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ViOlence Impact on Children Evidence Synthesis
The impact on children of exposure to domestic violence and the implications for a primary care response: a systematic review and secondary analysis of qualitative evidence
Short title: VOICES (ViOlence: Impact on Children Evidence Synthesis)
20 February 2017
01 December 2015
01 February 2017
Children, young people, domestic violence and abuse, qualitative, systematic review, secondary analysis, impact, primary care.
Dr Ali Heawood, Senior Research Fellow in Primary Care, School for Social and Community Medicine, University of Bristol;
Dr Alison Gregory, Senior Research Associate, School for Social and Community Care, University of Bristol.
- Dr Lisa Arai, Honorary Senior research Associate, School of Social and Community Medicine, University of Bristol
- Prof Gene Feder, Professor of Primary Care, School of Social and Community Medicine, University of Bristol
- Theresa Moore, Senior Research Associate in Evidence Synthesis/Systematic Reviewing, School of Social and Community Medicine, University of Bristol
- Dr Emma Howarth, Senior Research Associate NIHR CLAHRC East of England, University of Cambridge
- Professor Harriet MacMillan, Department of Psychiatry and Behavioural Neurosciences, McMaster University, (Dept of Paediatrics) Ontario Canada
- Professor Nicky Stanley, School of Social Work, Care and Community, University of Central Manchester
1. understand the impact of exposure to domestic violence and abuse (DVA) on children’s health and well-being, from the perspective of children, non-abusing parents and survivors’ friends/family;
2. identify areas of need for children exposed to DVA and how these needs might best be met;
3. articulate the role of primary care in identifying and responding to these needs.
Changes to the proposal
The project was originally planned to run over eight months with the research associate recruited to the team employed at .8 FTE. The FTE was reduced (to .4) and the project timeline extended, with no additional cost.
We decided to prioritise the child’s voice in the systematic review rather than the non-abusing parent, since initial scoping of the literature indicated that this had not yet been done and we were keen to ensure that children’s voices inform future service and intervention development.
Prior to the full review, we completed a scoping review which identified a large body of work likely to meet inclusion criteria. We decided to adopt a two stage strategy to manage the analysis of this literature. First, we mapped the literature and subjected all items to a simple descriptive analysis. Second, from this larger pool of items, we selected a smaller number meeting additional inclusion criteria, critically appraised and data extracted all items, and undertook a thematic synthesis. While we had originally planned a meta-ethnography at the synthesis stage, a thematic synthesis became more appropriate due to the volume and type of studies identified.
In addition to the work originally planned, we also undertook a comprehensive scoping review of all systematic/other reviews on the impact of DVA on children. We identified 39 items and briefly summarised the findings to inform the review and synthesis.
The VOICES study had two main components: a systematic review and synthesis of the qualitative literature on children’s experiences of DVA; and a secondary analysis of qualitative data from a prior study of friends and relatives of DVA survivors.
Aims and objectives
The project’s primary aim was to understand the impact of DVA on children’s well-being, from the perspective of children, non-abusing parents and survivors’ friends/family.
1.1 Systematic review
Stages in the review & inclusion criteria:
A scoping review identified a potentially large number of items meeting inclusion criteria. We thus decided on a 2-stage review: Stage 1: mapping, where all items meeting inclusion criteria were identified, retrieved and subjected to simple descriptive analysis; Stage 2: focused synthesis, where a smaller number of Stage 1 items were subjected to detailed critical appraisal, full data extraction and synthesis.
At stage 1:mapping, items were included where:
- They focused on children/young people’s experience of witnessing DVA between parents/carers in a domestic setting;
- Data were provided by children/young people aged 18 or under with experience of DVA;
- The findings reported were from primary qualitative research or secondary analysis of qualitative data (commentaries and reviews were excluded);
- Verbatim text from children was presented;
- The item was written in
There were no date or geographical limits (other than those within the databases searched).
At stage 2: focused synthesis, additional criteria were applied, namely:
- The item presented sufficient verbatim text from children/young people to contribute to meaningful qualitative analysis;
- Children’s data could be distinguished from adults’ data;
- The item was in a peer-reviewed
Systematic review search strategy
Literature for the VOICES review was identified through five sources:
A pool of items identified for a predecessor NIHR-funded study ‘IMPROVE’:
IMPROVE searches involved a combination of MeSH and text word terms for ‘Children and adolescents’ combined with MeSH and text word terms for ‘domestic violence’ and text word terms for ‘exposure of children to domestic violence’ or ‘witnessing or growing up with domestic violence’. All databases were searched from inception to May 2013. We did not use a filter to limit the search by study methodology nor date or language limits. We searched 13 electronic bibliographic databases including MEDLINE, EMBASE, International Bibliography of the Social Sciences (IBSS), Social Services Abstracts and Social Care Online and found 8763 records after de-duplication. 106 references potentially relevant to the VOICES review were selected for further screening.
Updated search of electronic databases:
The IMPROVE search was updated, using the same search strategy but restricting items to those published in the period 2013-16. First stage screening involved reading the title and abstract only. To ensure consistency in screening, team members screened 30 items each using the stage 1 inclusion criteria and differences resolved. At second stage screening, three team members read the full text of 10 items each using a full text screening tool. One team member read the full text of all items and the full text screening decisions of team members.
A search of key websites (including: Department of Health; NICE; SCIE; NCB) was undertaken using the same keywords as for the electronic databases search.
Colleagues and experts in the field were asked about studies possibly meeting inclusion criteria
Selected citation checking:
Reference lists in selected key papers were checked for items meeting inclusion criteria (stage 2 only).
Producing the focused sample:
Additional stage 2 inclusion criteria were applied to all items identified at stage 1.
Critical appraisal & data extraction:
Three team members were involved in critical appraisal (using the CASP form for qualitative research) and data extraction (using a data extraction template). One team member appraised and data extracted all items. Two team members appraised and extracted a sample. Differences in quality assessment were resolved through discussion. We did not use critical appraisal for exclusion of items but to describe the reporting quality of items and, for a later ‘sensitivity’ analysis, to see how removing weaker papers impacted the synthesis finding.
All themes and sub-themes identified across included items were entered into an Excel spreadsheet, and then compared, aggregated and re-aggregated into final over-arching themes and sub-themes that accounted for extracted data across all items. The process of reading, comparing, regrouping and reinterpreting data across studies drew on the process of ‘translation’ as used within meta-ethnographic synthesis. Two team members were involved at this stage
The secondary analysis of qualitative data:
A secondary thematic analysis of qualitative interview data, originally collected to explore the impact of DVA on friends and relatives of DVA survivors, was undertaken. The purpose was to examine the impact of exposure to DVA on children, from the perspective of survivors’ friends and family members. Such accounts are largely absent from existing research in this area, and yet bring an adult, non-parent perspective which can broaden our understanding. One team member (AG) read and re-read the 23 interview transcripts, focusing on third parties’ perceptions of children’s experiences, the impact of DVA on survivors’ children, and their thoughts about children’s needs. The data were coded within NVivo10 software. AG provisionally coded all the interviews, and two others (AH, LA) each coded a subset. Through discussion, the codes were developed into higher level categories and themes. An inductive approach was taken, and the coding framework and developing themes were regularly discussed by the study team (particularly in relation to emerging findings from the systematic literature review) and with the project steering group. A final set of themes was agreed.
Findings (compared with objectives)
56 items from the IMPROVE study were identified as meeting VOICES inclusion criteria. An additional 13 items were added from the updated search. The key website search produced 6 items and 2 items were identified by word-of-mouth. Overall, the stage 1 (mapping) stage produced 77 items. Most of these (46) were journal papers. Seventeen PhD theses were identified. Items were published in the period 1991-2016. Data were collected from children and young people aged from 3-25 years old (though our interest was primarily in the accounts by respondents aged under 18). Most items (25) were written by US-based authors, and 21 items written by UK-based authors.
In respect of focus, very few items focused on impact on children’s health/well-being per se. Most items (around a third) had a general focus, while a smaller number reported children’s experiences of interventions. Most authors collected data in face-to-face interviews and thematic analysis was widely used.
At Stage 2 focused synthesis, we selected papers meeting additional inclusion criteria from this pool of 77 items, and identified a small number of key papers via a search of reference lists. The final sample at stage 2 was 33 items. Critical appraisal identified most items as medium-high quality. As noted above, we did not exclude papers on quality grounds.
Synthesis of themes reported in all items identified six over-arching themes:
- Lived experience of DVA: This theme is focused on the nature of the DVA itself, its severity and frequency, and the family and wider context in which DVA occurred. This theme is about context and the lived reality of DVA;
- Actions, agency & coping with DVA: Children’s agency is the focus of this theme, and the myriad ways in which children respond to, and cope with, DVA. These responses occur in the home and can involve leaving home to escape violence. Children report employing a diverse array of tactics and strategies to manage DVA. These change over time in response to changing circumstances, the child’s age, the presence of siblings and the needs of the mother. The ways in DVA is managed can differ by gender and race;
- Seeking help, getting help: This theme captures children’s reports of the point (or points) at which their experience of DVA changed (either by escaping it, or through a parent being killed or through help being sought);
- Managing relationships post-separation: DVA often continues in some form after separation, and can be a feature of fathers’ contact with children. Children can struggle to manage relationships with parents in the post-separation period;
- Impact of DVA: This theme is focused on children’s own reports of the impact of DVA on health and well-being. These can be physical, but are mostly on emotional or mental health, and can also be about effect on own intimate relationships. Disrupted sleep patterns either during or after DVA was a significant health-related issue (referred to in 12 studies);
- 6. Reflecting & learning from DVA: This is a future-oriented theme, one focused on the ways in way children reflect on their experiences, see meaning in it and, in some cases, see the positives in their experiences. Children may draw on religious or spiritual beliefs to help them do this, and they often express a strong sense in a more hopeful
21 of the 23 participants described (to a greater or lesser extent) the experiences of, and subsequent impact on, children exposed to DVA. Participants drew on a variety of sources to identify these experiences, including: participants’ reflections about their own experiences of witnessing DVA during their childhood; participants’ third party reflections on the experiences and impact they had seen on a DVA survivor’s children; participants’ third party reflections on the impacts in adulthood that childhood exposure had had on adults they knew; participants’ third party reflections (where they were also a DVA survivor) about the impacts they had seen on their own children; participants’ third party reflections on the experiences and impact they had seen on children who were the victim of the DVA (i.e. on a DVA survivor aged between 16 and 18 years).
The following themes and sub-themes were generated from their accounts:
- Roles within the abusive situation: Witness of abuse: This theme is about the witnessing (including: seeing, hearing and being exposed to the aftermath) of DVA by children. It includes particular incidents, and also children's arrival in the world following (and in the midst of) abusive behaviours. Victim of abuse: This theme includes direct physical, sexual, emotional and financial abuse of the child/ren by the perpetrator. The abuse may be actual or threatened and occasionally includes a child being at significant risk of harm, whether or not they are aware that this is the case. It also includes examples where children receive disproportionately harsh punishment from DVA perpetrators for minor misdemeanours, and where children were harmed because they tried to intervene in the situation. Conduit of abuse: This theme describes children being used as a means or channel to inflict abuse on the DVA survivor, for example, where they are manipulated, threatened with harm unless the survivor complies, or directly used to abuse the survivor.
- The context of abuse: Chaotic and unpredictable home life: This theme captures the day- to-day inconsistencies and chaos for children exposed to DVA, in terms of the parenting they receive and the changes in contact they have with their parents and other significant It also includes changes to their living environment as a result of the DVA and their inappropriate exposure to co-occurring activities (drug use, crime and pornography) in their home environment.
- Impact of abuse: This theme incorporates the general and specific emotional impacts that are experienced by children exposed to DVA, including: emotional, relationship, physical, sexual and financial impacts. Additionally, the experience of heightened responsibility and having to grow up quickly are
- Resilience and coping: This theme captures some of the longer terms implications of exposure to DVA, covering examples where 'recovery' has or hasn't taken place. It incorporates reflections over time from childhood into
Overarching synthesis of both phases
Across the synthesis and secondary analysis, we identified three overarching themes:
- The lived experience of DVA: chaos, coping, change & uncertainty: This is a large theme focused on the lived experience of DVA - its type, scope and nature - and the child’s role in DVA, as well as the context within which DVA occurs. This context is one often characterised by chaos and an unpredictable home life where drugs and crime may be co-occurring. Even in this setting, children experiencing DVA find often creative ways to manage abuse or protect others. This theme captures the day-to-day inconsistencies and chaos for children exposed to DVA, in terms of the parenting they receive and the changes in contact they have with their parents and other significant people. Importantly, DVA can continue post-separation and children can struggle to manage relationships with parents in the post-separation period;
- Impact of DVA: This theme is about the physical, emotional and other impacts of DVA on Key health impacts for children, from the perspective of children, are often related to injuries sustained during DVA and are also about disrupted sleep patterns;
- Reflection, recovery & resilience: This is a future-oriented theme, focused on reflection and meaning-making. Religion or spiritual beliefs may be part of the process of reflection, as might a belief in a more hopeful future. This theme also captures some of the longer terms implications of exposure to DVA, where 'recovery' has or hasn't taken place. It incorporates reflections over time from childhood into
We noted many similarities, as well as differences, across the two datasets (systematic review and secondary analysis). In relation to the first overarching theme (The lived experience of DVA), a chaotic home and pre-existing family problems were described by both children and friends/family members of survivors. The difficulties of parenting during and after DVA were also reported by children and third parties. Children more frequently (and in greater detail) described their actions when managing DVA compared with survivors’ friends/family members. The impact of DVA on health and well-being was an important theme for both children and friends and family members. Children were less likely to refer to impacts as such, though their accounts do point to these, while third parties had a more ‘global’ understanding of the effects of DVA. Disruption to sleep because of DVA was reported by many children. The financial impacts were described by adults more than children. The idea of Reflection, recovery & resilience was central to accounts of experiences of DVA in both datasets. Friends/family members of survivors - as adults, able to understand DVA from a variety of positions - were able to reflect over a longer time-span than children and make more connections between life event
Expected impact on the relevant field and conclusions
While existing qualitative research does not often focus specifically on impact, accounts from children and related third parties point to profound and long-lasting effects of DVA. Children’s everyday lived reality of DVA often means living with pervasive fear, uncertainty and secrecy, living a childhood far from ‘normal’.
Impacts on health (especially psychological) have been extensively described in the quantitative research. Our findings echo these and add another dimension to our understanding. Qualitative research tells children’s stories of coping against the odds (in often materially deprived environments), responding strategically and creatively to violence, and demonstrating maturity and protectiveness towards others impacted by DVA (e.g. abused mothers, siblings).
This body of work also points to the myriad ways in which children reflect on their experiences to make meaning, and even draw strength from them when thinking about (a more hopeful) future. In addition, accounts by related third parties suggest that this group of people are very mindful of children’s exposure to DVA, often aware of the ways in which children are victims of abuse themselves, are experiencing impact and are coping/recovering. We recommend that professionals interacting with children impacted by DVA (including professionals working within primary care) should be mindful of the diversity in children’s experiences of DVA, listen carefully to children’s own accounts and be prepared to amend support or treatment approaches as children’s stories unfold.
Plain English summary
Around 14% of children will be exposed to domestic violence and abuse (DVA) at some point in their childhoods. Children growing up with DVA can experience major physical and psychological health consequences, many of which will present to general practitioners. Much of the work that measures the impact of DVA on children is based on survey research, which neither captures the depth of experience or the voice of the children themselves. This means that strategies to help children recover may target issues that researchers feel are important, rather than those important to children. As part of a review of programmes for children exposed to DVA, we found several papers reporting how DVA affects children. As part of a qualitative study looking at the impact on friends and relatives of survivors, we generated rich information from other concerned third parties (non-parents) about the impact on children. VOICES aimed to review evidence about how being exposed to DVA affects children’s health and well-being, explore children’s needs after DVA and make recommendations about how primary care might address these needs.
We identified a large, broad body of research on children’s experiences of DVA. From this, we selected key papers for further analysis. The findings from these were summarised, and six main themes focused on children’s experience of DVA could be discerned. Impacts on health are the focus of statistical research in this area; the analysis of the qualitative literature adds another dimension to our understanding. This research tells children’s stories of coping against the odds, responding creatively to violence and demonstrating maturity and empathy (when keeping younger siblings safe, for example, or caring for abused mothers). Qualitative research also points to the many ways in which children reflect on their experiences, and even draw strength from them when thinking about the future. The findings from the secondary analysis with accounts from concerned third parties reinforce notions about the roles children take, the many and varied impacts they experience and the ways in which they cope. Additionally, the context of the abuse, is highlighted, in particular the chaos and unpredictability of these children’s lives.
We recommend that professionals interacting with children exposed to DVA – including professionals working within primary care - should be mindful of the diversity in children’s experiences of DVA, listen carefully to children’s own accounts and amend support and treatment approaches as needed
We submitted the study protocol for publication on the PROSPERO international register of systematic reviews. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016042062
The team wrote a blog post at the start of the study (https://capcbristol.blogs.ilrt.org/2016/04/13/lisa-arai/)
We presented a poster at the NIHR 10 year event (https://www.spcr.nihr.ac.uk/events/ty/10ya-programme-website.pdf).
We presented findings at an internal (CAPC) seminar (17th January) and will present again at a seminar at City University (London) in June 2017.
We plan at least two journal papers. One of these will be an overview of review findings on children’s experience of DVA, to be submitted April/May 2017. The second will focus on reporting the secondary analysis of qualitative data on third party perspectives on impact of DVA on children and will be prepared for submission in April/May 2017.
A key outcome of our study is to generate recommendations for primary care. These recommendations are outlined below and will be incorporated into the various planned dissemination strategies.
Recommendations for primary care to be disseminated
- Given that children can experience diverse forms of DVA, respond to or manage it in different ways, and are differentially impacted, practitioners are advised to be mindful of the dangers of making generalisations when treating children who have experienced DVA;
- Children who have experienced DVA have often experienced multiple instances of loss and disruption (education, home, loss of friends, possibly the murder of a parent). Awareness of this is important in professional interaction with such children;
- Young people’s experiences of DVA happen alongside other life events. Social and economic disadvantages, as well as problems such as drugs, violence and crime, are likely to exacerbate problems faced at home. Professional cognizance of the ways in which some children are multiply disadvantaged is likely to facilitate more effective treatment of children affected by
Nature and impact of DVA:
- Findings from both the review of qualitative research and the secondary analysis resonate with those in statistical work in showing that DVA impacts children’s health and well-being. DVA can affect physical health (especially where a child was deliberately or accidentally injured) and psychological and emotional health (causing fearfulness and anxiety). The impact of DVA varies depending on factors such as the child’s age, the nature of the DVA, pre-existing family difficulties, type and level of professional support available, support from friends and wider family members, as well as the child’s own disposition. Though many commonalities in experience were identified in VOICES, the impact of DVA on each child is, to some extent, unique to that child. Practitioners may find that, when treating such children, what works for one child, may not work for another;
Some research has highlighted how children’s sleep patterns can be disrupted byDVA (because a child remains ‘watchfully’ awake, or sometimes because of the noise generated by arguments). Specialist help may be needed to help children resume normal
- Young people may report coping with DVA in ways which practitioners may see as ‘healthy’ (exercising, playing sports, engaging with services) or ‘unhealthy’ (being aggressive or violent, fighting with siblings, using drugs and alcohol). The latter behaviours are often attempts to cope with DVA and its aftermath. There is a danger of withdrawal from services if young people feel they will be admonished for reporting such activities. A non-judgemental approach is likely to be more effective;
- DVA does not finish post-separation. It can be a feature of a child’s contact with a non- resident father, though the nature of abuse may change, and the child may find that s/he has to manage relationships between separated parents rather than protect an abused mother. Professionals might be consulted by children experiencing on-going problems after parents have separated, and there may be an on-going need for intensive help and support for such
Communication with children:
- Children can struggle to articulate their experiences, which may be related to the severity of their experience, or a sense of DVA being a secret or fear of not being Children need the time and space to relate their experiences to professionals;
- Additional disclosures of abuse may occur over time, as the child reflects on their experience and ‘processes’ it. Healthcare professionals may need to reassess the needs of children at different points in time and be prepared for significant re-evaluation of needs;
- VOICES found that children and young people report responding strategically to DVA, and in diverse ways, many of which involve protecting self and others (mothers, siblings) or being innovative (enlisting the help of others, being proactive in protecting pets, minimising own exposure to DVA). Children might be proud of this and want to describe their actions to
- Professionals providing treatment - whether in primary care or within specialist services – are advised to be careful not to assume that children are ‘damaged’ because of their exposure to DVA. The literature suggests that professionals can differentiate children who have experienced DVA from ‘normal’ children, but not all children appreciate this type of approach;
- Professionals, especially those in specialist services, may find it helpful to consider the role that youth culture plays when dealing with young people who have experienced This is a time of life when young people can be acutely aware of issues around identity, and young people may not want to be seen as different to their peers;
Some research describes differences between girls’ and boys’ coping strategies to the experience of DVA. Boys may describe desires to avenge self or mother, to be a ‘man’ and punish an abusive father. Girls may internalise feelings and struggle to articulate their experiences. These different ways of dealing with DVA may inform treatment approaches, though the type of professional help and support offered will vary according to the preference of the child.
We have encountered problems with the PPI&E element of the project. It has proven difficult to identify a children’s DVA group we might involve in the study, since the group we had originally planned to engage with was no longer in existence. However, we have recently identified new opportunities for engaging with PPI&E work in a related study within the Centre for Academic Primary care and plan to develop this element in the coming weeks, and before submission of papers. This will involve sharing summaries of our data with relevant groups (e.g. children and parents affected by DVA) to ‘sense check’ our interpretations and help develop recommendations for appropriate primary care responses.
While there are a number of reviews (systematic and otherwise) of the quantitative research on the impact of DVA on children and young people, and one qualitative synthesis on children’s experience of coping with DVA (limited to studies published in the period 1991- 2012), this is the first large-scale, systematic review of the qualitative research on children’s (more general) experience of DVA. We believe this review adds a significant new dimension to lay, academic and clinical understandings of the impact of DVA on children. Most of the research previously reviewed, because of its quantitative nature and focus on a limited number of outcomes, provides a useful but partial analysis of children’s experiences.
Qualitative reports drawing on children’s own accounts, and those of concerned adult (non- parent) third parties, resonate with the findings produced by quantitative researchers, but present a broader, more complex, and often more nuanced, picture of children’s experiences and the context within which they occur. This picture also includes evidence of children’s agency and creativity in responding to DVA, and their capacity for meaning making. Read alongside the many quantitative reviews, VOICES will help practitioners gain a more rounded understanding of children’s experiences, so that treatment approaches are evidence-based and appropriately tailored to children’s needs.
This project was funded by the National Institute for Health Research School for Primary Care Research (project number 201852)
Department of Health Disclaimer
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.