhood maltreatment-related PTSD and hippocampal and amygdala volumes (Woon & Hedges, 2008), and symptoms of inattention, impulsivity, and noncompliance have been connected to FV (Hungerford, Wait, Fritz, & Clements, 2012). The limited data on relations between exposure to IPV and cognitive functioning consistently show that children’s verbal abilities are especially affected (Hungerford et al., 2012). Existing data on the effects of IPV indicate a negative relationship with social competence, and recent studies show that the reactions of both preschool and school-aged children to IPV are moderated by maternal psychological functioning and parenting behavior (Hungerford et al., 2012). Two meta-analyses (Kitzman et al., 2003; Wolfe et al., 2003) and one mega-analysis (Sternberg et al., 2006) showed no gender differences with regard to the effects of FV. Only one meta-analysis of IPV found gender effects—boys showed more externalizing symptoms after exposure to domestic violence (Evans et al., 2008), a finding that was supported in a more recent review article (Wood & Sommers, 2011).

One mega-analysis showed age effects (Sternberg et al., 2006). Preschool children were at a higher risk of internalizing and externalizing symptoms, but only if they had both witnessed IPV and were victims of CA. Children aged 10 to 14 years who were victims of CA were at a higher risk of externalizing symptoms than younger children, especially if they were also exposed to IPV. In that analysis, a dose–response relationship was also found between IPV exposure and symptoms, especially internalizing symptoms (Sternberg et al., 2006).

Violence perpetrated by caregivers, whether IPV or CA, has the potential to cause more damage in children than violence from other persons (Margolin & Vickerman, 2007). Sometimes both parents, sometimes only one, are the perpetrators. The abused parent may have reduced parenting capacity (S. A. Anderson & Cramer-Benjamin, 1999), sometimes because of PTSD (Appleyard & Osofsky, 2003). In any case, the children are left with at least one caregiver who is a perpetrator and sometimes with another caregiver who is a victim, and thus unable to provide protection. From an attachment point of view, these children are caught in an impossible dilemma. They should seek protection from their caregivers, but fear of the violent parent urges them to flee. Disorganized attachment (Zeanah et al., 1999) and PTSD (Evans et al., 2008; Gilbert et al., 2009) can therefore result from both IPV and CA.

PTSD, often in combination with depression, anxiety, conduct disorder, aggression, and attention-deficit hyperactivity disorder (ADHD), is common in children exposed to FV and can exhibit a unique form of comorbidity with an increased risk of misuse of alcohol and drugs, suicide attempts, eating disorders, criminality, school problems, and dating violence (Margolin & Vickerman, 2007). These behaviors could be a form of self-medication or coping to ease the PTSD symptoms. Also children with subthreshold PTSD may demonstrate substantial distress and functional impairment (Margolin & Vickerman, 2007). If comorbid symptoms emanate from the traumatic state, it should be best to offer interventions for PTSD (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012). If exposure to IPV or CA is not detected, or if trauma symptoms are not evaluated, these children may instead receive the standard treatment for specific problems or diagnoses, and thus not recover (Margolin & Vickerman, 2007).

Among children aged 9 and above with psychiatric disorders, internalizing problems are generally more common and more severe among girls (Klein, Torpey, Bufferd, & Dyson, 2008; Weems & Silberman, 2008), and are also more likely to occur comorbidly with externalizing symptoms among girls (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Minority background in youth is also documented in many studies as a risk factor for poorer mental health status, self-reported stress, and depression, and this elevated risk may, in turn, be associated with disadvantaged environmental and social conditions, for example, poverty and exposure to community violence (E. R. Anderson & Mayes, 2010).

Few studies in the general population on children’s exposure to violence in various domains (Finkelhor, Ormrod, & Turner, 2007; Finkelhor, Ormrod, Turner, & Holt, 2009; Margolin, Vickerman, Oliver, & Gordis, 2010; Turner et al., 2010) indicate that experiencing different forms of victimization is more highly related to trauma symptoms than experiencing repeated victimization of a single type. Finkelhor suggested the concept “poly-victimization” to describe exposure to multiple forms of maltreatment or violence (Finkelhor et al., 2009). Precursors of poly-victimization are growing up in a dangerous environment, exposure to FV, neglect, and individual vulnerability (Finkelhor et al., 2009). A recent study on maltreated adolescents showed that community violence can worsen externalizing and post-traumatic symptoms (Cecil, Viding, Barker, Guiney, & McCrory, 2014). The authors conclude that the effects of maltreatment might be overestimated if the effect of community violence is not taken into account. Other researchers have described how such interpersonal traumas in childhood can result in an interrelated set of symptoms not sufficiently captured by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) PTSD diagnosis: dysregulation of affect and behavior, disturbances of attention and consciousness, distortions in attributions and interpersonal difficulties (D’Andrea et al., 2012).

Children attending CAM

Few published studies show associations between violence exposure and symptoms. One study showed that exposure to FV and/or IPE was associated with more severe externalizing symptoms than exposure to non-interpersonal traumas (e.g., accidents and losses) but not with more anxiety or depression (Ford, Gagnon, et al., 2011). Witnessing community violence, but not being directly assaulted or injured, was unrelated to symptom severity. Another study of an outpatient CAM sample showed a relationship between poly-victimization and parent-reported externalizing problems, PTSD, and clinician-rated psychosocial impairment (Ford, Wasser, & Connor, 2011). Less is known about the combined effects of FV and exposure to IPE, as studies on violence within and outside of the child’s home environment are often done separately (Margolin et al., 2010). The number of adverse childhood experiences (ACEs; Felitti et al., 1998) was related to parent-reported symptoms of PTSD in a clinical sample of children aged 2 to 12 years (Lamers-Winkelman, Willemen, & Visser, 2012).

To enhance the quality of assessment and treatment of CAM patients exposed to violence (FV) as well as violence outside the home (IPE), we need to know whether and how these children differ from other CAM patients with regard to background (i.e., age, gender, type of household), cause of referral, psychiatric symptoms, diagnoses, and general social functioning. To be able to offer children who have been exposed to violence and show symptoms of trauma adequate treatment, for example, trauma-focused therapy, the exposure needs to be reported and documented.

Aims

The aim of this study was to relate 9- to 17-year-old CAM patients’ self-reported experiences of violence exposure to their current psychiatric symptoms, and to compare patients exposed to violence (a) in the family (FV), (b) outside the family (IPE), or (c) both (FV + IPE) with patients who reported no such exposure. Our research was guided by four main questions:

Research Question 1: Do patients who report exposure to FV, IPE, or FV + IPE differ with regard to gender, age, reason for or origin of referral, habitation, custody, or migration from patients not reporting such events?

Research Question 2: Do patients’ reported impact of traumatic events differ between children exposed to FV, IPE, or FV + IPE?

Research Question 3: Do patients exposed to FV, IPE, or FV + IPE report more (or different) mental health problems than unexposed patients?

Research Question 4: Do patients exposed to FV, IPE, or FV + IPE have more or different DSM-IV disorders or lower general functioning than patients without such exposure?

Method

The study population consisted of 425 nine- to seventeen-year-old patients consecutively enrolled during an 18-month period at an outpatient CAM in a Swedish city. The age group was chosen because of their capability to self-report on traumatic life events using a questionnaire administered by clinicians with children in privacy at the first visit. The screening procedure for exposure to violence within and/or outside the family was part of a treatment study. Data regarding children’s age and sex, reason for the referral, origin of the referral, habitation, custody, and migration were obtained from medical charts. The district had more immigrants, single households, and people living on social welfare, lower average income and a higher unemployment rate compared with the city as a whole. Ethical approval was granted by the regional ethical committee in Gothenburg D.nr. 166-11.

Participants

Of the 425 patients, 110 (26%) did not answer the questionnaire. Reasons for not administering the questionnaire were not recorded but plausibly include the complexity of the intake interview, making it difficult for clinicians to introduce the questionnaire (e.g., in cases involving the loss of a loved one, suicide attempts, self-mutilation, or a generally high psychosocial risks). Ten children (2%) were excluded because of incomplete answers. Thus, the study sample comprised of 305 children (72%).

Attrition analysis

The 120 eligible children who did not participate were compared with the 305 responders (χ² tests), and they did not differ from the participants in gender, age, reason for referral, or custody. Non-responders were, however, more often born outside Sweden; χ²(df = 1, N = 418) = 8.85, p = .003, lived more often with both parents and less often with none of the parents (i.e., in foster care or residential care, etc.), χ²(df = 2, N = 422) =10.00, p = .007. Non-responders were also compared with responders on parental reports of psychiatric symptoms at intake. Responders and non-responders did not differ on the Strengths and Difficulties Questionnaire (SDQ; see “Measures” section) total problems scale (F = .782, df = 1, p < .377) or on clinician-rated global assessment of functioning (GAF; F = 1.81, df = 1, p < .180).

Teenagers (13-17 years) comprised 69% of the 305 responders (n = 211); SDQ self-reports were filled in completely by 165 teenagers (response rate = 78%), and one teenager completed the questionnaire partly. Among the 46 teenagers who did not complete the SDQ, 11 parental SDQ forms were completed. An independent-samples t test was conducted to compare the parental SDQs of responders with those of non-responders. There was no significant difference on parental SDQ scores on the total problems scale among the 145 responders (M = 14.79, SD = 5.66) and the 11 non-responders (M = 16.45, SD = 5.18; F = 2.86, df = 154, p = .092).

Statistical Analysis

Children’s reports of exposure to violence were analyzed in four groups: no violence exposure, IPE, FV, and FV + IPE. Between-groups differences in categorical data were analyzed using χ². In the χ² analyses, standardized residuals of 2 standard deviations or more were considered significant. Standard deviations between 1.5 and 2 were discussed as possibly significant. ANOVA was used to estimate differences in continuous data. Bonferroni’s test was used for post hoc analyses. SPSS version 22 was used for the analyses.

All responders answered the questions about violence, so that they could be grouped according to the aims of the study. Statistical calculations were sometimes based on fewer than 305 individuals because children failed to answer specific questions or because of lack of information in charts.

Cases were deleted pairwise. Background variables were migration (n = 3), custody (n = 1), peri-traumatic impact (n = 18), and post-traumatic impact (n = 13; of the 205 children affected by any type of violence). In the ANOVA table, cases were deleted for a specific subscale (SDQ) if more than one of the five questions was not answered (n = 45) and for the total scale if four or more questions were not answered (n = 46). Fifty-two patients (n = 52) did not receive a DSM-IV Axis 1 diagnosis but did receive a Z-diagnosis; 12 patients received no diagnosis at all; and 16 patients received a diagnosis not belonging to any of the categories under study as described below (n = 16). GAF scores were missing for 67 patients. There were no significant differences between groups (FV, IPE, FV + IPE, no exposure) for missing data on any of the instruments.

Measures

Reason for referral was generated from a 14-item list used at the time of admission. One main reason was registered for each patient. The 14 reasons were collapsed into five groups: (a) neuropsychiatric problems and/or externalizing problems (neuropsychiatric signs, school problems, oppositional conduct, developmental deviance, aggression); (b) depression, suicide attempt, or self-mutilation; (c) other internalizing problems (symptoms of anxiety, crisis reaction, eating disorder, psychosomatic problems, obsessive compulsive symptoms; (d) psychosocial risk (suspected CA, neglect, substance abuse, family relational problems); and (e) other reasons (psychotic symptoms).

Referral from was the person or institution that initiated the contact subsumed under one of the following categories: family, school, social services, health care, and other (shelters, non-governmental organizations, residential care, and others).

Habitation was categorized as living with mother and father (including alternating habitation between parents), either parent (with or without a step-parent), or no parent (i.e., foster care, residential care, etc.).

Custody was categorized as shared or one parent.

Migration was defined as child being born outside of Sweden.

Children’s self-reported exposure to violence was obtained through a somewhat modified version of the Life Incidence of Traumatic Events (LITE; Greenwald & Rubin, 1999). The instrument’s reliability has been tested and found satisfactory (Nilsson et al., 2010). IPEs on the LITE scale have been shown to be related to scores on the clinical scales on the Trauma Symptom Checklist for Children (TSCC). The modification of the LITE was undertaken to differentiate IPV and CA from IPE. One item was used to capture IPV: “seen parents hitting each other or destroying furniture.” Three items were used to capture CA: “being beaten at home,” “being tied up or locked up at home,” and “being subjected to sexual abuse at home.” Items were scored on a 1 to 3 scale (not at all, a little, a lot). In the analyses, the IPV item and the three CA items were merged into FV. To capture exposure to IPE, the three CA items were rephrased, asking whether the child had been subjected to any of these events by someone outside the family.

LITE impact

Children were also asked how much the event had upset them (not at all, a little, a lot) at the time of the event “peri-trauma,” and how much the event disturbed them (not at all, a little, a lot) at the time of the interview “post trauma.” The highest reported impact score on any item within each group (FV or IPE) was counted to document peri- and post-traumatic impact. We then subtracted post-traumatic from peri-traumatic reactions to obtain a measure of recovery from the initial stress.

Psychiatric symptoms was measured using the self-report measure SDQ (Goodman, Ford, Richards, Tatward, & Meltzer, 2000). The SDQ covers children’s problems with “emotions,” “conduct,” “peers,” and “hyperactivity.” Each symptom scale has five items and is scored 0 (never) to 2 (often), and the total symptom scale ranges from 0 to 40 points.

Results from a large Swedish study on children Grade 9 (n = 81,840) showed mean scores on the SDQ for girls: total score 11.46, emotions 3.89, conduct 1.91, peers 1.72, hyperactivity 3.93 and for boys: total score 10.35, emotions 2.10, conduct 2.37, peers 1.90, hyperactivity 3.98 (NBHW, 2012).

Functional impairment was measured using the SDQ impact scale, which measures impairment in four domains: “at home,” “with peers,” “in school,” and during “leisure time” as well as “in general” using the child’s response to the question, ‘Do the difficulties interfere with your everyday life in the following areas?” (range = 0-10 points).

Psychiatric diagnoses were obtained from the charts. Only diagnoses during the current treatment period were registered. If the patient received two or more diagnoses, the following rules were used: (a) PTSD was chosen over other diagnoses (n = 21) and (b) the diagnosis (if not PTSD) assigned at most visits to the clinic was chosen (n = 27). Diagnoses were categorized into five groups: “PTSD,” “adjustment disorders,” “other anxiety disorders,” “mood disorders,” and “ADHD and disruptive behavior disorders.” The categories, rather than specific diagnoses, were used as outcome measures, to make it possible to calculate relations in this small sample. Given that diagnoses were assigned by clinicians without using structured interviews, we also aimed for enhanced reliability by collapsing specific diagnoses into broader categories. Only PTSD was registered as a unique diagnosis because of earlier documented associations between violence exposure and trauma symptoms. In total, 80 patients were excluded from analyses regarding diagnosis. At least one DSM-IV (APA, 1994) Axis I main diagnosis was assigned by a clinician to each of 241 patients. Diagnoses were assigned after children had answered questions about violence and completed questionnaires about mental health problems. Sixteen children were excluded because their diagnoses (psychosis, n = 1; eating disorders, n = 5; mental retardation, n = 2; autism spectrum disorders, n = 8) did not fit into the chosen five categories, and were not considered to be related to exposure to violence. Fifty-two patients who were diagnosed exclusively with a Z-diagnosis on Axis IV (psychosocial and environmental problems) and the 12 patients who did not receive any diagnosis (R69.9) were also excluded from analyses of psychiatric diagnoses.

Comorbidity was defined as having diagnoses from more than one of the five categories. If, however, a child was assigned two or more diagnoses within the same category, only one diagnosis was reported and the child was not considered to suffer from comorbidity. PTSD and adjustment disorders were not considered comorbidity because adjustment disorder is often assigned until a thorough assessment concludes that criteria for PTSD are fulfilled.

Daily functioning was assessed using the clinician-rated GAF (range = 0-100) at admission, which was obtained from the chart included in the DSM-IV (APA, 1994). Higher scores indicate better function.

Results

Most of the patients (67%) reported exposure to some kind of violence (Table 1). Poly-victimization (FV + IPE) was reported by 27%, FV only by 21%, and IPE only by 19%. Poly-victimized patients less often had contact with both parents in terms of custody and habitation, were more negatively affected by the events, and reported more symptoms. A dose–response relationship seemed to exist between degree of violence exposure and PTSD diagnosis. In general, IPE was related to the outcome measures only when combined with FV.

Table 1.

Violence Exposure and Background Variables.

Characteristics	n (%)	No IPE or FV	IPE Only	FV Only	IPE and FV	Test Statistics
Violence exposure	305 (100)	100 (33)	59 (19)	63 (21)	83 (27)
Gender						χ² = 9.78 df = 3, p = .021
Female	150 (49)	47 (47)	21 (36)	40 (63)	42 (51)
			(z = −1.5)	(z = 1.6)
Male	155 (51)	53 (53)	38 (64)	23 (37)	41 (49)
			(z = 1.5)	(z = −1.6)
Age (years)						χ² = 2.54 df = 6, p = .864
9-11	75 (24)	25 (25)	18 (31)	13 (21)	19 (23)
12-14	109 (36)	36 (36)	18 (31)	26 (41)	29 (35)
15-17	121 (40)	39 (39)	23 (38)	24 (38)	35 (42)
Migration						χ² = 15.11 df = 3, p = .002
Patient born in a foreign country	62 (21)	12 (12)	10 (17)	23 (37)	17 (20)
		(z = −1.8)		(z = 2.9)
Patient born in Sweden	240 (79)	87 (88)	48 (83)	39 (63)	66 (80)
				(z = −1.5)
Missing (excluded from the analysis)	3	1	1	1
Referral from						χ² = 12.47 df = 9, p = .188
Family	130 (45)	45 (46)	25 (44)	22 (38)	38 (49)
School	55 (19)	18 (19)	17 (30)	9 (15)	11 (14)
Social service	51 (17)	15 (15)	5 (9)	16 (27)	15 (20)
Health care	55 (19)	20 (20)	10 (17)	12 (20)	13 (17)
Other (excluded from the analysis)	14	2	2	4	6
Reason for referral						χ² = 9.54 df = 6, p = .145
Neuropsychiatric and/or externalizing problems	81 (37)	27 (31)	22 (46)	9 (26)	23 (50)
Depression, suicidal attempt, or self-mutilation	82 (38)	34 (39)	15 (31)	17 (48)	16 (35)
Other internalizing symptoms	53 (25)	26 (30)	11 (23)	9 (26)	7 (15)
Psychosocial risk (excluded from the analysis)	87	9	13	21	44
Other reasons (excluded from the analysis)	2	2	0	0	0
Habitation						χ² = 33.04 df = 6, p < .001
With mother and father (together or alternating between divorced parents)	136 (44)	61 (61)	33 (56)	21 (33)	21 (25)
		(z = 2.5)			(z = −2.6)
With mother or father	133 (44)	34 (34)	22 (37)	31 (49)	46 (56)
		(z = −1.5)			(z = 1.6)
Foster care, residential care, with relatives, etc.	36 (12)	5 (5)	4 (7)	11 (18)	16 (19)
		(z = −2.0)			(z = 2.0)
Custody						χ² = 23.48 df = 3, p < .001
Shared	197 (65)	77 (78)	46 (78)	34 (54)	40 (49)
		(z = 1.5)			(z = −1.8)
Mother, father, or other only	107 (35)	23 (22)	13 (22)	29 (46)	42 (51)
		(z = −2.1)	(z = −1.7)		(z = 2.4)
Missing (excluded from the analysis)	1

Note. Standard residuals (z) are reported if 1.5 or higher. The FV group was split into three groups and IPE cases removed; CA only (n = 16), IPV only (n = 25), and IPV + CA (n = 20) to analyze specific characteristics for these groups. The analyses (χ² and Fischer’s exact test) came out with no significant results between these three groups regarding background variables. IPE = interpersonal events; FV = family violence; CA = child abuse; IPV = intimate partner violence.

Background Characteristics

The mean age in the sample was 13.5 years, and the distribution of gender was almost equal (150 girls and 155 boys; Table 1). The groups did not differ with regard to age, origin of referral, or reason for referral. Groups did, however, differ with regard to gender, migration, habitation, and custody. Children in the no violence group more often lived with both parents (z = 2.5), were less often in residential care, etc. (z = −2.0), and were less often in one-parent custody (z = −1.5) compared with the FV + IPE group (Table 1). Children in the FV group were more often born abroad (z = 2.9).

There were more boys (z = 1.5) and fewer girls (z = −1.6) in the IPE group than in the FV group, and patients in the IPE group more often lived in one-parent custody (z = −1.7) than children in the FV + IPE group (z = 2.4).

Children in the FV group were more often born abroad (z = 2.9) than children in the no violence group (z = −1.8).

Children in the FV + IPE group more often lived in residential care, institutions, foster homes, etc. (z = 2.0) than children in the no violence group (z = −2.0). Children in this group also more often had parents with single custody (z = 2.4) than children in the no violence group (z = −2.1).

Impact of Traumatic Events

Children in the FV + IPE group rated the impact of violence exposure more negatively than children in the IPE group both peri-trauma (M difference = 0.42, SD = 0.10, p = .000) and post-trauma (M difference = 0.82, SD = 0.14, p = .000; Table 2). In the FV group, the impact of violence exposure was rated more negatively than in the IPE group both peri-trauma (M difference = 0.26, SD = 0.11, p = .046) and post-trauma (M difference = 0.37, SD = 0.15, p = .044). The impact in the FV + IPE group was rated more negatively than in the FV group post-trauma (M difference = 0.45, SD = 0.14, p = .003) but not peri-trauma.

Table 2.

ANOVA: Violence Exposure and Impact Peri- and Post-Traumatic.

Violence Exposure	IPE	FV	FV + IPE	Total M (SD)	F; p
n	54	55	78	187
Impact peri-traumatic	2.46 (0.75)	2.73 (0.59)	2.88 (0.36)	2.72 (0.59)	F = 8.97; p < .001; df = 2
n	54	56	82	192
Impact post-traumatic	1.70 (0.86)	2.07 (0.85)	2.52 (0.67)	2.16 (0.85)	F = 18.48; p < .001; df = 2
n	49	53	77	179
Difference between impact score peri-and post- trauma	0.82 (0.1.38)	0.70 (0.82)	0.42 (0.66)	0.61 (0.96)	F = 2.99; p = .053; df = 2

Note. Means and (SD) shown. Range of impact scale is 1 to 3. In all, 205 children were exposed to either IPE or FV. The impact question was answered by 187 children peri-trauma and 192 children post-trauma. The impact question was answered by 179 children both peri- and post-trauma, so that difference could be measured. IPE = potentially traumatic interpersonal events; FV = family violence.

The difference in impact scores from peri- to post-trauma in the FV + IPE group decreased less than in the IPE group, but the difference was only marginally significant (M difference = 0.40, SD = 0.17, p = .067). There were no significant differences between the other groups.

Most children (n = 50) in the FV + IPE group rated the experiences of FV and IPE as equally disturbing peri-trauma, but 15 children rated FV, and 8 children rated IPE, as more disturbing peri-trauma. Post-trauma, 38 children rated the experience of FV and IPE as equally disturbing, while 25 rated FV and 10 rated IPE as more disturbing post–trauma (Fisher’s exact test [df = 4, n = 73] = 14.02, p = .003).

Self-Reported Mental Health Problems

The no violence group had the lowest, and the FV + IPE group had the highest, SDQ scores, except on the hyperactivity problems subscale, on which the FV group had the lowest scores and the IPE group the highest (Table 3).

Table 3.

ANOVA: Violence Exposure and Self-Reported SDQ.

Violence Exposure	No FV or IPE	IPE Only	FV Only	FV and IPE	Total M (SD)	F; p	n
Emotion	4.06 (2.91)	4.58 (2.97)	4.57 (2.55)	4.89 (2.21)	4.49 (2.68)	F = .84; p = .474	166
Conduct	2.13 (1.57)	2.77 (1.88)	2.72 (1.58)	3.01 (1.70)	2.61 (1.70)	F = 2.56; p = .057	166
Hyperactivity	5.02 (2.77)	5.74 (2.10)	4.97 (2.37)	5.66 (2.28)	5.33 (2.45)	F = 1.12; p = .342	166
Peer problems	1.59 (1.63)	2.63 (2.41)	2.16 (1.77)	3.00 (2.28)	2.30 (2.08)	F = 4.436; p = .006	166
Total problems	12.96 (5.94)	15.72 (5.73)	14.42 (5.64)	16.57 (4.68)	14.79 (5.66)	F = 3.91; p = .009	165
Total impact	2.79 (2.58)	3.18 (2.58)	3.00 (2.78)	2.87 (2.41)	2.94 (2.55)	F = .14; p = .938	130

Note. ns range from 130 to 166 due to missing data. SDQ = Strength and Difficulties Questionnaire; FV = family violence; IPE = potentially traumatic interpersonal events.

Children in the FV + IPE group reported more symptoms than the no violence group on the total problems scales (M difference = 3.61, SD = 1.10, p = .008) and the peer problems scale (M difference = 1.40, SD = 0.40, p = .004), and close to significantly more reports of conduct problems than the no violence group (M difference = 0.88, SD = 0.33, p = .053), but these groups did not differ in their scores on the emotion, hyperactivity, and impact scales.

DSM-IV Diagnoses and GAF

Children in the no violence group were more often diagnosed with other anxiety disorders and less often diagnosed with PTSD than children in the FV and FV + IPE group. Children in the FV group were more often diagnosed with adjustment disorder than children in the no violence group. Children in the FV group were least often diagnosed with attention-deficit or disruptive behavior disorders. Children in the FV and FV + IPE groups were more often diagnosed with PTSD than children in the no violence group (Table 4).

Table 4.

Violence Exposure Diagnosis, Comorbidity, and GAF.

Characteristics	n (%)	No IPE or FV	IPE	FV	IPE and FV	Test Statistics
Violence exposure	225 (100)	70 (31)	42 (19)	49 (22)	64 (28)
Diagnosis						χ² = 43.35 df = 12, p < .001
Posttraumatic stress disorder	37 (16)	2 (3)	4 (9)	13 (27)	18 (28)
		(z = −2.8)		(z = 1.7)	(z = 2.3)
Adjustment disorder	62 (27)	12 (17)	12 (28)	22 (45)	16 (25)
		(z = −1.7)		(z = 2.3)
Other anxiety disorder	47 (21)	22 (31)	10 (24)	6 (12)	9 (14)
		(z = 1.9)
Mood disorder	31 (14)	14 (20)	4 (9)	4 (8)	9 (14)
Attention-deficit/Disruptive behavior	48 (22)	20 (29)	12 (30)	4 (8)	12 (19)
				(z = −2.0)
Characteristics	N (%)	No IPE or FV	IPE	FV	IPE and FV	Test Statistics
Violence exposure	225 (100)	70 (31)	42 (19)	49 (22)	64 (28)
Comorbidity						χ² = 1.39 df = 3, p = .707
One diagnosis	178 (79)	58 (83)	31 (74)	38 (78)	51 (80)
Two or more diagnoses	47 (21)	12 (17)	11 (26)	11 (22)	13 (20)
Characteristics	N (%)	No IPE or FV	IPE	FV	IPE and FV	Test Statistics
Violence exposure	238 (100)	60 (25)	63 (26)	37 (16)	78 (33)
GAF						F = 4.32 df = 3, p = .005
GAF 1-100	M (SD) = 56.05 (100)	M (SD) = 58.63 (100)	M (SD) = 55.76 (100)	M (SD) = 55.41 (100)	M (SD) = 54.59 (100)

Note. n = 238 in GAF statistics due to missing data. n = 226 in diagnosis statistics due to exclusion of patients who did not receive Axis I diagnosis. GAF = General Assessment of Function; FV = family violence; IPEs = interpersonal events.

Groups did not differ with regard to comorbidity. The most prevalent comorbidity was between PTSD and mood disorder (n = 13). Other diagnostic categories were much less often combined, ranging from 0 (adjustment disorder in combination with anxiety disorders or ADHD/disruptive disorder) to 4 (mood disorder in combination with anxiety disorder). Children in the FV + IPE group received lower GAF scores than the non-exposed group (M difference = 4.04, p < .003).

Discussion

Children both exposed to IPE and subjected to FV were more burdened with the negative impact of the events both at the time of the event and at the time of the interview. They also reported more psychiatric symptoms and were more often assigned PTSD diagnoses by clinicians. Children exposed to FV only gave the impact a more negative rating than children exposed to IPE only, but this difference was not found in self- and clinician-reported psychiatric symptoms. The IPE group did not differ independently from other groups on any outcome measure. Violence-exposed children comprised a majority (67%) of this clinical population. The proportion of children exposed to FV (with or without exposure to IPE) was 48%. This figure is at least 5 times higher than the prevalence found in the general population in Sweden (Annerbäck et al., 2010; Janson et al., 2011). Our study confirms the high prevalence of exposure to FV among CAM patients found in some samples in the United States, and it exceeds previous international prevalence estimates in general CAM, ranging from 20% (Ford, Gagnon, et al., 2011) to 39% (Ormhaug et al., 2012).

Background Variables

Associations between background variables and outcome measures were found mostly among the poly-victimized patients (FV + IPE). These patients were more likely to live with none of their parents or under one-parent custody than children in the no violence group. Children living without their parents are sometimes in residential care specifically because of their exposure to FV. A strong relation between out-of-home placements and emotional, behavioral, and psychosocial impairments in a clinical sample has been reported (Ford, Connor, & Hawke, 2009). Children in the no violence group more often lived with both parents, which is a protective factor in the general population. The few reports of violence among children living with both parents in our sample, however, could also be explained to some degree by reporting bias. It could be more difficult to disclose IPV or CA when living with both parents than when living in a single household in which one parent has left the perpetrating parent.

One-parent custody might have been preceded by a dispute over the child. Custody disputes are often associated with FV (Jaffe, Crooks, & Poisson, 2003). This could explain why more children living in single-parent custody and in one-parent households were more often found in the FV + IPE group.

Children exposed to violence in their family were more often born abroad. This could be a result of stress in families who have migrated. Family stress is related to harsh parenting, as documented in another Swedish study (Janson et al., 2011). Also, corporal punishment as a form of discipline is common and socially accepted in many countries outside the Nordic countries. Cross-cultural research suggests that IPV is more common in societies with stronger ideologies of male dominance and in societies dominated by conflict and political struggle (Jewkes, 2002). Refugees in Sweden generally come from countries with these features.

Girls were more often subjected to FV than boys, who were more often subjected to IPE. No such difference has been found in most other studies except for sexual abuse (Gilbert et al., 2009). But a Swedish study found that girls were more often subjected to physical abuse and exposed to IPV than boys, who were more often subjected to bullying (Annerbäck, Sahlqvist, Svedin, Wingren, & Gustafsson, 2012). In line with previous studies (Costello et al., 2003), boys were more often assigned a diagnosis of ADHD or disruptive behavior (n = 33) than girls (n = 15), which could explain the fact that boys more often get in trouble with peers outside the family.

Impact of Violence

Patients in the FV + IPE group consistently reported a more negative impact of violence, both recalling their reactions at the time of the event and reporting their current reactions to the events. There seems to be a dose–response relationship between violence exposure and reactions.

The enduring impact of violence was higher in the FV and FV + IPE groups, possibly because violence within the family is more detrimental than violence from outside the family. This finding is in line with an ecological-transactional framework (Lynch & Cicchetti, 1998).

Psychiatric Symptoms

Poly-victimized patients reported more symptoms on the SDQ, both on the total problems scale and on the peer problems and conduct problems subscales than the no violence group. On the hyperactivity and emotion subscales also, children in the FV + IPE group reported more symptoms than the no violence group, although the differences were not statistically significant. The result indicates a dose–response relationship between violence exposure and symptoms in a clinical sample. Such a relationship has previously been documented in the general population regarding victimization and mental health (Turner, Finkelhor, & Ormrod, 2006), but a study on a clinical population found no relation between the number of ACEs and self-reported symptoms (Lamers-Winkelman et al., 2012). In another clinical CAM sample, poly-victimized children exhibited more externalizing symptoms and PTSD, but no association was found between poly-victimization and internalizing symptoms or other psychiatric diagnoses (Ford, Wasser, & Connor, 2011).

Diagnoses and General Functioning

Very few children with a PTSD diagnosis were found in the no violence and IPE groups as opposed to the FV group and the FV + IPE group. This result is in line with another study documenting a relationship between poly-victimization and PTSD (Ford, Wasser, & Connor, 2011). Other anxiety disorders were more common in the no violence group and mood disorders did not differ between groups. In the general population, associations between internalizing symptoms and exposure to FV have been found (Chan & Yeung, 2009; Evans et al., 2008), but these studies did not use psychiatric diagnoses.

Adjustment disorder diagnoses were found more often in the FV group than in the no violence group. Adjustment disorder can be viewed as a mild PTSD diagnosis. The few existing studies on clinical CAM populations of patients exposed to violence show a relationship between PTSD and FV (Luthra et al., 2009) and between PTSD and poly-victimization (Ford, Wasser, & Connor, 2011; Hickman et al., 2013; Lamers-Winkelman et al., 2012). Thus, we conclude that post-traumatic symptoms are related most strongly to FV. Our data on psychiatric diagnoses also lend further support to a dose–response relation between violence exposure and PTSD, in that PTSD was most common in the poly-victimized group (FV + IPE).

Among the 48 children diagnosed with ADHD or disruptive behavior, 33 were boys and 15 were girls—a significant difference; χ²(df = 1, n = 226) = 10.53, p = .001. The FV group as a whole consisted of 49 children and adolescents, 4 of whom (3 boys and 1 girl) had a diagnosis of ADHD or disruptive behavior. The FV + IPE group consisted of 64 children and adolescents, 12 of whom had a diagnosis of ADHD or disruptive behavior. This distribution does not differ from the expected numbers—statistically. That children and adolescents exposed to FV (with or without IPE) did not get diagnoses of ADHD or disruptive behavior more often compared with the no violence group is contrary to previous findings in both clinical (Ford, Gagnon, et al., 2011) and general populations (Chan & Yeung, 2009). Girls were, however, overrepresented in the FV group, which could explain our finding, given that girls are less often diagnosed with ADHD or disruptive disorders compared with boys (Merikangas et al., 2010). Still, teenagers in our study did self-report more conduct and peer problems compared with children in the no violence group. Contrary to findings in community studies, comorbidity did not increase with more violence exposure (FV + IPE) (Margolin et al., 2010), but again community studies did not use independent psychiatric diagnoses. Calculating diagnoses in categories, as we did in this study, restricted comorbidity. However, it saved us from “spurious” comorbidity, such as having several anxiety-disorder diagnoses.

Interestingly, the IPE group did not differ from other groups on its own. Only when combined with FV were differences between groups found.

We found no link between violence exposure and mood disorders, which has been documented in one study on clinical populations (Luthra et al., 2009) but not in another (Ford, Wasser, & Connor, 2011). The most frequently assigned secondary diagnosis to PTSD was, however, mood disorder (n = 23), and mood disorder was not calculated when it was a secondary diagnosis, which could explain this null finding.

Poly-victimized patients had lower clinician-rated GAF than those in the no violence group, adding further to our dose–response finding and that the combination of FV and IPE is the most detrimental. The between-groups differences in GAF were, however, small (only around 4 points on the 0- to 100-point scale). We are aware of no other study that has used the DSM-IV Axis 5 GAF scale on violence-exposed CAM patients, and given the very narrow range of ratings (35-80) and small standard deviation (6.87) we conclude that the GAF was not a very helpful measure.

Our finding of a higher prevalence of FV in CAM patients than in the general population is in line with other studies. Only children in the poly-victimized group showed more self-reported and clinician-rated psychiatric problems than patients who did not report violence exposure. Moreover, FV was experienced more than 2.5 years earlier (M = 7.08, SD = 3.70) than IPE (M = 9.84, SD = 3.15). Intervention targeting children’s exposure to FV could possibly eliminate some exposure to IPE.

Limitations

The sample was too small to analyze moderating and mediating variables such as gender and age. The sample was also too small to separate FV into IPV and CA, which is necessary to investigate specific effects of different types of violence. Also, it is important to analyze sexual abuse as a separate category, given the vast support for its having the most negative influence on child development. Diagnoses obtained through charts can be affected by local diagnostic cultures—in this case, a trauma-informed institution. Other important risk factors such as household dysfunction, loss, and neglect were not among the measured in this study.

We do not know the frequency and severity of the violence reported by the children, and we did not collect data on how closely in time children were exposed to FV and IPE, respectively.

Diagnoses were assigned by clinicians with no external validity check. However, because of an ongoing treatment study, the clinicians had training in administering structured clinical interviews; Kiddie-Sads-Present and Life Time Version (K-SADS), which should have increased the validity of the diagnoses they assigned. The relationships between the various diagnoses and between the diagnoses and self-reported symptoms add to the validity of the diagnoses.

Comorbidity was counted if a patient received more than one diagnosis during contact with CAM. Thus, two diagnoses could have been counted as comorbid, even if the symptoms were not present simultaneously. For patients who had undergone a structured clinical interview (such as the K-SADS), we would have chosen a more conventional definition when assigning a comorbid diagnosis.

The results of this study might be generalized to other CAM units in areas with a predominantly low socioeconomic status. Units in areas with more affluent and well-educated households and with fewer immigrants might differ in the prevalence of violence exposure both within and outside the patients’ families.

We do not have any external data validating children’s reports of violence. Children, especially those from intact families, could underreport violence in the home.

Practice Implications

We can conclude that self-rated psychological symptoms, impact of violence exposure, and clinical diagnostic evaluations all point to the importance of knowing whether a CAM patient has been exposed to violence within or outside the family. Routinely inquiring about violence is therefore recommended for CAM patients.

The high rate of PTSD and adjustment disorders shows how important it is to offer appropriate trauma-informed treatment when necessary (Silverman et al., 2008). To confirm whether the general prevalence of violence exposure among CAM patients is as high as that found in this study, more research is needed in different catchment areas.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by Swedish Research Council for Health, Working life and Welfare, Children’s Welfare Association, the Mayflower Charity Foundation for Children, and the Swedish Crime Victim Compensation and Support Authority.

Author Biographies

Ole Hultmann is a PhD student and licentiate of psychology at the Department of Psychology, University of Gothenburg, Sweden. He is also a licensed psychologist and psychotherapist, with more than 20 years of experience as a clinical psychologist at the Child and Adolescent Psychiatry Clinic at Queen Silvia Children’s Hospital in Gothenburg. His research interests include research in child psychotherapy and child maltreatment. He is currently the project leader of a randomized controlled trial (RCT) in child and adolescent mental health care.

Anders G. Broberg is a professor of clinical psychology at the Department of Psychology, University of Gothenburg, Sweden. He is also a licensed psychologist and psychotherapist, with more than 20 years of experience as a clinical psychologist at the Child and Adolescent Psychiatry Clinic at Queen Silvia Children’s Hospital in Gothenburg. His research interests are attachment and developmental psychopathology more broadly. He has more than 150 publications and is the primary author of textbooks on child clinical psychology as well as attachment, books that have been translated also to the other Nordic languages.

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