IPV and Health Consequences Among CPS-Involved Caregivers: A Fixed Effects Analysis Stratified by Race and Ethnicity

Abstract

Intimate partner violence (IPV) is a public health dilemma that disproportionately affects minority women in the United States. The present study utilized data from the National Survey of Child and Adolescent Well-Being (NSCAW II) to examine the longitudinal course of IPV outcomes reported by minority women involved with Child Protective Services (CPS). Our findings highlight the heterogeneity of the relationship between IPV and mental or physical health based on race/ethnicity. Nonetheless, additional research is necessary to investigate the impact of IPV severity on physical and mental health outcomes to ultimately facilitate race-specific interventions for women involved with CPS.

Keywords

intimate partner violence minority women

Introduction

Intimate partner violence (IPV) is a significant public health dilemma affecting the lives of millions of women worldwide (Alhabib et al., 2010). Nearly one in four women in the United States experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime and reported some form of IPV-related impact (Smith et al., 2018). National estimates indicate that 33% of women involved with Child Protective Services (CPS) experienced IPV in the year preceding their involvement with CPS (Flanagan et al., 2015).

Prior empirical work suggests that women who experience IPV report worse physical and mental health outcomes that hinder their abilities to provide a safe and stable environment for their children compared with women without any experiences of IPV in the general population (Edleson, 1999; Edleson et al., 2003). In recent analyses of the National Survey of Child and Adolescent Well-Being (NSCAW), an association between women’s experience of IPV and their children’s exposure to maltreatment was identified (Dettlaff et al., 2011; Dolan et al., 2011; Hazen et al., 2004). Numerous studies have highlighted IPV as a significant predictor of child maltreatment including child verbal abuse, physical aggression, and physical punishment in families involved with CPS (Hazen et al., 2004). A few studies with male perpetrators and women victims have highlighted that IPV and child maltreatment co-occur at a rate of roughly 80% (Coulter & Mercado-Crespo, 2015; Hazen et al., 2004; Jouriles et al., 2008). These studies further revealed that IPV is often underreported in households with child welfare involvement for a variety of possible reasons, including mothers being wary of researchers and trying to hide the fact that they were experiencing IPV (Hazen et al., 2004; Jouriles et al., 2008).

Although most maltreatment research has relied on cross-sectional comparisons between depressed and non-depressed mothers, previous observational studies have identified an association between emotional distress and poor parenting. Studies that collected temporally sequenced data on depression and maltreatment highlighted that IPV victimization and depression are highly prevalent among female caregivers involved with CPS (Connelly et al., 2006). Recently, NSCAW studies exploring the impact of maternal depression on child outcomes following a maltreatment investigation indicated that maternal depression is positively associated with maternal perpetration of psychological aggression, hence compromising mothers’ abilities to meet the needs of their children, leading to neglect and lower levels of attachment (Buchbinder, 2004; Humphreys et al., 2002; Levendosky & Graham-Bermann, 2001; McIntosh, 2003).

Racial minorities are a large and an increasingly growing portion of the U.S. population, comprising nearly 40% of Americans in 2018 (U.S. Census Bureau, 2019). Within the context of IPV, more prominent disparities for health conditions occur among racial minority groups correlated with the intersection of IPV and race, socioeconomic status, and foreign-born status (Centers for Disease Control and Prevention [CDC], 2014). Extant research demonstrates that racial minorities are disproportionately affected by IPV (Breiding et al., 2014). In a national study assessing the risk for IPV victimization, minority women were found to have greater odds of experiencing IPV compared with White women (Millett et al., 2015). Women who identify as Native American, Multiracial, Hispanic, and African American report significantly higher rates of IPV victimization (Black et al., 2011). For example, Multiracial non-Hispanic women were found to have more than 50% greater risk of IPV victimization than their White-born counterparts (Black et al., 2011). In a national study that assessed the risk of IPV victimization, four of 10 African American women (43.7%) and 37.3% of Hispanic women were found to be victimized (Black et al., 2011). The same study found that foreign-born women tend to be considered marginalized populations and are more likely to experience IPV compared with U.S.-born women (Black et al., 2011).

Past research has recorded significant racial and ethnic disparities in the child welfare system, particularly focusing on the overrepresentation of certain racial populations (Padilla & Summers, 2011; Wells, 2011). Although some racial and ethnic groups in the child welfare system are overrepresented, such as children of color, other groups, such as Hispanic and Asian children, are underrepresented (Cheung & LaChapelle, 2011). It is unclear whether the underrepresentation of certain racial/ethnic groups occurs due to fewer incidents of child maltreatment among those groups—due to cultural protective factors—or if it occurs due to cultural norms that reduce the likelihood of reporting incidents of child maltreatment (Cheung & LaChapelle, 2011). Furthermore, recent reviews on child maltreatment revealed that reporters of maltreatment often base their suspicions on racial biases. In addition, staff of government agencies may have more contact with minority families looking for governmental benefits or services. The greater visibility of ethnic minority families may cause them to be directed to the child welfare system at an increased rate compared with other families (Cheung & LaChapelle, 2011; Padilla & Summers, 2011).

Poverty and subsequent household stress are documented correlates of IPV (Jewkes, 2002). Racial minority women are more likely to have lower levels of education, live in poverty, and have less access to health care and insurance, which further exacerbates the consequences of IPV (Campbell et al., 2002). Racial minorities often shoulder the burden of these hardships as their families are overrepresented in the percentage of the U.S. population living at or below the poverty line (Casey et al., 2017; Cunradi et al., 2000). Furthermore, minority women are more likely to experience economic and social inequities related to poverty such as lower levels of education, unemployment, and social isolation, which often limits their ability to seek help (e.g., stable and secure housing, medical care, legal assistance) (Campbell et al., 2002; Phillips et al., 2004).

Female-headed households, predominantly comprised of racial minorities, are overrepresented among the bottom tiers of federal income levels (Jackson, 2003). While previous studies have shown an association between IPV and its negative impacts on the mother’s ability to develop authority and exert control over her children, other studies have indicated that women victims are met with multiple economic hurdles (Jackson, 2003; Ulman & Straus, 2003). As such, many survivors attribute the loss of economic support and subsequent inability to provide for their children as barriers to leaving an abusive, cohabitating partner (Hendy et al., 2003).

IPV has been linked to numerous adverse physical and mental health outcomes among women of all backgrounds (Campbell et al., 2002; Dillon et al., 2013; Plichta, 2004). A recent comprehensive review found that IPV is associated with a range of adverse mental, physical, and reproductive health behaviors and consequences among women (Stockman et al., 2015). Among minority women specifically, reviews of physical health consequences of IPV highlight multiple outcomes, including gastrointestinal disorders, chronic pain, and neurological issues. Some outcomes, such as disordered eating patterns, have been especially prevalent among women who experienced physical and sexual abuse (Bryant-Davis et al., 2009; Stockman et al., 2015). The psychological consequences of IPV on minority women include an increased risk of depression, post-traumatic stress disorder (PTSD), and low self-esteem compared with their White counterparts who have experienced IPV as well as their White counterparts who have not experienced IPV (Bryant-Davis et al., 2009). Although health outcomes correlated with IPV have been reported and researched over the years, the distinct experiences of minority women in terms of their risks for health-related outcomes remain understudied. Given the experiences of Black and Latina women, it is evident throughout the literature that they are more likely to undergo depression as a mental health consequence of their IPV experience, but they use mental health services at lower rates for IPV-inflicted injuries compared with U.S.-born White women whose mental health outcomes were caused by their IPV experiences (Lucea et al., 2013).

Research on women’s IPV experiences in terms of severity and the associated health outcomes among minority women remain lagging. Empirical findings regarding IPV outcomes among minority women remain mixed. Although limited studies have used national data to explore the health outcomes experienced by minority women with a history of IPV, recent research is beginning to examine how patterns of risk vary across population groups (Stockman et al., 2015).

Past research highlights the varying rates of IPV prevalent among poor groups that tend to identify as “minorities” (Stockman et al., 2015). However, limited studies have examined IPV victimization among minority women using national data. More recently, findings from cross-sectional studies identified different patterns of IPV risk factors by race/ethnicity. Although estimates of IPV exist, little is known about the trajectory of IPV among women caregivers from racial minority groups. In other words, what are the differences in health outcomes in the context of IPV among minority women in the United States? Such an examination is crucial because understanding the extent to which female caregivers are at greater risk for one or more health outcomes may inform researchers about the existing heterogeneity among minority women involved with CPS that may hinder their abilities to provide a safe home for their children. A greater understanding of the differences in health outcomes experienced by minority women involved with CPS can inform efforts to identify existing problems and create tailored interventions appropriate to addressing them to enhance caregivers’ health and well-being.

An estimated US$3.6 trillion is spent annually because of the medical costs, lost productivity, and other costs that are associated with IPV (Peterson et al., 2018). Within the context of IPV, disparities related to race/ethnicity and socioeconomic status are more prominent for worse physical and mental health outcomes (Peterson et al., 2018). Minority women are more likely to have lower income, lower education levels, and have less access to medical care, which further aggravates the dire health consequences of IPV. Past studies have examined IPV and its aggregated health outcomes retrospectively (Bryant-Davis et al., 2009; Dillon et al., 2013; Stockman et al., 2015); however, there is no published study that focuses solely on the longitudinal course of IPV among minority women and its associated physical and mental health consequences. This study examines the longitudinal course of IPV outcomes reported by minority caregivers from a nationally representative sample of families referred to CPS. Furthermore, the study utilizes the NSCAW, a national data set, which enables us to detect changes in IPV victimization status over time, a phenomenon that has not been explored in other studies on IPV among minority women. This is one of the first reports of a national study to assess associations between IPV and long-term mental and physical health among minority women.

In this article, we provide an overview of selected physical and mental health conditions in the context of IPV among minority women (Non-Hispanic White, Black, and Hispanic) in the United States, some of whom are foreign born. Moreover, we examine changes in IPV prevalence among minority caregivers over three years. We hypothesize that the physical and mental health outcomes experienced by caregivers with a history of IPV will differ by race/ethnicity.

Method

Sample

Data were derived from three waves of the second cohort of the National Survey of Child and Adolescent Well-Being (NSCAW II). The study utilized a two-stage stratified sampling design. The first step was to select nine sampling strata consisting of the eight states with the largest Child Protective Services (CPS) caseloads and the remainder of the United States (see Dolan et al., 2011). The primary sampling units (PSUs), which for the study were defined as geographic areas that encompassed the population served by a CPS agency, were then selected within each of the nine strata. The same number of families was then sampled within each of the 83 selected PSUs. The NSCAW II study sampled cases from CPS investigations that were closed between February 2008 and April 2009 nationwide (n = 5,873). The final sample of children was representative of the national population of children, birth to 17 years of age, in families being investigated for allegations of maltreatment (Dowd et al., 2011).

The sampled cohort included both substantiated and unsubstantiated investigations, as well as cases that received family preservation services following an investigation and those who did not receive services. Face-to-face interviews with children and current caregiver by trained NSCAW practitioners were completed on average 4 months after the close of the investigation (baseline), and again approximately 18 months after investigation close (Wave 2) and 36 months after investigation close (Wave 3).

Measures

Intimate partner violence

IPV was measured using the Reduced Conflict Tactics Scale 2 (CTS2; Straus et al., 1996). At each wave, mothers were asked to report the frequency of physical violence, perpetrated by a partner, in the previous year. Violence ranged from thrown at, pushed/grabbed/shoved, and slapped, to kicked/bit/hit with fist, hit or tried to hit with an object, beat up, choked, threatened, or used a knife or gun. A dichotomous measure of IPV was created for this study: any IPV in previous year = 1 versus no IPV in previous year = 0.

Caregiver physical and mental health

The 12-item Short Form Health Survey (SF-12; Ware et al., 1996) was used to assess both physical and mental health problems. The SF-12 is a standardized score with a mean of 50 and a standard deviation of 10, with lower scores indicating greater problems. Physical health items included questions about general health, whether current physical health status or pain limited caregivers in the areas of climbing stairs or participating in regular daily living activities. Mental health items included questions about feelings of anxiety or depression and whether these feelings interfered with daily activity, energy levels, and social activities. Physical and mental health problems were coded as 1 if mothers scored less than 40 on the scales, compared with scoring at or over 40 = 0.

Family poverty

Poverty was measured by calculating the family’s income-to-needs ratio, which was estimated by dividing family income by its corresponding poverty threshold in 2009. The poverty threshold varies by family size and is based on the money necessary for the minimally accepted amounts of food, with 1.00 representing the overall poverty threshold (Bishaw & Iceland, 2003). Caregivers reported both family income and household size. This measure was dichotomous, with families at or below 100% of the poverty line = 1 and families above 100% of the poverty line = 0.

Drug and alcohol dependence

Drug or alcohol dependence was self-reported by the caregiver and was assessed using the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST-20). The AUDIT is a 10-item questionnaire that identifies alcohol dependence and risky alcohol consumption (Babor et al., 2001). Items measure the amount and frequency of alcohol intake, as well as the adverse consequences associated with drinking. The DAST-20 is a 20-item questionnaire that measures substance use and identifies individuals who are abusing psychoactive drugs (Skinner & Goldberg, 1986). Each measure was continuously coded.

Live-in partner

Mothers also reported whether they had a live-in partner at the time of the interview at each wave. Mothers who reported a cohabiting spouse, biological parent, boyfriend, girlfriend, or unmarried partner were coded 1 and all others coded 0.

Time invariant characteristics

Mothers self-reported their age, race/ethnicity, immigration status, work status, and level of educational attainment. Age was a continuous measure, while race/ethnicity was self-reported as either Black Non-Hispanic, Hispanic, White Non-Hispanic, or Other. Other was dropped from the analysis due to small numbers. Immigration status was coded as “legal resident” if mothers reported they were a legal resident of the United States, have a green card, a working visa permit, or other legal immigration documents = 1, and all others = 0. For work status, mothers who reported full-time employment were coded 1, while part-time, only when work is available, unemployed and looking for work, not working due to family responsibilities, retired, disabled, or student were coded 0. For educational attainment, mothers who reported less than high school = 1, GED or a high school diploma = 2, and some college, associate degree, bachelor’s degree or more = 3.

Placement at the time of interview was reported by mothers and cross-referenced by the caseworker, with biological placement = 1, adoptive placement = 2, and kinship placement =3. Caseworkers reported whether the family had a prior investigation for child abuse or neglect = 1 compared with no prior report = 0. Caseworkers also reported whether the evidence of abuse or neglect was substantiated, indicated, or neither substantiated nor indicated. Children were classified as having a “substantiated” maltreatment case based on the caseworker’s report of the final disposition allocated to the case. “Indicated” is a term used in some states to denote that evidence of abuse or neglect exists, but not at a sufficient level to warrant substantiating the allegations. In this study, substantiated or indicated determinations were coded 1 and all others were coded 0. The caseworker-reported Limited Maltreatment Classification System (L-MCS; Barnett et al., 1993) was used to describe allegations of abuse or neglect at the time of the investigation. Allegation type included physical abuse, sexual abuse, emotional abuse, supervision neglect, substance abusing parent, IPV exposure, or other. These categories were not mutually exclusive.

Analytic Approach

All analyses were performed using STATA Statistical Software Release 13 (Stata, 2013). Due to the NSCAW’s complex sampling design, special STATA survey commands were applied to obtain unbiased estimates of population parameters (NSCAW Research Group, 2002). All percentages were weighted for sample probabilities; therefore, percentages reported in tables. All percentages were weighted for sample probabilities; therefore, percentages reported in tables represent national estimates. Fixed-effects logistic regression was used to test the within-subject change in IPV status and mental and physical health outcomes (Allison, 2009). Both mental health and physical health problems were dichotomous measures, and therefore, we ran a series of logistic regression models with a binary outcome and multiple controls for three points in time. Five separate models were run for each outcome, stratified by racial group, that modeled a mental health problem or a physical health problem as a function of IPV while controlling for other time-variant mother and family characteristics. In our models, the fixed-effects logistic regression used each individual mother as her own control over the three waves. In other words, we were able to treat all unobserved, time-invariant mother or family characteristics as fixed, that is, locked in place (Stata, 2013).

Results

The baseline characteristics of mothers are presented in Table 1. The majority (93%) of caregivers were biological mothers of the child investigated for maltreatment. Our sample was diverse by race/ethnicity and educational attainment. The mean age of caregivers was 33 years, and the racial distribution was 49% Non-Hispanic White, 25% Hispanic, and 20% Non-Hispanic Black. Most caregivers (44%) had received a high school diploma. Neglect was the most frequent form of alleged maltreatment at the event that determined study eligibility. Allegations of supervision neglect and physical neglect were made on behalf of 49% of children. Physical abuse was alleged regarding one-fourth (27%) of the sample, while sexual and emotional abuse were alleged on behalf of 16.9 % of children. With regard to immigration status, 95% of mothers were legal residents of the United States.

Table 1.

Sample Characteristics of Mothers—Time-Invariant (N = 5,774).

	%	SE
Parent age (mean)	32.83	0.31
Parent Race
Black	20	2.73
White	49	3.92
Hispanic	25	3.17
Other	6	0.92
Parent immigration status
Legal resident	95	1.04
Not legal resident	5	1.04
Mother work status
Full-time	31	1.58
Other	69	1.58
Parent education
Less than high school	28	1.78
High school	44	1.92
More than high school	28	1.58
Placement type
Biological	93	0.85
Adoptive	2	0.27
Kinship	5	0.32
Prior CPS investigation	27	1.36
Substantiated allegation	22	1.61
Type of alleged maltreatment
Physical abuse allegation	27	1.77
Sexual abuse allegation	8	1.04
Emotional abuse allegation	9	1.54
Physical neglect allegation	12	1.29
Supervision neglect allegation	37	2.04
Other types of abuse allegation	13	1.20

Note. Sampling weights are applied. SE = standard error; CPS = Child Protective Services.

Estimates of IPV, household, and caregiver characteristics per wave of data collection are presented in Table 2. At baseline, 25% of mothers reported experiencing IPV in the previous year. During the three-wave study, reporting of IPV declined over time from 25-9%. The average number of people living in the same household was approximately three individuals per wave of data collection. Approximately 46% of mothers lived with their partners in the same household, and the majority (58%) of mothers were living in poverty during the 36-month study. At baseline, 22% of caregivers reported poor mental health outcomes and 23% reported poor physical health. Over time, the percentage of caregivers with poor mental health decreased slightly to 19%. However, physical health problems increased to 28%. Alcohol and drug dependency scores remained stable over time.

Table 2.

Maternal Depression, Physical Health, Intimate Partner Violence, Maltreating Behaviors, and Other Time-Varying Characteristics.

	Baseline	Wave 2	Wave 3
	%	%	%
Intimate partner violence	25	17	9
Household characteristics
Mean individuals in household	2.5	2.6	2.4
Live-in partner in household	48	45	44
Poverty	60	58	55
Caregiver’s characteristics
Mental health	22	16	19
Physical health	23	22	28
Mean alcohol dependency	1.4	1.5	1.3
Mean drug dependency	0.8	0.7	0.6

Note. Sampling weights are applied.

Tables 3 and 4 report the fixed-effects logistic regression results of the relationship between physical health, mental health, and IPV, which was stratified by race/ethnicity. IPV was significantly associated with maternal mental health problems for all mothers regardless of racial group in Table 3. In the first model, all women who reported IPV had 2.07 (SE = 0.50) greater odds of experiencing mental health problems compared with women with no experience of IPV. After stratifying by race, Black women (OR = 4.22, SE = 1.75) had significantly greater odds of experiencing mental health problems because of IPV compared with Black women who did not experience IPV. Poverty was significantly associated with mental health problems only after stratifying by race, whereby White women who were living in poverty had significantly greater odds (OR = 2.53, SE = 0.76) of experiencing mental health problems compared with their counterparts not living in poverty. However, Hispanic women who were living in poverty had significantly lower odds (OR = 0.22, SE = 0.16) of experiencing mental health problems compared with Hispanic women who were not living in poverty.

Table 3.

Fixed-Effects Logistic Regression Models of the Relationship Between Maternal Mental Health and Intimate Partner Violence.

	All		Black		White		Hispanic
	Un-Adj OR (SE)	Adj OR (SE)	Un-Adj OR (SE)	Adj OR (SE)	Un-Adj OR (SE)	Adj OR (SE)	Un-Adj OR (SE)	Adj OR (SE)
IPV	2.21** (.49)	2.07** (.50)	4.75** (2.05)	4.22** (1.75)	1.92* (.58)	1.66 (.58)	1.50 (.69)	1.33 (.57)
Physical health		0.80 (.22)		0.77 (.34)		0.65 (.22)		1.08 (.65)
Alcohol		1.03 (.04)		1.03 (.04)		0.99 (.03)		1.14 (.15)
Drug		1.01 (.05)		1.12 (.13)		1.03 (.06)		0.97 (.07)
Number children in HH		1.09 (.15)		0.92 (.16)		1.15 (.20)		1.61 (.54)
Poverty		0.98 (.28)		1.08 (.47)		2.53** (.76)		0.22* (.16)
Live-in partner		0.98 (.20)		0.41 (.20)		1.16 (.30)		1.08 (.64)

Note. Sampling weights are applied. OR = odd ratio; CI = confidence interval. If the CI does not include the null value (i.e., 1), then there is a statistically significant difference between groups.

p < .05. **p < .01.

Table 4.

Fixed-Effects Logistic Regression Models of the Relationship Between Maternal Physical Health and Intimate Partner Violence.

	All		Black		White		Hispanic
	Un-Adj OR (SE)	Adj OR (SE)	Un-Adj OR (SE)	Adj OR (SE)	Un-Adj OR (SE)	Adj OR (SE)	Un-Adj OR (SE)	Adj OR (SE)
IPV	1.03 (.30)	1.05 (.31)	1.31 (.62)	2.39* (1.02)	0.68 (.23)	0.58 (.20)	1.46 (.65)	1.66 (.67)
Mental health		0.85 (.24)		0.67 (.27)		0.68 (.28)		0.97 (.47)
Alcohol		.98 (.04)		0.96 (.04)		0.96 (.07)		0.96 (.17)
Drug		0.99 (.07)		0.88 (.15)		0.97 (.07)		0.99 (.10)
Number children in HH		0.94 (.11)		0.85 (.15)		0.96 (.17)		0.92 (.27)
Poverty		0.95 (.17)		0.42 (.21)		1.55 (.38)		0.68 (.35)
Live-in partner		1.58 (.37)		5.00** (1.75)		1.57 (.57)		0.54 (.35)

Note. Sampling weights are applied; OR = odd ratio; CI = confidence interval. If the CI does not include the null value (i.e., 1), then there is a statistically significant difference between groups.

p < .05. **p < .01.

IPV was only associated with physical health problems for Black mothers in Table 4. Black women who experienced IPV had 2.39 times greater odds (SE = 1.02) of experiencing physical health problems compared with Black women who did not experience IPV. Black women who were living with partners had significantly greater odds (OR = 5.00, SE = 1.75) of experiencing physical health problems compared with Black women who were not living with their partners.

Discussion

In this study, we explored the association between IPV and differences in mental and physical health outcomes among mothers involved with CPS. We hypothesized that the relationship between IPV and mental and physical health outcomes would differ by race/ethnicity. We found that non-Hispanic Black and non-Hispanic White women who experienced IPV were more likely to experience poor mental health problems, including depression and symptoms of anxiety, over time. There was no relationship between experiencing IPV and change in mental health outcomes for Hispanic mothers. These relationships changed when examining changes to physical health over time. Our results showed that only Black mothers who experienced IPV were more likely to report more physical health problems over time. There were no relationships between IPV and physical health changes for White or Hispanic mothers. These associations are consistent with previous studies that highlighted limited associations between IPV and poor physical health (Dillon et al., 2013; Golding, 1999; Stockman et al., 2015). Previous studies have reported that many women victims of IPV do not access services (Lacey & Mouzon, 2016; Lucea et al., 2013). These findings have been especially prevalent among women from different minority groups. For example, past research highlighted that Black women with an experience of IPV tend to seek medical and legal services at lower rates compared with other minority women (Lacey & Mouzon, 2016; Lucea et al., 2013). This may suggest that the underutilization of mental health resources/services among Black women with IPV experience may explain the higher odds of poor mental and physical health outcomes. Past research has also highlighted that Black women may not seek help for mental health problems, which may consequently exacerbate their mental health problems (Hien & Ruglass, 2009).

Comparisons of the stratified models of physical health problems experienced by Black, non-Hispanic White, and Hispanic women revealed some interesting findings. Black women with live-in partners were more likely to report physical health problems compared with women without live-in partners. This study’s findings support the heterogeneity of women caregivers with IPV victimization, substance abuse, and mental health across the CPS population, along with the homogeneity that emerged within ethnic and racial subpopulations. These findings support past research highlighting associations of CPS caseworkers’ perceptions of caregiver substance abuse with their own perceptions that children have experienced severe danger due to alleged maltreatment with an increased probability of CPS involvement and outcomes (Berger et al., 2010). For example, caregivers who reported substance abuse issues were more likely to be perceived as having maltreated children (Berger et al., 2010).

Our study results highlighted that Hispanic women who were living in poverty were less likely to report mental health problems compared with Hispanic women not living in poverty. Although previous research has shown an association between economic abuse and symptoms of depression, anxiety, or PTSD, the impact of poverty on mental health problems among Hispanic women has not been explored (Davila et al., 2017). Considering the influence of sociodemographic factors, acculturation, and different forms of IPV could help explain the differences noted between different minority groups of caregivers (Davila et al., 2017). In addition, this finding may be indicative of the effect of stigma on mental health disclosure among Hispanic caregivers. Although IPV is an issue affecting women across all racial and ethnic groups, it should be noted that past studies have shown a considerable difference in help-seeking behaviors among women who experience IPV. Extant literature suggests that stigma pertaining to mental illness often keeps low-income women from minority groups from seeking treatment for common mental health conditions (e.g., anxiety, depression) (Das et al., 2005; Gary, 2005). Moreover, Hispanic women are more likely to endorse stigma concerns in talking to primary care clinicians about mental health issues compared with U.S.-born White women (Alvidrez & Azocar, 1999). In addition to stigma related to mental health disclosures, previous cross-sectional studies have highlighted that minority women are less likely to access or utilize mental health services compared with White women (Ahmed & McCaw, 2010; Durfee & Messing, 2012). Although minority women are less likely to disclose mental health issues, the odds of utilizing mental health services after the disclosure of mental health problems was found to be influenced by race and ethnicity. In one study, Non-Hispanic White women were most likely to utilize mental health services within 60 days of mental health problem identification followed by Black women and Hispanic women who were least likely to utilize mental health services even after the disclosure of mental health problems (Durfee & Messing, 2012).

In comparison to our findings, previous research on Hispanic women with a history of IPV found evidence of associations between IPV victimization and mental health problems, particularly when living in poverty (Basile et al., 2015; Lara et al., 2014; Stockman et al., 2015). Previous studies that have indicated a significant association between poverty and mental health problems among Hispanic women have explored an array of mental health problems in their studies, including PTSD, which was not included in our data collection material. Although our research explored mental health consequences, the specific mental health attributes included in our examination were limited to symptoms of anxiety and depression. Compared with our study, the associations between IPV and mental health consequences in previous studies were observed using validated comprehensive measurement tools for measuring poor mental health (Dillon et al., 2013; Postmus et al., 2012). Furthermore, poverty seems to exacerbate IPV consequences except in the presence of certain individual factors like education and employment status that are regarded as protective factors enabling women to manage households despite lower financial resources (Lara et al., 2014; Postmus et al., 2012). Contrary to our findings, literature on IPV has consistently identified financial hardships as significant challenges to escaping IPV, especially among poor minority women (Dillon et al., 2013; Lara et al., 2014; Postmus et al., 2012).

Some studies have suggested that sociocultural and immigration-related factors may exacerbate the IPV victimization experiences of Hispanic caregivers (Black et al., 2015; Dillon et al., 2013; Golding, 1999). Notably, past research suggests that Hispanic women may be at greater risk of prolonged IPV in abusive relationships due to limited knowledge of mental health services or access to culturally appropriate public safety (Black et al., 2015). For Hispanic women with a history of IPV, poverty results in help-seeking barriers that may limit women’s abilities to speak up and access support. Poverty may further exacerbate the challenges and difficulties that Hispanic women appear to face after disclosing mental health problems related to IPV. Lipsky and Caetano (2007) found that Hispanic women are more likely to report to the Emergency Department compared with Black and non-Hispanic White women. One possible reason for this may be due to the difficulties that minority women face in the utilization of resources and services for IPV survivors (Lipsky & Caetano, 2007).

Limitations

The findings of our study should be interpreted with the following limitations in mind. First, we were unable to measure the full scope of IPV types, such as sexual and emotional violence. It is reasonable to assume that rates of these types of IPV will vary by race and ethnicity and differentially affect maternal well-being (Stockman et al., 2015). Second, we did not examine the association between the severity of IPV and the health outcomes experienced by women affected by IPV; however, we assume that those will vary based on race/ethnicity and IPV type. Likewise, due to a small number of cases, we were limited in the number of different racial groups that we could stratify and analyze. Third, our study can only be generalized to families involved with CPS in the United States (Dillon et al., 2013). This may limit the validity of results among different families outside the scope of CPS as there may be systematic differences among minority families who are investigated for child maltreatment compared with those who are not. The NSCAW’s data underestimate the prevalence of child maltreatment in the general population, since many maltreated children are not reported or investigated (Fallon et al., 2010).

When interpreting the findings of this study, it is important to also note that we cannot determine direct cause-and-effect relationships. Although certain sociodemographic factors (such as poverty) were linked to mental health problems for Non-Hispanic White mothers, they were found to be protective for Hispanic mothers. Thus, other interpersonal, sociodemographic, and sociopolitical factors need to be considered when attempting to understand the factors that are associated with poor health outcomes among minority women. In addition, as with all self-reported retrospective measures, the data gathered for this research may have been biased due to recall problems, response distortion caused by social desirability bias, reluctance to report certain personal problems (e.g., emotional symptoms), and fear of overstepping cultural boundaries (including the discussion of mental health problems).

Notwithstanding these limitations, the specific strengths of our study merit mention. First, our analysis examined the relationship between IPV and health outcomes over time using a within-subject statistical analysis method. A large majority of previous studies have been cross-sectional and retrospective in nature, which may increase the risk of confounding influences of other variables. Fixed-effects regression allows an examination of changes in mental and physical health over time, and how that within-subject variation changes due to changes in IPV status while removing time-invariant confounds. Our study is also among the first studies that explore the effects of IPV on caregivers’ health outcomes after stratifying by race. Furthermore, although recall and social desirability bias could be limiting factors, mothers in our study reported IPV for the previous year at three time points. This short time window should reduce recall bias compared with more retrospective studies.

Implications for Policy and Practice

Our study underscores the importance of standardized, comprehensive, and culturally relevant screening for IPV and mental and physical health outcomes for CPS-involved caregivers. Indeed, CPS employees are trained to report suspected child maltreatment, abuse, or neglect (Sankaran, 2009). Furthermore, their scope of work involves asking about exposure to conflict or violence in the household and conducting an “intimate partner violence assessment” if IPV is suspected (Sankaran, 2009). Although CPS employees could help identify cases of IPV, they only suggest filing an IPV Protection Order if a woman reported experiencing IPV that she fears would impact her children’s safety (Sankaran, 2009). Identification of IPV provides caregivers with opportunities to access critical supports (e.g., education, referrals, safety planning) which may reduce the incidence of violence, improve physical and mental health outcomes, and mitigate the negative implications of IPV exposure on children.

Many states in the United States have endeavored to formalize collaborations between CPS and IPV agencies, recognizing the salience of both systems in responding to children and families impacted by IPV and other forms of child maltreatment (DiBella et al., 2017). Typically, this collaboration involves a co-located advocate model where a trained IPV advocate is housed within child welfare offices to assist in screening and intervening in cases of child exposure to IPV (Nikolova et al., 2020). Despite the utility of such collaborations, extant research demonstrates how different priorities of both systems (i.e., IPV organizations focus on adult survivors and CPS focuses on the children and often view the caregiver as failing to protect the child from exposure to IPV) undermine their efficacy (Coulter & Mercado-Crepo, 2015; Fusco & Cahalane, 2013; Nikolova et al., 2020). More research is needed to elucidate factors that make CPS and IPV staff and organizations more amenable to collaboration despite differing perspectives on how to help families impacted by IPV and child abuse.

Our study lays the foundation for future studies looking at the health consequences of IPV among minority women involved with CPS. As our analysis did not look at the association between educational attainment, poverty, and associated health consequences, additional research is needed to examine the role that educational attainment might play in the association between poverty and acculturation and their influence on mental and physical health problems. Future studies could focus on assessing the impact of IPV severity on health outcomes among minority women involved with CPS. Certain factors, such as living in poverty with dependent children, were highlighted as a commonality between minority women experiencing IPV. Those factors are important to consider when designing interventions for ameliorating IPV within communities, particularly those of minority groups. Such findings stress the need to make financial resources accessible to minority women experiencing IPV as an important intervention.

Conclusion

There are few investigations on mental and physical health conditions in the context of IPV, and even less is known about IPV and health consequences experienced by minority women in the United States. This study attempted to fill these gaps by examining the relationship between IPV and mental and physical health changes in a sample of women involved with CPS in the United States. Our findings advance the existing literature in this area, highlighting the heterogeneity of relationships between IPV and mental or physical health for different racial and ethnic groups. More research is needed to examine the effects of poverty, minority groups, and stigma on mental health disclosures and IPV reporting. Additional research is required to advance our understanding of IPV severity and its impact on physical and mental health outcomes to ultimately facilitate race-specific interventions for women involved with the CPS.

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) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Mirvat Termos

Vithya Murugan

Author Biographies

Mirvat Termos, MPH, is a PhD student in the Department of Social Work at Saint Louis University. Her primary research interests are on women’s reproductive health and intimate partner violence, focusing on minority and immigrant populations. She has also been engaged in recent research that addresses the impact of gender-based violence on women during the COVID-19 pandemic. Through her research, she strives to impact global health policies to improve the overall health and well-being of women, particularly those living in low-middle income countries.

Vithya Murugan, PhD, is an assistant professor in the Department of Social Work at Saint Louis University. Her research interests revolve around intimate partner violence, focusing on vulnerable minority and immigrant populations. She has also been engaged in research that addresses the prevention and development of interventions aimed at intimate partner violence. In addition, she has served as a panelist at community events related to domestic violence, sexual assault, and mental health among ethnic/minority women.

Jesse J. Helton, PhD, is an associate professor in the Department of Social Work at Saint Louis University. His primary research interests include child abuse and neglect. He has also been engaged in research that addresses disability and food insecurity. In his most recent work, he analyzed data from the Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project to estimate confirmed cases of child abuse nationally while highlighting that child maltreatment is an ongoing and important public health issue.

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