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6 HEALTH CARE INTERVENTIONS
Pages 206-259

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From page 206...
... In their direct contact with individual patients, who may include past, present, and future victims of family violence, health care providers have daily opportunities to screen for, diagnose, treat, and prevent individual cases of child abuse and neglect, domestic violence, and elder abuse. Estimates of the impact of family violence on the public health and the health care system indicate that family violence accounts for 39,000 physician visits each year; 28,700 emergency room visits, 21,000 hospitalizations, and 99,800 hospital days Rosenberg and Mercy, 1991)
From page 207...
... Some efforts involve system-wide approaches that include interactions between health care providers and representatives of community agencies, advocacy groups, and the media to address family violence in the general population. Prevention efforts have usually targeted individuals rather than the family unit, with the exception of services based in family practice and some mental health settings.
From page 208...
... The existing research on health care interventions focuses primarily on the incidence and prevalence of abuse in specific populations, the characteristics of victims and perpetrators, and the health consequences of victimization. Although attention is most often given to the immediate impact of family violence on victim use of health services and resources, the health impact of family violence can affect different stages of development over the life course, including pregnancy outcomes and fetal development, infancy, early and middle childhood,
From page 209...
... Family violence has been identified as a contributing factor for a broad array of fatal and nonfatal injuries and health disorders, including pregnancy and birth complications, sudden infant death syndrome, brain trauma, fractures, sexually transmitted diseases, HIV infection, depression, dissociation, psychosis, and other stress-related physical and mental disorders (Journal of the American Medical Association, 1990)
From page 210...
... . • Extend protocols for routinely identifying, treating, and properly referring suicide attempters, victims of sexual assault, and victims of spouse, elder, and child abuse to at least 90 percent of hospital emergency departments (Baseline data unavailable)
From page 211...
... Evaluations of family violence treatment and prevention interventions in health care settings are not well developed in the research literature. Child maltreatment interventions are the most commonly studied services, especially mental health services and home visitation programs.
From page 212...
... mental health services for adult survivors of child abuse, and (6) home visitation and family support programs.
From page 213...
... Nor have they examined the possibility that increased detection may provide diminishing returns for both child and adult victims if additional remedies are not available. As a result, the ability of health care providers and institutions to recommend appropriate care for recognized victims of family violence, monitor treatment implementation and success, and influence eventual health outcomes for children and families has yet to be adequately documented.
From page 214...
... No studies have evaluated the impact of such training programs, however, and uncertainty exists as to whether they improve collaborative efforts between health professionals and the law enforcement officials, improve the prosecution of offenders and the protection of victims, or alter long-term health outcomes for children. In addition, the absence of compensation for the time and diagnostic tests that may be involved in preparing such testimony may discourage many health professionals from participating in law enforcement actions.
From page 215...
... . Relative to routine community services, both individual cognitive-behavioral and family therapy were associated with greater reductions in child-to-parent violence and children's externalizing behavior, parental distress and risk of abuse, and family conflict and cohesion, although the three conditions
From page 216...
... 6A-3: Mental Health Services for Child Victims of Sexual Abuse In 1994, McCurdy and Daro estimated that 150,000 sexual abuse cases were substantiated by child protective services. Interventions in these cases include counseling programs for the child victims, treatment programs for the offenders (discussed in Chapter 5)
From page 217...
... 6A-4: Mental Health Services for Children Who Witness Domestic Violence Whether or not they are also the victims of abuse themselves, some children who witness violence in their home or their community not only are more disturbed in their interpersonal relationships than other children, but also are at significant risk of repeating dysfunctional relationship patterns, which can contribute to a cyclic pattern of family violence (Bell and Jenkins, 1991; Zuckerman et al., 1995; Jaffe et al., 1986a,b)
From page 218...
... . Girls who witness domestic violence may also be more violent in dating relationships, but such exposure does not appear to be a significant risk factor for adult victimization.
From page 219...
... . These opportunities can assist with the development of tools to address the hard-to-count and the hard-tomeasure dimensions of family violence, child development, and family functioning, especially in high-risk environments in which young children may be disproportionately vulnerable to familial stress factors.
From page 220...
... In contrast to the parenting practices and family support services discussed in Chapter 4, home visitation is offered to families at risk of child maltreatment but who have not been reported for it; home visitation seeks to influence parenting practices during critical transitions in family life. Home visitation is a health care strategy to improve child health and development outcomes in families determined to be at risk for poor infant and child outcomes, based on risk factors of low birthweight, prematurity, young age of mother, primiparity, maternal education, poverty or low socioeconomic status, lack of maternal social support, and substance abuse (Brayden et al., 1993; Infante-Rivard et al., 1989; Seitz et al., 1985; Bennett, 1987; Brooks-Gunn, 1990; National Research Council, 1993a; Institute of Medicine, 1994)
From page 221...
... A 15-year follow-up study of the long-term effects of the original intervention indicated that the prenatal and early childhood home visitation program showed positive results, including a reduction in the number of subsequent pregnancies, the use of welfare, child abuse and neglect rates, and criminal behavior on the part of low-income, unmarried mothers (Olds et al., 1997)
From page 222...
... Despite the methodological difficulties and uncertainties about the duration of program impact on preventing child maltreatment, home visitation remains one of the most promising interventions for prevention of child abuse or neglect; there is some indication of its success with families at risk, and it would be useful to compare its benefits as a secondary (targeted) or a primary (provided to all)
From page 223...
... Most new babies and their mothers are seen in the health care setting for a prescribed routine of well-care visits, which may provide many opportunities to offer the same kinds of prevention strategies as home visitation. This strategy has not yet been evaluated, and its comparative strength relative to home visitation or other community family support services is not known.
From page 224...
... Innovative hospital-based advocacy programs are increasing in number, and medical and nursing programs are beginning to integrate family violence materials into their standard curriculum (Warshaw, 1996)
From page 225...
... Pregnancy is an important opportunity for abuse assessment and intervention. Screening for abuse prior to or during pregnancy may be effective in identifying patterns of family violence, due to the frequency and pattern of prenatal visits.
From page 226...
... In addition, health care organizations provide information to health care providers about state and federal reporting requirements, community resources to which patients may be referred for social services and legal assistance, emergency temporary custody arrangements, guidelines for testimony on abuse findings in legal proceedings, and risk management regarding legal liability. Also in 1992, the Joint Commission on Accreditation of Healthcare Organizations required emergency departments and hospital ambulatory care services to have written procedures and staff training for the identification and referral of victims of violence.
From page 227...
... The Health Resource Center, administered by the Family Violence Prevention Fund in San Francisco, has developed a manual and a training model for teams of health care providers and advocates to improve hospital, clinic, and community responses to domestic violence. This model evolved from a growing recognition that traditional training was not sufficient to change individual provider behavior or to generate the kinds of system changes necessary to respond appropriately to victims of domestic violence.
From page 228...
... The study will measure changes in knowledge, attitudes, and skills among health care providers and advocates; frequency of diagnosis and referral; patient satisfaction with services; number of repeat contacts with the program; and utilization of community services. The Agency for Health Care Policy and Research has funded a 3-year study that is designed to help primary care providers in a managed care setting identify and treat victims of domestic violence.
From page 229...
... program at Children's Hospital in Boston screens mothers of abused children for domestic violence in order to improve the welfare of the mothers and prevent future incidents of child abuse (Robertson, 1995)
From page 230...
... . A key question that has not been well studied is the extent of mental health symptoms, including substance abuse, that may have existed prior to the family violence compared with problems that develop as a consequence of the violence.
From page 231...
... As noted in the discussions of child maltreatment and domestic violence, provider awareness of family violence and mandated reporting requirements do not necessarily translate into effective treatment and prevention services. Ehrlich and Anetzberger (1991)
From page 232...
... Special training programs regarding elder abuse are also available in many communities for those who must respond to the needs of the elderly as health professionals, social service personnel, or caregivers.
From page 233...
... Although the research base in the first two of these three areas is still in an early stage of development, some significant observations are clear: • Efforts to encourage health care providers to ask their patients routine questions about the source and nature of their injuries and to inquire about experiences with abuse are only a first step in addressing in health settings the broader dimensions of family violence. Chart modification practices and training to raise provider awareness of the characteristics and consequences of child maltreatment, domestic violence, and elder abuse appear to be successful strategies for improving the rate of identification of current and potential victims of family violence.
From page 234...
... What remains uncertain is the extent to which these approaches will affect the documentation of incidents and histories of experience with family violence in individual and group health records, and the impact of such documentation on health care provider referral and reimbursement practices. Whereas the efforts of social service and law enforcement agencies may be of primary importance in investigating and intervening in violent home situations involving child maltreatment and elder abuse, in cases of domestic violence and child maltreatment involving adolescents, health care providers can help increase options for victims as well as hold batterers accountable for their actions.
From page 235...
... Most important in improving and expanding health care responses to family violence is resolving the question of whether the role of health interventions should be limited to reactive treatment of immediate injuries and crisis intervention or extended to include collaboration in developing community health promotion, improved treatment, and the prevention of violence. As professional organizations expand their role in alerting health care professionals about symptoms,
From page 236...
... 236 VIOLENCE IN FAMILIES consequences, and interventions for victims of child maltreatment, domestic violence, and elder abuse, they will need to educate their constituencies about alternative settings in which victims gain access to recommended services. Health care providers will also need to develop collaborative efforts with other private and public agencies to increase the availability of recommended services and to determine the appropriate balance between primary and secondary preventive interventions.
From page 238...
... SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
From page 239...
... Comprehensive health services did not alter the reported abuse rate for high-risk parents and was associated with an increased number of neglect reports.
From page 240...
... = 12 abused, school-aged children and their offending parents/families. Control group received routine community services 12 1-hour weekly clinic sessions within a 16-week period 1-year follow-up SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
From page 241...
... Conflict Tactics Scales, Weekly Report of Overall levels of parental anger and physical Abuse Indicators, Child Abuse Potential discipline/force were lower in CBT than FT Inventory, Severity Ratings of Individualized families, though each group showed a Treatment Problems, Sexual Abuse Fear reduction on these items from the early to Evaluation, Children's Attributions and late treatment sessions. Perceptions Scale, Youth Self-Report, Children's Hostility Inventory, Child Behavior Checklist, Child Conflict Index, Global Assessment Scale for Children, Brief Symptom Inventory, Beck Depression Inventory, Child Rearing Interview, Parenting Scale, Parent Opinion Questionnaire, Parent Perception Inventory, Family Environment Scale, Family Assessment Device, Conflict Behavior Questionnaire, official reports of abuse and neglect.
From page 242...
... received only routine community services Psychodynamic (P) group counseling, Downing et al., 1988 N(P)
From page 243...
... Parent Information Form, Therapist Information Form Preschool Symptom Self Report, Child Within-group comparison of pretreatment Behavior Checklist, Child Sexual Behavior and posttreatment outcome measures Inventory, Weekly Behavior Report demonstrated that, although significant changes were not observed in the NST group, the CBT group had significant improvement on most outcome measures. Schedule for Affective Disorders and Results indicated that mothers assigned to Schizophrenia for School-Age Children, the experimental treatment condition State-Trait Anxiety Inventory for Children, described significant decreases in their Child Depression Inventory, Child Behavior child's externalizing behaviors and Checklist, Parenting Practices Questionnaire increases in effective parenting skills; their children reported significant reductions in depression.
From page 244...
... sexually abusive families offered by the Hillsboro, Oregon, chapter of Parents United. Treatment group compared with a delayed training comparison group from the same Parents United chapter Eight 90-minute weekly sessions 8-week follow-up SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
From page 245...
... HEALTH CARE INTERVENTIONS 245 Data Collection Results Children's Depression Inventory, Although the control children's self-esteem, Achenbach Child Behavior Checklist, depression, and behavior scores showed little McMaster Family Assessment Device, change over time, the treatment children's General Health Questionnaire, Indices of scores were more likely to move toward the Coping Responses, Newcastle Child and normal range although some remained Family Life Events Schedule dysfunctional. No relationship was found between therapy and outcome.
From page 246...
... 10 weeks 6-month follow-up SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998. TABLE 6A-5 Quasi-Experimental Evaluations of Interventions of Mental Health Services for Adult Survivors of Child Abuse Initial/Final Sample Size Duration of Intervention Intervention Citation Follow-up Group therapy and Interpersonal Alexander et al., N (X)
From page 247...
... The second variable, safety and support skills, showed no significant difference between groups. Data Collection Results Beck Depression Inventory, Modified Fear Both groups proved to be effective relative Survey, Symptom Checklist, Revised, Social to the wait-list control condition.
From page 248...
... Biweekly home visits by trained community members from the Comparison group baby's first postpartum check-up until received standard first birthday, providing postpartum agency services health and social services. including prenatal, postpartum, family planning, and gynecological services, on-site HIV testing, and social services Average 10 months Hawaii's Healthy Start home visitation National Committee N(X)
From page 249...
... Addiction Severity Index, history of Child After an average of 10 months exposure, the Protective Services involvement, HOME experimental group reported significantly Environment Scale, Norbeck Social Support increased social support, greater access to Questionnaire, Brief Symptom Inventory, services, and decreased psychological Rosenberg's Self-Esteem Scale distress. Child Abuse Potential Inventory, Michigan Early and intensive home visitation by Screening Profile of Parenting; Maternal paraprofessional produces measurable Social Support Index; Nursing Child benefits for participants in the areas of Assessment Satellite Training parental attitudes toward children, parent child interaction patterns, and type and quantity of child maltreatment.
From page 250...
... Provided to parents of children aged 2 years in Bermuda. SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
From page 251...
... High-risk mothers (described as young, adolescent, and poor) visited during their child's infancy were less likely to be reported for child abuse and neglect (0.04)
From page 252...
... = 7.7% 8-year follow-up to measure rates of identification Emergency department protocol to Olson et al., 1996 N (female trauma identify battered women. patients identified as battered preprotocol)
From page 253...
... cases were identified as number of women identified as battered domestic violence in the baseline month, 49 (3.4%) in the chart modification month, and 49 (3.6%)
From page 254...
... = 22.97% SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
From page 255...
... HEALTH CARE INTERVENTIONS 255 Data Collection Results Hospital records Enhanced knowledge and interviewing skills of nurses can lead to increased identification of battered women.
From page 256...
... = 59 not warranted by injuries, counseling after release, referrals to social services, 5-year follow-up legal services offered to women self-identified as battered. Personal and vocational counseling Cox and Stoltenberg, N (counseling only)
From page 257...
... Profile of Mood States, Texas Social The group program was not significantly Behavior Inventory, Social Support more effective than individual couple Questionnaire, Reid-Ware Three Factor counseling in reducing physical violence or Locus of Control Scale, Conflict Tactics improving the participants' level of Scales psychological well-being. Those who received couple counseling were four times more likely to drop out of treatment than those who participated in the group program.
From page 258...
... SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998.
From page 259...
... HEALTH CARE INTERVENTIONS 259 Data Collection Results Modified Conflict Tactics Scales, Participants in both forms of treatment for Psychological Maltreatment of Women Scale, wife abuse reported a significant reduction Dyadic Adjustment Scale, Positive Feelings in both psychological and physical Questionnaire, Beck Depression Inventory, aggression at posttreatment and at 1-year fear of husband scale, attribution of follow-up. No significant differences responsibility scale between treatments on any dependent variable.


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