Children exposed to intimate partner violence and/or abused - findings from Swedish research projects in child psychiatry and child protection work Ole Hultmann, Department of Psychology, University of Gothenburg (ole.hultmann@psy.gu.se) Non Violent Childhoods Stockholm, 8th of May, 2017

Child mental health care (CAM) – studies in Gothenburg 2009 – aims… Enhancing skills in identifying patients in child mental health care (CAM) affected by intimate partner violence (IPV) and child abuse Developing structured interviews to assess amount, type and chronicity of violence => iRiSk-project…. Deepening understanding of the impact of violence on patients’ psychological symptoms Testing TF-CBT in a randomised controlled study. https://gupea.ub.gu.se/handle/2077/40838 Dessa fyra frågor kommer föreläsningen att handla om. Freud upptäckte barn utsatta för sexuella övergrepp, Kempe upptäckte barn utsatta för misshandel på 60-talet och därmed uppmärksammades också frågan i Sverige Först på 80-talet uppmärksammades traumas påverkan på barn Upptäckt av våld är fortfarande ett stort problem i Sverige och internationellt Bra stöd vet vi mycket om hur det bör utformas, problemet är att det inte görs. 1) och 2) Båda perspektiven är viktiga för att förstå avvikelser från normalutveckling eller anpassning i det nya landet 3) Det är ett svek mot barn om vi inte uppmärksamma våldsutsatthet och traumareaktioner 4) Tillsammans med barn och ungdomar själva, deras familj och andra professionella går det att rehabilitera barnet

Aims and data collection 2011-14 Primary Aim: to compare CAM patients who had both witnessed IPV and been subjected to child abuse (b) been subjected to either child abuse or witnessed IPV, but not both. Three items captured child abuse: “being beaten at home, being tied up or locked up at home, being subjected to sexual abuse at home”. One item captured IPV: “seen your parents hit each other or destroying furniture” Dessa fyra frågor kommer föreläsningen att handla om. Freud upptäckte barn utsatta för sexuella övergrepp, Kempe upptäckte barn utsatta för misshandel på 60-talet och därmed uppmärksammades också frågan i Sverige Först på 80-talet uppmärksammades traumas påverkan på barn Upptäckt av våld är fortfarande ett stort problem i Sverige och internationellt Bra stöd vet vi mycket om hur det bör utformas, problemet är att det inte görs. 1) och 2) Båda perspektiven är viktiga för att förstå avvikelser från normalutveckling eller anpassning i det nya landet 3) Det är ett svek mot barn om vi inte uppmärksamma våldsutsatthet och traumareaktioner 4) Tillsammans med barn och ungdomar själva, deras familj och andra professionella går det att rehabilitera barnet

Method Participants: 578 consecutively enrolled patients aged nine to 17 years old were asked about experiences of violence Measures - violence: Ocurrence of child abuse and IPV Frequency age of first experience impact Violence outside the family Outcome measures: Self-reported symptoms, diagnoses, impact of violence exposure

Main results – impact on psychological symptoms 14% of the patients reported abuse only, 14% exposure to IPV only, and 22% both (double exposure) No differences in psychiatric symptoms or diagnoses were found between those exposed to IPV only or abused only, compared to those neither abused nor exposed to IPV Double-exposed were more often assigned a PTSD diagnosis, had more self-reported psychological problems and regarded the impact of events as more severe compared to patients who were abused only or exposed to IPV only

Development and validation of a risk assessment interview for children exposed to intimate partner violence and child abuse. -project reported 2013-2014 http://psy.gu.se/digitalAssets/1532/1532050_irisk-rapport-2015x.pdf -ongoing project Testing the usefulness and feasability of structured risk assessments in child protection work iRiSk – Utveckling av bedömningsinstrument och stödinsatser för våldsutsatta barn. Anders Broberg, Ulf Axberg, Åsa Cater, Maria Eriksson, Ole Hultmann & Clara Iversen .

Levels in the process of collection of information in child protection work Routine questions about IPV and CA (parental reports) In depth questions if a parent screens positive on routine questions (parental reports) Full risk assessment with children and the non-abusive parent (and the abusive parent – to be developed)

Levels in the process of collection of information in child protection work Routine questions about IPV and CA (parental reports) In depth questions if a parent screens positive on routine questions (parental reports) Full risk assessement with children and non-abusive parent (and abusive parent – to be developed)

Step 1. Screening questions on IPV and child abuse in CAM and social service: Have you been hit, kicked, punched, or otherwise hurt by someone? When? By whom? (IPV) Have your child been kicked, punched, or otherwise hurt by the same person? (child abuse) Responders; N = 776, mostly women Main results: Approximately 3 of 10 parents reported IPV Those affected by IPV reported child abuse in 6 of 10 cases http://psy.gu.se/digitalAssets/1532/1532050_irisk-rapport-2015x.pdf

Levels in the process of collection of information in child protection work Routine questions about IPV and CA (parental reports) In depth questions if a parent screens positive on routine questions (parental reports) Full risk assessment with children and non-abusive parent (and abusive parent – to be developed)

Step 2. In depth questions… …parents, whom screened positive on partner violence screen instrument, were asked about type (physical, psychological, sexual), degree and frequency of IPV and child abuse screening positive on PVS indicated extensive and serious exposure to IPV and showed that the children were affected directly by violence as well. A majority of the children lived in a single parent family (with the mother) and had visitation with the alleged perpetrator of violence.

Violence against mothers (VMV) Physical violence – 8/10 Psychological violence – 9/10 Sexual violence violence – 3/10 A majority reported violence during the last year. Conclusion: If parents screened positive on the routine questions, there was a good chance that the violence was extensive.

Violence against children (VMV) Physical violence – 4/10 Psychological violence – 4/10 Sexual violence violence – > 1/10 The answers about violence against the child showed high levels of violence

Levels in the process of collection of information in child protection work Routine questions about IPV and CA (parental reports) In depth questions if a parent screens positive on routine questions (parental reports) Full risk assessment with children and non-abusive parent (and abusive parent – to be developed)

Assessing risk for recurrent IPV and CA The common strategy in child protection is an open interview with non-leading questions (Cederborg) Research shows that a combination of intuitive reasoning and analytic appraoach is the best way to make decisions Many layers in the information have to be regarded; parental capacity, amount and character of the violence, drug use, childrens developmental needs, etc. We know very little about the process of information gathering – how to elicit relevant information about violence through structured interviews

Aims of the current iRiSk study Testing the usefulness and feasability of structured risk assessments in child protection work from the perspectives of the social workers, parents and children. Further, the aim is to test the ability of the instrument to predict recurrent violence.

Risk assessments Parental form 60 – 90 minutes, depending on the character and extension of violence against parent and child Children 9 – 17 years 40 – 60 minutes Children 5 – 8 years 30 minutes

References Broberg, A., Almqvist, K., Appell, P., Axberg, U., Cater, Å., Draxler, H., . . . Röbäck, K. S. (2015). Utveckling av bedömningsinstrument och stödinsatser för våldsutsatta barn. [Development of instruments for assessment and support for children exposed to violence]. Broberg, A., Hultmann, O., & Axberg, U. (2016). Förekomst, bedömning och behandling inom barn- och ungdomspsykiatrin (BUP) av patienter som utsatts för våld i familjen. Bilaga till slutrapport till FORTE avseende FAS- projekt nr. 2011-0350. Göteborg: Psykologiska institutionen. Hultmann, O. (2015). Child Psychiatric Patients Affected by Intimate Partner Violence and Child Abuse – Disclosure, Prevalence and Consequences. (PhD), University of Gothenburg, Gothenburg. Hultmann, O., & Broberg, A. (2015). Family violence and other potentially traumatic onterpersonal events Among 9- to 17-year-old children attending an outpatient psychiatric clinic. Journal of Interpersonal Violence. doi:10.1177/0886260515584335 Hultmann, O., Broberg, A., & Axberg, U. (2016). A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual in a child psychiatric clinic. Manuscript in preparation. Hultmann, O., Broberg, A., & Axberg, U. (2017). Child Psychiatric Patients Exposed to Intimate Partner Violence and/or Abuse - the Importance of Double Exposure. Submitted manuscript.