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Academic and School Health Issues Among Children Exposed to Maternal Intimate Partner Abuse
Mary A. Kernic, PhD, MPH;
Victoria L. Holt, PhD, MPH;
Marsha E. Wolf, PhD;
Barbara McKnight, PhD;
Colleen E. Huebner, PhD, MPH;
Frederick P. Rivara, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:549-555.
ABSTRACT
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Objective To determine the association between children's exposure to maternal
intimate partner violence (IPV) and academic problems and school health concerns.
Design The study population consisted of 153 children aged 5 to 16 years who
attended public school and whose mothers experienced police- or court-reported
IPV. The comparison group consisted of public school peers of the exposed
children. Generalized linear modeling using a binomial distribution and log-link
function served as the primary method of analysis.
Setting Urban public school district.
Main Outcome Measures The occurrence of academic problems and type-specific school nurse visits
during the 1-year study period.
Results Children whose mothers experienced IPV were more likely to be suspended
from school (relative risk [RR], 1.8; 95% confidence interval [CI], 1.2-1.7)
and to have had frequent non–suspension-related absences (RR, 1.6; 95%
CI, 1.0-2.3) than comparison children after adjusting for relevant confounders.
Intimate partner violence–exposed children were more likely to have
a school nurse visit for social or emotional complaints (RR, 2.2; 95% CI,
1.3-3.9), a visit that resulted in being sent home from school (RR, 1.6; 95%
CI, 1.1-2.3), or a visit that led to referral to the school speech pathologist
(RR, 7.5; 95% CI, 1.9-29.6) relative to comparison schoolchildren after adjusting
for relevant confounders.
Conclusions Children's exposure to maternal IPV is significantly associated with
the occurrence of academic problems and school health concerns. Describing
the increased risk of the academic and health problems exhibited by IPV-exposed
children relative to nonexposed children offers the possibility of improving
the likelihood that clinicians will identify the woman who experienced abuse
and her children, and promote referral to appropriate resources.
INTRODUCTION
MORE THAN 3 million children are exposed to their mother's abuse by
an intimate partner in the United States each year. Case series1-4
suggest that many of these children have academic problems, including poor
grades, grade repetition, absenteeism, and problematic school behavior. However,
most studies5-8
using control groups have not confirmed these associations, and only one9 has reported on school behavior among these children.
An additional area of concern for children exposed to intimate partner violence
(IPV) is whether these children are more likely than other children to exhibit
physical health problems. Descriptive studies4, 10-11
have reported stress-related somatic complaints, including headaches, abdominal
pains, and speech problems, among IPV-exposed children. Only one analytic
study12 has examined the somatic complaints
of IPV-exposed children. Controlled studies that have evaluated academic and
health problems among children exposed to maternal IPV share important methodological
limitations, including a small sample size, sampling only among shelter populations,
failure to account for child abuse, measurement of outcomes solely by maternal
report, and/or use of volunteer comparison groups.
The present study examines the academic and school health histories
of children exposed to maternal IPV compared with their public school counterparts.
Our aim was to determine if children exposed to IPV, either with or without
a history of child abuse, were more likely to exhibit academic problems and
to seek school health services than their school peers. This study addressed
the gaps in information about the consequences of maternal IPV on children's
health and academic functioning in several ways. First, we used citywide data
on police-reported IPV incidents, allowing for greater generalizability to
all children exposed to police-reported maternal IPV. Second, we collected
data on the timing of exposure to maternal abuse, enabling us to examine exposure
before the outcome. Third, information about child abuse was collected for
the IPV-exposed group, allowing us to generate risk estimates of academic
and health problems associated with exposure to maternal IPV and maternal
IPV in conjunction with child abuse. Finally, computerized school data were
used, providing more accurate information than obtained by parent report alone.
SUBJECTS AND METHODS
SUBJECTS
The exposed group consisted of children whose mothers experienced police-
or court-reported male-perpetrated IPV in Seattle, Wash, and who participated
in the Women's Wellness Study (WWS), previously described in detail.13 Briefly, the WWS population consisted of a random
sample of 448 Seattle-area women 18 years and older who experienced abuse
by a male intimate partner that resulted in a police-reported incident or
the filing of an order of protection between October 15, 1997, and December
31, 1998. The response rate of the WWS was 60.4%, and participants were somewhat
more likely to have obtained protection orders and less likely to be living
with their abusers than were nonparticipants.13
Eligible children were aged 6 to 17 years on their mother's enrollment into
the WWS, attended Seattle public schools, and lived with their mother at least
part-time during the study period (the 12 months before her enrollment in
the main study).
Study subjects were the 153 eligible children who attended Seattle public
schools during some or all of the 12 months of observation. Thirty (20%) of
the IPV-exposed study children also experienced child abuse. Data on child
abuse were collected for the IPV-exposed children using referrals made to
the police department (primarily by Child Protective Services) for investigation
of child physical abuse, sexual abuse, or severe neglect.
The comparison group consisted of children aged 5 to 16 years who attended
Seattle public schools for any period between October 1, 1996, and December
31, 1997. Enrollment into the study occurred on the randomly assigned start
date or the date the student was first in attendance in Seattle schools, whichever
occurred later. The end of the observation period for all children was defined
as the date the child left Seattle public schools (and did not return) or
1 year following the child's study enrollment date, whichever came first.
Of the 74 034 students who attended Seattle public schools during the
1996-1997, 1997-1998, and 1998-1999 academic years (the academic years that
spanned recruitment and follow-up), 48 406 attended during their randomly
assigned 12-month observation period and were eligible for inclusion in the
study. Study protocols, including consent by WWS participants to access identifiable
school records of their children, were approved by the University of Washington
and the Seattle School District Human Subjects Divisions.
ACADEMIC PERFORMANCE AND SCHOOL BEHAVIOR OUTCOMES
The academic problems assessed included any academic suspension, any
academic expulsion, frequent absenteeism (absent for  15% of school days
other than for academic suspension), receipt of special education services,
grade retention, and a cumulative grade point average (GPA) of 1.0 or lower
on a scale of 4.0 (representing a GPA in the "D" to "F" letter-grade range)
during the 12-month observation period. Absenteeism rates were defined as
number of days absent (other than for academic suspension) of total possible
days of school enrollment. Because academic suspensions were counted toward
the total number of days absent in the original data, we subtracted total
number of days suspended from total days absent to provide absenteeism rates
independent of the outcome of disciplinary suspension. Information about absenteeism
and special education services was obtained for children in all grades (kindergarten
through 12th grade). Academic grades were available in computerized format
only for children in grades 6 through 12 and, therefore, were evaluated only
among children in these grades. Grade retention was ascertained for children
in grades 3 and higher to better identify problems of academic ability rather
than social immaturity.
SCHOOL HEALTH OUTCOMES
Data on school health services were available from a database maintained
by Seattle public schools. The database included information from standardized
forms filled out by school nurses on all visits to the school nurse by students
attending Seattle public schools. Variables included date and time of service,
referral source, referral reason(s), services provided, and any outside referrals
that were made. School health outcomes included the proportion of children
with at least 1 school nurse visit for each of the following reasons: social
or emotional concerns, alcohol or other drug concerns or receipt of alcohol
or other drug assessment, visits resulting in a referral to the speech pathologist,
and visits resulting in the child being sent home. Visits to the school nurse
were either self-initiated or at the suggestion of school personnel for the
stated physical or psychological complaint. Referrals to the school speech
pathologist were based on school nurse assessment.
ANALYSIS
Risk estimates of academic problems and school nurse visits were calculated
separately for IPV-exposed children with and without a history of child abuse,
relative to comparison group children. Neither child abuse history nor IPV
exposure data were available for the comparison group children; therefore,
for analysis, we considered this group to be unexposed to both factors. We
hypothesized that exposure to maternal IPV and child abuse would be associated
with a greater level of adverse outcomes than exposure to maternal IPV alone,
based on prior work14-16
that has shown an increased risk of behavioral problems with increasing number
of life stressors. Likelihood ratio statistics were used to determine the
statistical significance of the exposure-outcome relationship. Because most
of our outcomes were moderately frequent, we computed relative risks (RRs)
and confidence intervals (CIs) using generalized linear modeling with a binomial
distribution and log-link function.17 The following
variables, obtained from school databases, were evaluated as potential confounders:
age (5-7, 8-10, 11-13, and 14-16 years); sex; race or ethnicity (white, black,
Asian, Latino, and Native American); ZIP code, grouped as a census-based proxy
for annual household income (<$30 000, $30 000-$39 999,
$40 000-$49 999, and $50 000); bilingual program eligibility
(yes or no); and academic grade (kindergarten-5th, 6th-8th, and 9th-12th grade).
In addition, number of weekly hours of school nurse availability (continuous)
was evaluated as a potential confounding factor for analyses involving school
health visit outcomes. Confounding variables were included in the models if
their inclusion led to meaningful changes in the exposure RR estimate, using
a 10% change as a minimal guideline.18-19
The matching variable, month of study enrollment, grouped in 2-month increments,
was included in all analyses. We examined effect modification by age, sex,
and socioeconomic status and found no evidence of effect modification by these
factors.
To verify the validity of our results, we performed subanalyses with
families in which the mothers experienced IPV for 1 year or longer at the
time of the index incident date. This allowed us to confirm the association
between exposure and outcome within a group in which we were certain that
the exposure preceded the outcome of interest. In doing so, we obtained comparable
results to those obtained using the entire cohort of IPV-exposed children;
therefore, we present results for all IPV-exposed children in this report.
RESULTS
The IPV-exposed children were somewhat younger, had a slightly different
racial or ethnic composition, were more likely to live in households headed
by single parents, and had lower household incomes than the comparison children
(Table 1).
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Table 1. Demographics and Characteristics of Study Subjects by Exposure
Status*
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BEHAVIOR AND ACADEMIC PROBLEMS
After adjusting for confounders (Table 2), children exposed to maternal IPV only were almost twice
as likely, and those exposed to maternal IPV and child abuse were twice as
likely, as comparison children to have been suspended from school during the
study period. Nonabused and abused IPV-exposed children were significantly
more likely to have been suspended for disruptive or delinquent behavior than
comparison children (12% and 17%, respectively, vs 4%; P = .01), and abused IPV-exposed children were significantly more likely
to have been suspended for aggressive behavior than comparison children (13%
vs 3%; P = .02). Academic expulsion was not associated
with exposure to maternal IPV only or with exposure to maternal IPV and child
abuse after adjusting for the same set of covariates.
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Table 2. Relative Risk Estimates of the Association Between Adverse
Academic Outcomes and Maternal IPV Exposure by Child Abuse History Status*
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Students exposed to maternal IPV only were 1.6 times as likely, and
those exposed to maternal IPV and child abuse were 2.2 times as likely, to
have been frequently absent from school during the study period relative to
students in the comparison group, after adjusting for the set of covariates
listed in Table 2.
Intimate partner violence exposure in the absence of child abuse was
not significantly related to measures of academic performance. However, children
exposed to maternal IPV and child abuse were more likely to have a cumulative
GPA at or below 1.0 and to have been retained a grade relative to students
in the comparison group, after adjusting for the relevant confounders listed
in Table 2.
HEALTH PROBLEMS
Physical health complaints and injuries were the most common reason
for school nurse visits among IPV-exposed children and comparison children
(Table 3). Intimate partner violence–exposed
children, with or without a history of child abuse, were no more likely to
have had a nurse visit for physical health problems or complaints than were
comparison children after adjusting for age, household income, and month of
study enrollment. Injury-related visits were more likely among IPV-exposed
children with or without concomitant child abuse after adjusting for weekly
hours of school nurse availability, household income, and month of study enrollment.
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Table 3. Relative Risk Estimates of School Nurse Visit(s) by Maternal
IPV Exposure and Child Abuse Status*
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Children exposed to maternal IPV without a history of child abuse were
60% more likely to have had a nurse visit that resulted in being sent home
from school, relative to comparison children, after adjusting for weekly hours
of school nurse availability, household income, and month of study enrollment.
We did not observe this same association for IPV-exposed children with a history
of child abuse.
Nonabused IPV-exposed children were more than twice as likely as comparison
children to have had at least 1 school nurse visit related to social or emotional
concerns during the study period, after adjusting for weekly hours of school
nurse availability, student race or ethnicity, and month of study enrollment.
Visits for social or emotional concerns were not significantly more frequent
among IPV-exposed children with a history of child abuse than among comparison
children.
Nurse visits related to alcohol or other drug assessments or concerns
were almost 4 times as likely among nonabused IPV-exposed children as among
comparison children, but this association was only marginally significant
with adjustment for weekly hours of school nurse availability, age, and month
of study enrollment. No visits of this type occurred among abused IPV-exposed
children during the study period.
Speech pathology referrals were more than 7 times as likely among nonabused
IPV-exposed children relative to comparison group children after adjusting
for relevant confounders. No speech pathology referrals occurred among the
abused IPV-exposed children.
COMMENT
This retrospective cohort study found that children exposed to maternal
IPV were significantly more likely to be frequently absent and to be suspended
from school than were comparison schoolchildren. Children exposed jointly
to maternal IPV and child abuse were at significantly greater risk of absenteeism,
academic suspension, a low cumulative GPA, and grade retention relative to
comparison children. In addition, we found that children exposed to maternal
IPV were more than twice as likely to visit the school nurse for social or
emotional reasons, were 1.6 times as likely to have a visit resulting in being
sent home, and were more than 7 times as likely to be referred to a speech
pathologist relative to comparison children, after adjusting for relevant
confounders.
We found that 15% of nonabused IPV-exposed children had been suspended
during the 1-year study period. Our findings extend what has been found in
prior research related to IPV exposure and school disciplinary actions by
providing evidence that this association persists in the absence of a history
of reported child abuse. Furthermore, our results are consistent with the
findings of previous studies7, 9, 15, 20-21
that children's exposure to maternal IPV is associated with heightened aggression
and delinquency. Consistent with findings from related studies14, 16
that a cumulative increase in number of stressful life events translates into
increasing risk of child behavioral problems, we found risk of academic suspension
to be greatest among the children exposed to maternal IPV and child abuse.
The results on frequent absenteeism among IPV-exposed children were
comparable to the results among abused and IPV-exposed children in the study
by Dawud-Noursi et al.6 Although the results
of this previous study did not show a significant difference between study
groups, the researchers reported 17% truancy among 10- to 14-year-old abused
and/or IPV-exposed children vs 8% among a school comparison group. This compares
to 19% of nonabused IPV-exposed and 25% of abused IPV-exposed children with
frequent absenteeism vs 12% of comparison schoolchildren from our study, both
significant findings.
We found no increased risk of poor academic performance, measured by
grade retention, special education, and low GPAs, among nonabused children
exposed to maternal IPV. These findings are consistent with most, but not
all, prior controlled studies that examined academic performance, as indicated
by evaluative ratings provided by the mother or teacher or by self-report.5-8 In contrast,
Jaffe et al14 reported a significantly lower
mean score on the school performance portion of the social competence scale
of the Child Behavior Checklist for boys from a battered women's shelter relative
to a community comparison group. However, the researchers were unable to adjust
for potentially important confounding factors, particularly subject history
of child abuse.
Although overall visits for physical health complaints were fairly similar
in likelihood among IPV-exposed children and comparison group children, IPV-exposed
children were 60% more likely to be sent home from school by the school nurse.
We did not have information on the specific types of health complaints to
draw conclusions about consistency with earlier descriptive studies regarding
specific stress-related symptoms, including headaches and gastrointestinal
complaints, but did confirm the association between IPV exposure and speech
problems. We confirmed the association of IPV exposure and risk-taking behaviors,
as manifested by the higher occurrence of injury-related and alcohol- and
other drug–related visits, consistent with studies7, 9, 15, 20-21
that have shown greater externalizing behaviors among IPV-exposed children
sampled from battered women's shelters. Our results that IPV-exposed children
were more likely to be referred for visits related to social or emotional
concerns corroborate the findings of general psychological health problems
among children in shelters and IPV agencies reported in prior studies and,
more important, the present study established that this association remains
for IPV-exposed children without a history of reported child abuse.5, 22-24 Our
findings on the relative frequency with which IPV-exposed children visit school
nurses, combined with the recognition that school health services are important
sites for prevention programs, delineate a path for future intervention programs
and evaluative research.25-28
Because of the relatively small number of IPV-exposed children who had
also experienced child abuse, the conclusions we can draw about their academic
problems and school health services use are limited. We did find an increased
likelihood of injury-related visits among this group; however, it is possible
that this outcome could be a consequence of the abuse itself. The shelter
populations represented by earlier studies tended to have a much higher prevalence
of child abuse among IPV-exposed children compared with our study. The higher
prevalence of child abuse from some prior research may also be explained in
part by the differences in their use of maternal report vs our use of system
report.
Our sample was more broadly representative of children whose mothers
are abused by an intimate partner than samples drawn from battered women's
shelters; therefore, the results we provide are likely to be of greater generalizability
to the population of IPV-exposed children. Nevertheless, our sample was limited
to children of women whose abuse was reported to the police or court system.
There is some suggestion that reported IPV incidents may comprise more serious
incidents of IPV than incidents that are not reported.29
Therefore, it is possible that our results may not be generalizable to children
of mothers who are abused by an intimate partner but whose abuse goes unreported.
A related limitation of this study is the possibility of misclassification
of exposure. Neither exposure to maternal IPV nor history of child abuse was
available for comparison children. For analysis, we assumed no exposure to
either of these factors among the comparison group children. Clearly, the
"unexposed" group may have contained children with either or both of these
exposures, thus resulting in an underestimate of the risk of academic problems
or health problems associated with children's exposure to maternal IPV. To
provide an indication of the degree of underestimation, we used an observed
estimate of police-reported IPV in Seattle (33.5 cases per 1000 women-years)
and the National Crime Victimization Survey estimate that 50% of IPV is reported
to police, and calculated what we would expect for RR estimates had we been
able to remove the approximately 3243 IPV-exposed children from our comparison
group. We calculated that our crude RR estimates for any suspension, frequent
absenteeism, and low cumulative GPA associated with IPV exposure in the absence
of child abuse would be underestimated by 7.7% (RR, 2.3; 95% CI, 1.5-3.6),
3.1% (RR, 1.7; 95% CI, 1.1-2.5), and 6.4% (RR, 2.0; 95% CI, 0.7-5.9), respectively.
Similarly, the crude RR estimates for any school health visit resulting in
the child being sent home, any visit for social or emotional reasons, and
any injury-related visit associated with IPV exposure in the absence of child
abuse would be underestimated by 4.7%, 9.0%, and 2.3%, respectively.
Our measure of socioeconomic status was limited to the use of ZIP code
as a proxy for household income, which may have resulted in residual confounding
by socioeconomic status. However, it is also likely that household income
is lower among members of the exposed group as a consequence of the violence
because women are more likely to leave an abusive relationship, with consequent
loss of partner's income contribution to the household. If this were the case,
our adjustment for household income might have provided us with conservative
estimates of the effect of maternal IPV on academic problems because it would
measure only that result of violence that is not a consequence of reduced
income.
Because the outcomes we evaluated were based on school records, they
are more likely to provide an unbiased measure of school problems than those
based on maternal or child report. More important, we found no evidence of
referral bias for school nurse visits; IPV-exposed children were not significantly
more likely to be referred by school personnel or others (who might be aware
of the IPV exposure) than comparison children. In addition, examining the
effects of child abuse and exposure to maternal IPV separately provides a
clearer picture of their respective impacts. We were able to address another
major limitation of previous research among children exposed to IPV, that
of lack of generalizability, by using a more representative sample rather
than a sample derived from the select group represented by battered women's
shelters.
This study found evidence that children exposed to maternal IPV are
at an increased risk of academic problems and school health services use for
physical and psychological health complaints and concerns. Although meaningful
discussion of the mechanisms through which children's exposure to IPV may
affect their academic functioning and health concerns is beyond the scope
of this article, our results do suggest the need for additional studies with
this specific aim. Intimate partner violence exposure is likely to affect
academic functioning and child health directly and indirectly, through such
factors as occurrence of posttraumatic stress disorder, behavioral problems,
socioeconomic decline, decreased parental effectiveness, child neglect, social
isolation, maternal and/or child depression, anxiety, and alcohol and other
drug use.30-39
For example, some researchers40-41
have found that abused and neglected children show more speech and language
deficits than nonabused or nonneglected children. It is possible that the
occurrence of speech disorders among the IPV-exposed children from our study
was mediated through neglect exhibited by the overwhelmed and unavailable
parent who experienced abuse.42 The impact
of IPV-related stress on immune function may also play a role in the health
of these children.43-44 Furthermore,
the likelihood of an adverse event among children with the additional exposure
to child abuse would be expected to be elevated beyond that of exposure to
IPV alone as a direct consequence of that abuse and through stronger activation
of adverse mediating factors. Research directed toward elucidating these mechanisms
could be useful in identifying prevention strategies aimed at ameliorating
the academic and health problems experienced by these children.
Our results offer a starting point from which we may broaden our understanding
of the pervasiveness of the effects of maternal IPV on children's academic
functioning and health. For clinicians, a description of the problems exhibited
by these children offers the possibility of increasing the likelihood of identifying
the woman who experienced abuse and her children, and promoting referral to
appropriate resources. These data also provide an understanding of the needs
exhibited by IPV-exposed children to the school personnel and pediatricians
providing care for this population.
| What This Study Adds
Although more than 3 million children are exposed to maternal IPV in
the United States each year, little is known about whether these children
are at an increased risk of academic and health-related problems. Descriptive
studies have reported that academic and health problems are quite prevalent
among this population. However, most studies using control groups have not
confirmed these associations, and are limited in their interpretability because
of important methodological problems, including small sample sizes, sampling
only among shelter populations, failure to account for child abuse, measurement
of outcomes solely by maternal report, and use of volunteer comparison groups.
A major contribution of this study is the rigorous examination of the
association between maternal IPV and child health and academic problems, controlling
for the important confounding effect of child abuse, the failure of which
has been a serious limitation of prior research in this area. This study provides
ample evidence of the increased academic and health problems associated with
children's exposure to maternal IPV with or without concurrent exposure to
child abuse. For clinicians, a description of the problems exhibited by these
children offers the possibility of increasing the likelihood of identifying
the abused woman and her children, and promoting referral to appropriate resources.
These data also provide an understanding of the needs exhibited by IPV-exposed
children to the school personnel and pediatricians providing care for this
population.
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AUTHOR INFORMATION
Accepted for publication January 31, 2002.
This study was supported by grant R49/CCR002570 from the Centers for
Disease Control and Prevention, Atlanta, Ga (Harborview Injury Prevention
and Research Center, Seattle).
Corresponding author and reprints: Mary A. Kernic, PhD, MPH, Harborview
Injury Prevention and Research Center, 325 Ninth Ave, Campus Box 359960, Seattle,
WA 98104-2499 (e-mail: mkernic{at}u.washington.edu).
From the Harborview Injury Prevention and Research Center (Drs Kernic,
Holt, Wolf, and Rivara), the Departments of Epidemiology (Drs Kernic, Holt,
Wolf, and Rivara), Biostatistics (Dr McKnight), and Health Services (Dr Huebner),
School of Public Health and Community Medicine, University of Washington;
the Department of Family and Child Nursing, School of Nursing, University
of Washington (Dr Huebner), and the Department of Pediatrics, School of Medicine,
University of Washington (Dr Rivara), Seattle, Wash.
REFERENCES
| |
1. Jaffe P, Wolfe DA, Wilson SK. Children of Battered Women. Newbury Park, Calif: Sage Publications; 1990.
2. Wildin SR, Williamson WD, Wilson GS. Children of battered women: developmental and learning profiles. Clin Pediatr (Phila). 1991;30:299-304.
3. Levine MB. Interparental violence and its effect on the children: a study of 50
families in general practice. Med Sci Law. 1975;15:172-176.
ISI
| PUBMED
4. Moore JG. Yo-yo children: victims of matrimonial violence. Child Welfare. 1975;54:557-566.
ISI
| PUBMED
5. Christopoulos C, Cohn DA, Shaw DS, et al. Children of abused women, I: adjustment at time of shelter residence. J Marriage Fam. 1987;49:611-619.
FULL TEXT
6. Dawud-Noursi S, Lamb ME, Sternberg KJ. The relations among domestic violence, peer relationships, and academic
performance. In: Lewis M, Feiring C, eds. Families, Risk and
Competence. Mahwah, NJ: Lawrence A Erlbaum Associates; 1998:207-226.
7. Fantuzzo JW, DePaola LM, Lambert L, Martino T, Anderson G, Sutton S. Effects of interparental violence on the psychological adjustment and
competencies of young children. J Consult Clin Psychol. 1991;59:258-265.
FULL TEXT
|
ISI
| PUBMED
8. Mathias JL, Mertin P, Murray A. The psychological functioning of children from backgrounds of domestic
violence. Aust Psychol. 1995;30:47-56.
9. Jaffe P, Wolfe D, Wilson S, Zak L. Similarities in behavioral and social maladjustment among child victims
and witnesses to family violence. Am J Orthopsychiatry. 1986;56:142-146.
ISI
| PUBMED
10. Hilberman E, Munson K. Sixty battered women. Victimology. 1977;2:460-470.
11. Kerouac S, Taggart ME, Lescop J, Fortin MF. Dimensions of health in violent families. Health Care Women Int. 1986;7:413-426.
PUBMED
12. Gleason WJ. Children of battered women: developmental delays and behavioral dysfunction. Violence Vict. 1995;10:153-160.
PUBMED
13. Wolf M, Holt VL, Kernic MA, Rivara FP. Who gets protection orders for intimate partner violence? Am J Prev Med. 2000;19:286-291.
FULL TEXT
|
ISI
| PUBMED
14. Jaffe P, Wolfe D, Wilson S, Zak L. Critical issues in the assessment of children's adjustment to witnessing
family violence. Can Ment Health. 1985;33:15-19.
15. O'Keefe M. Adjustment of children from maritally violent homes. Fam Soc. 1994;75:403-415.
16. Shaw DS, Winslow EB, Owens EB, Hood N. Young children's adjustment to chronic family adversity: a longitudinal
study of low-income families. J Am Acad Child Adolesc Psychiatry. 1998;37:545-553.
FULL TEXT
|
ISI
| PUBMED
17. McCullagh P, Nelder JA. Generalized Linear Models. 2nd ed. Boca Raton, Fla: Chapman & Hall; 2000.
18. Rothman K. Modern Epidemiology. Boston, Mass: Little Brown & Co Inc; 1986.
19. Maldonado G, Greenland S. Simulation study of confounder selection strategies. Am J Epidemiol. 1993;138:923-936.
FREE FULL TEXT
20. Jaffe P, Wolfe D, Wilson SK, Zak L. Family violence and child adjustment: a comparative analysis of girls'
and boys' behavioral symptoms. Am J Psychiatry. 1986;143:74-77.
FREE FULL TEXT
21. Rossman BB, Rosenberg MS. Family stress and functioning in children: the moderating effects of
children's beliefs about their control over parental conflict. J Child Psychol Psychiatry. 1992;33:699-715.
ISI
| PUBMED
22. Holden GW, Ritchie KL. Linking extreme marital discord, child rearing, and child behavior
problems: evidence from battered women. Child Dev. 1991;62:311-327.
FULL TEXT
|
ISI
| PUBMED
23. Cummings JG, Pepler DJ, Moore TE. Behavior problems in children exposed to wife abuse: gender differences. J Fam Violence. 1999;14:133-156.
FULL TEXT
24. Kolbo JR. Risk and resilience among children exposed to family violence. Violence Vict. 1996;11:113-128.
PUBMED
25. Espeland K. Promoting mental wellness in children and adolescents through positive
coping mechanisms. J Sch Nurs. 1998;14:22-25.
PUBMED
26. Evans SW, Axelrod JL, Sapia JL. Effective school-based mental health interventions: advancing the social
skills training paradigm. J Sch Health. 2000;70:191-194.
ISI
| PUBMED
27. Weist MD, Christodulu KV. Expanded school mental health programs: advancing reform and closing
the gap between research and practice. J Sch Health. 2000;70:195-200.
ISI
| PUBMED
28. Payton JW, Wardlaw DM, Graczyk PA, Bloodworth MR, Tompsett CJ, Weissberg RP. Social and emotional learning: a framework for promoting mental health
and reducing risk behavior in children and youth. J Sch Health. 2000;70:179-185.
ISI
| PUBMED
29. Bachman R, Saltzman LE. Violence Against Women: Estimates From the Redesigned
National Crime Victimization Survey. Washington, DC: Bureau of Justice Statistics; August 1995:8. Publication
NCJ-154348.
30. McLoyd VC. Socioeconomic disadvantage and child development. Am Psychol. 1998;53:185-204.
FULL TEXT
| PUBMED
31. Lupien SJ, King S, Meaney MJ, McEwen BS. Child's stress hormone levels correlate with mother's socioeconomic
status and depressive state. Biol Psychiatry. 2000;48:976-980.
FULL TEXT
|
ISI
| PUBMED
32. Hinshaw SP. Externalizing behavior problems and academic underachievement in childhood
and adolescence: causal relationships and underlying mechanisms. Psychol Bull. 1992;111:127-155.
FULL TEXT
|
ISI
| PUBMED
33. Hidalgo RB, Davidson JR. Posttraumatic stress disorder: epidemiology and health-related considerations. J Clin Psychiatry. 2000;61:5-13.
34. Beardslee WR, Versage EM, Gladstone TR. Children of affectively ill parents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1998;37:1134-1141.
FULL TEXT
|
ISI
| PUBMED
35. Davies PT, Windle M. Gender-specific pathways between maternal depressive symptoms, family
discord, and adolescent adjustment. Dev Psychol. 1997;33:657-668.
FULL TEXT
|
ISI
| PUBMED
36. Rivara FP. Developmental and behavioral issues in childhood injury prevention. J Dev Behav Pediatr. 1995;16:362-370.
ISI
| PUBMED
37. Samaan RA. The influences of race, ethnicity, and poverty on the mental health
of children. J Health Care Poor Underserved. 2000;11:100-110.
ISI
| PUBMED
38. McLennan JD, Kotelchuck M. Parental prevention practices for young children in the context of
maternal depression. Pediatrics. 2000;105:1090-1095.
FREE FULL TEXT
39. Velting ON, Albano AM. Current trends in the understanding and treatment of social phobia
in youth. J Child Psychol Psychiatry. 2001;42:127-140.
FULL TEXT
|
ISI
| PUBMED
40. Law J, Conway J. Effect of abuse and neglect on the development of children's speech
and language. Dev Med Child Neurol. 1992;34:943-948.
ISI
| PUBMED
41. McFadyen RG, Kitson WJ. Language comprehension and expression among adolescents who have experienced
childhood physical abuse. J Child Psychol Psychiatry. 1996;37:551-562.
ISI
| PUBMED
42. Leung AK, Kao CP. Evaluation and management of the child with speech delay. Am Fam Physician. 1999;59:3121-3128, 3135.
ISI
| PUBMED
43. Boyce WT, Jemerin JM. Psychobiological differences in childhood stress response, I: patterns
of illness and susceptibility. J Dev Behav Pediatr. 1990;11:86-94.
ISI
| PUBMED
44. Agarwal SK, Marshall GD Jr. Stress effects on immunity and its application to clinical immunology. Clin Exp Allergy. 2001;31:25-31.
FULL TEXT
|
ISI
| PUBMED
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