Executive Summary

In the past three decades, family violence—which includes child maltreatment, domestic violence, and elder abuse—has emerged as a major social, health, and law enforcement issue. In addition to child and adult homicides, family violence contributes to a broad array of fatal and nonfatal injuries and medical and psychiatric disorders each year. In addition, family violence has been associated with numerous social problems, including teenage pregnancy, runaway and homeless youth, alcoholism and substance abuse, and crime and delinquency. The association of family violence victimization with such an extensive range of health, mental health, and behavioral dysfunctions suggests that interventions that can lead to the reduction or prevention of family violence would contribute to the resolution of these other problems as well.

The rate of family violence victimization in the U.S. population is widely regarded as a serious problem that affects large numbers of children and adults, but there are currently no generally agreed-on national statistics that measure the experience with family violence across the life span. Varying estimates of the scope of the different forms of family violence exist that draw on self-report surveys, crime reports, and child protective services records. Recent government surveys indicate that almost 3 million children in the United States are annually reported to child protective services agencies as alleged victims of maltreatment (including neglect, physical abuse, sexual abuse, and emotional maltreatment), and at least one-third of these cases are confirmed. National crime victimization surveys indicate that the rate of reported violent attacks by family members was 9.3 per 1,000 in 1992-1993. Other self-report surveys have indicated annual rates of domestic violence that range from 12 per 1,000 (for acts of marital rape) to 116



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--> Executive Summary In the past three decades, family violence—which includes child maltreatment, domestic violence, and elder abuse—has emerged as a major social, health, and law enforcement issue. In addition to child and adult homicides, family violence contributes to a broad array of fatal and nonfatal injuries and medical and psychiatric disorders each year. In addition, family violence has been associated with numerous social problems, including teenage pregnancy, runaway and homeless youth, alcoholism and substance abuse, and crime and delinquency. The association of family violence victimization with such an extensive range of health, mental health, and behavioral dysfunctions suggests that interventions that can lead to the reduction or prevention of family violence would contribute to the resolution of these other problems as well. The rate of family violence victimization in the U.S. population is widely regarded as a serious problem that affects large numbers of children and adults, but there are currently no generally agreed-on national statistics that measure the experience with family violence across the life span. Varying estimates of the scope of the different forms of family violence exist that draw on self-report surveys, crime reports, and child protective services records. Recent government surveys indicate that almost 3 million children in the United States are annually reported to child protective services agencies as alleged victims of maltreatment (including neglect, physical abuse, sexual abuse, and emotional maltreatment), and at least one-third of these cases are confirmed. National crime victimization surveys indicate that the rate of reported violent attacks by family members was 9.3 per 1,000 in 1992-1993. Other self-report surveys have indicated annual rates of domestic violence that range from 12 per 1,000 (for acts of marital rape) to 116

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--> per 1,000 (for any act of violence). There are no self-report surveys of elder abuse, and the surveys of elder abuse reporting and recognition are incomplete. The U.S. General Accounting Office has estimated that treatment services for child maltreatment alone (such as child protective services, child mental health services, and court expenses) cost in the range of $500 million annually. Preliminary estimates of the costs of direct services and enforcement efforts aimed at family violence in Canada range between $1.5 and $4.2 billion. These estimates are generally regarded as conservative, since family violence may be a hidden but contributing factor to injuries, disorders, and crimes for which services or enforcement efforts are provided. The urgency and magnitude of the problem of family violence have caused policy makers, service providers, and advocates to take action in the absence of scientific knowledge that could inform policy and practice. The rush to do something has resulted in a broad array of community agency services, law enforcement approaches, and health care practices—a wealth of program experimentation that is extensive but uncoordinated. Most interventions have their origins in local and national advocacy efforts, and as such they have remained largely undocumented and unanalyzed in the research literature. Programs are often put into place without collecting baseline information about existing services or client characteristics, testing preliminary designs, or specifying—let alone measuring—the outcomes that the interventions are expected to achieve. Existing interventions include child and adult protective services, battered women's shelters, special police and prosecution units focused on child maltreatment and domestic violence, victim advocates in health and law enforcement agencies, fatality review teams, guidelines and treatment protocols for health care providers, family support services (including home visitation and intensive family preservation services), and child advocacy centers. They can be arrayed conceptually along a continuum of strategies that include prevention, identification, protection, treatment, enforcement, punishment, and deterrence. Many services have been put into place with limited resources. The extent to which interventions have been implemented as designed is seldom documented, and often they are not fully implemented because of budget shortages in local agencies. For the research community, service providers, program sponsors, and policymakers, the challenge is to determine if and where the research evidence is sufficient to guide a critical examination of selected components of family violence interventions. This examination is complicated by the fragmentation and uneven distribution of the research and program literature. Service providers and researchers who focus on one type of family violence or one institutional setting (social services, law enforcement, or health care) are often unfamiliar with key interventions and research evaluations in other areas. Yet there are multiple interventions focused directly or indirectly on family violence alongside each other in most communities, raising important but unexamined questions about interactive and synergistic effects.

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--> Services are separated by the institutional settings and community jurisdictions in which they are located. Family violence interventions may focus on victims, offenders, service providers, witnesses, families, or communities. Interventions are generally specific to a certain type of maltreatment. Although many different agencies play important roles in seeking to prevent, identify, treat, or punish family violence, their efforts are largely uncoordinated. As a result, they lack shared strategies and common frameworks that could guide efforts to identify common goals, create common measures of service performance, pool resources when appropriate, and guide the implementation and development of selected interventions. The Role Of Science In The Assessment Of Interventions In reviewing the research literature on evaluations of family violence interventions, the Committee on the Assessment of Family Violence Interventions identified 114 evaluation studies conducted in the period 1980-1996 that have sufficient scientific strength to provide inferences about the effects of specific interventions in the area of child maltreatment, domestic violence, and elder abuse. Because the committee was charged with focusing on questions about the effectiveness of interventions (rather than, for example, questions about the severity of the problem of family violence or the process of implementing interventions), we identified a core group of studies for review that included a control or comparison group (rather than simply conducting pre- and postintervention studies on the clients of a specific treatment or prevention program). Hundreds of other descriptive research studies or process evaluations have been published that provide other insights into the characteristics of an intervention and its clientele, but they do not have sufficient rigor to examine the impact or the relative effectiveness of the intervention compared with other treatment or prevention efforts. In most cases, the set of 114 studies that forms the evidentiary base for this report also used reliable research instrumentation to measure the impact of the intervention itself on child or adult cognitive skills, attitudes, behavior, and physical and mental health as well as the impact on rates of family violence reports. However, it is important to note that comparison groups can be severely distorted by selection bias, differential attrition, and failure to consider critical unmeasured differences among groups—factors that have plagued the literature in the family violence area. In addition, the number of participants in these individual evaluation studies is often very small, which reduces their strength in examining the overall effectiveness of the intervention in addressing family violence. What can be said about the relative effectiveness of specific innovative interventions is also limited by the absence of reliable research information about the nature, quality, and impact of existing community services. A critical review of this core group of studies illuminates both the quality of

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--> TABLE S-1 Total Number of Quasi-Experimental Evaluations of Family Violence Interventions by Service Sector, 1980-1996   Type of Family Violence Service Sector Child Maltreatment Domestic Violence Elder Abuse Social service 50 7 2 Legal 4 19 0 Health care 24 8 0   SOURCE: Committee on the Assessment of Family Violence Interventions, National Research Council and Institute of Medicine, 1998. the family violence evaluation research and the developmental history of this field. Almost half of the studies identified (50 of 114 studies) involve evaluations of social service interventions for child maltreatment (see Table S-1). The majority of evaluations of domestic violence interventions (19 of 34 studies) focus on law enforcement strategies. Rigorous evaluations for elder abuse interventions in any institutional setting are almost nonexistent. Evaluations of any type of family violence intervention in health care settings (with the exception of home visitation programs) are comparatively rare. In some areas, nevertheless, the body of research is sufficient to inform policy choices, program development, evaluation research, data collection, and theory building; the committee's conclusions and policy recommendations about these interventions are highlighted below. In other areas, although the research base is not yet mature enough to guide policy and program development, in the committee's For this second tier of interventions, the committee makes recommendations for future evaluation studies, also presented below. The committee has also identified a set of four topics for basic research that judgment some interventions are ready for rigorous evaluation studies. reflect current insights into the nature of family violence and trends in family violence interventions. Conclusions The committee's conclusions are derived from our analysis of the research literature as well as discussions with service providers: Findings from small-scale studies are often adopted into policy and professional practice without sufficient independent replication or reflection on their possible shortcomings; Identification and treatment interventions predominate over preventive

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--> strategies in all areas of family violence, reflecting a current emphasis on after-the-fact interventions rather than proactive approaches in the design of interventions; Interventions exist in an uncoordinated system of services whose effects interact on the problem of family violence in a way that presents a major challenge to their evaluation; Secondary prevention efforts have emerged in some areas (such as home visitation services and child witness to violence interventions) that show some promise of impact on the problem of family violence by concentrating services on targeted populations at risk; An increasing emphasis on the need for integration of services is stimulating interest in comprehensive and cross-problem approaches that can address family violence in the context of other problem behaviors; and The duration and intensity of the mental health and social support services needed to influence behaviors that result from or contribute to family violence may be greater than initially estimated. Recommendations For Current Policies And Practices It is premature to offer policy recommendations for most family violence interventions in the absence of a research base that consists of well-designed evaluations. However, the committee has identified two areas (home visitation and intensive family preservation services) in which a rigorous set of studies offers important guidance to policy makers and service providers. In four other areas—reporting practices, batterer treatment programs, record keeping, and collaborative law enforcement strategies—the committee has drawn on its judgment and deliberations to encourage policy makers and service providers to take actions that are consistent with the state of the current research base. Recommendation 1: The committee recommends that states initiate evaluations of their current reporting laws addressing family violence to examine whether and how early case detection leads to improved outcomes for the victims or families and promote changes based on sound research. In particular, the committee recommends that states refrain from enacting mandatory reporting laws for domestic violence until such systems have been tested and evaluated by research. In reviewing the research base associated with the relationship between reporting systems and the treatment and prevention of family violence, we observed that no existing evaluation studies can demonstrate the value of mandatory reporting systems compared with voluntary reporting procedures in addressing child maltreatment or domestic violence. For elder abuse, studies suggest that a high level of public and professional awareness and the availability of comprehensive

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--> services to identify, treat, and prevent violence are preferable to reporting requirements in improving rates of case detection. The absence of a research base to support mandatory reporting systems raises questions as to whether they should be recommended for all areas of family violence. The committee therefore suggests that it is important for the states to proceed cautiously at this time and to delay adopting a mandatory reporting system in the area of domestic violence until the positive and negative impacts of such a system have been rigorously examined in states in which domestic violence reports are now required by law. In the committee's view, mandatory reporting systems have some disadvantages in cases involving domestic violence, especially if the victim objects to such reports, if comprehensive community protections and services are not available, and if the victim is able to gain access to therapeutic treatment or support services in the absence of a reporting system. Recommendation 2: In the absence of research that demonstrates that a specific model of treatment can reduce violent behavior for many domestic violence offenders, courts need to put in place early warning systems to detect failure to comply with or complete treatment and signs of new abuse or retaliation against victims, as well as to address unintended or inadvertent results that may arise from the referral to or experience with treatment. Court mandates for treatment are becoming increasingly widespread in the area of domestic violence, but the effectiveness of batterer treatment has not been examined in rigorous scientific studies. The research base does not yet suggest a specific treatment model that is appropriate for most batterers. Batterer treatment programs may be helpful for some offenders but require stronger mechanisms to enforce referrals, to establish penalties for failure to comply with program requirements, to identify and develop program components that can address the needs of different types of batterers, and to consider the unintended or inadvertent results that may be a consequence of the treatment program, such as the possible desensitizing effects of an offender's recognition that other individuals are batterers or exposure to experiences with diverse forms of violent or coercive behavior. Recommendation 3: The committee recommends that health care and social service providers develop safeguards to strengthen their documentation of abuse and histories of family violence in both individual and group records, regardless of whether the abuse is reported to authorities. Such documentation should be designed to record voluntary disclosures by both victims and offenders and to enhance early and coordinated interventions that can provide a therapeutic response to experiences with abuse or neglect. Safeguards are required, however, to ensure that such documentation does not lead to victim stigmatization, encourage discriminatory practices, or violate assurances of privacy and confidentiality.

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--> Recommendation 4: Collaborative strategies among caseworkers, police, prosecutors, and judges are recommended as law enforcement interventions that have the potential to improve the batterer's compliance with treatment as well as the certainty of the use of sanctions in addressing domestic violence. In the committee's view, collaborative law enforcement strategies that create a web of social control for offenders are worth testing to determine if such efforts can achieve a significant deterrent effect in addressing domestic violence. Collaborative strategies include such efforts as victim support and offender tracking systems that are designed to increase the likelihood that domestic violence cases will be prosecuted when an arrest has been made, that sanctions and treatment services will be imposed when evidence exists to confirm the charges brought against the offender, and that penalties will be invoked for failure to comply with treatment conditions. Creating the deterrent effect, however, requires extensive coordination and reciprocity among diverse sectors of the law enforcement and social services community that may be difficult to implement and evaluate. Early efforts to control domestic violence through deterrence relied on single strategies (such as the use of arrest) that have now been studied. Although the arrest studies provide empirical support for the use of deterrence in dealing with specific groups of batterers, the differing effects of arrest for employed/unemployed and married/unmarried individuals call into question the reliance of law enforcement officers on arrest as the sole or central component of their response to domestic violence incidents in communities where domestic violence cases are not routinely prosecuted, where sanctions are not imposed by the courts, or where victim support programs are not readily available. What remains to be determined is whether collaborative approaches have the ability to establish deterrence for larger numbers or different types of batterers and how the costs and benefits of increased agency coordination compare with those that could be achieved by a single law enforcement strategy (such as arrest) in dealing with different populations of offenders and victims. Recommendation 5: As part of a comprehensive prevention strategy for child maltreatment, the committee recommends that home visitation programs should be particularly encouraged for first-time parents living in social settings with high rates of child maltreatment reports. Evaluation studies are needed to determine the factors that may influence the effectiveness of home visitation programs, including (1) the conditions under which home visitation services are provided as part of a continuum of family support programs, (2) the types of parenting behaviors that are most and least amenable to change as a result of home visitation, (3) the duration and intensity of services (including amounts and types of training for home visitors) that are necessary to achieve positive outcomes for high-risk families, (4) the experience of fathers in general and of families in diverse ethnic communities in particular

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--> with home visitation interventions, and (5) the need for follow-up services once the period of home visitation has ended. Recommendation 6: Intensive family preservation services represent an important part of the continuum of family support services, but they should not be required in every situation in which a child is recommended for out-of-home placement. Research findings suggest that intensive family preservation services do not show an ability to resolve underlying family dysfunction or to improve child well-being or family functioning in most families. However, methodological shortcomings in these studies suggest that measures of child health, safety, and well-being often are not included in evaluations of intensive family preservation services, so it is difficult to determine their impact on children's outcomes as well as placement rates and levels of family functioning. It is particularly important to include evidence of recurrence of abuse of the child or other family members. Intensive family preservation services may provide important benefits to the child, family, and community in the form of emergency assistance, improved family functioning, better housing and environmental conditions, and increased collaboration among discrete service systems. These services may also result in child endangerment, however, when a child remains in family environments that threaten the health or physical safety of the child or other family members. Research Recommendations Determining which interventions should be selected for rigorous and in-depth evaluations in the future will acquire increased importance as the array of family violence interventions expands in social services, law, and health care settings. For this reason, clear criteria and guiding principles are necessary to guide sponsoring agencies in their efforts to determine which types of interventions are suitable for evaluation research. Recognizing that all promising interventions cannot be evaluated, public and private agencies need to consider how to invest research resources in areas that show programmatic potential as well as an adequate research foundation. To assist in this evaluation selection process, the committee developed the following guiding principles: An intervention should be mature enough to warrant evaluation. An intervention should be different enough from existing services that its critical components can be evaluated. Service providers should be willing to collaborate with the researchers and appropriate data should be accessible in the service records. Satisfactory measures should exist to assess service processes and client outcomes.

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--> Adequate time and resources should be available to conduct a quality assessment. With these principles in mind, the committee has identified a set of interventions that are the focus of current policy attention and service innovation efforts but have not received significant attention from research. In the committee's judgment, each of these nine interventions has reached a level of maturation and preliminary description in the research literature to justify their selection as strong candidates for future evaluation studies: (1) family violence training for health and social service providers and law enforcement officials; (2) universal screening for family violence victims in health care and child welfare settings; (3) comprehensive community initiatives; (4) shelter programs and other domestic violence services; (5) protective orders; (6) child fatality review panels; (7) mental health and counselling services for child maltreatment and domestic violence; (8) child witness to violence prevention and treatment programs; and (9) elder abuse services. The committee identified four research topics that require further development to inform policy and practice. These topics raise fundamental questions about the approaches that should be used in designing treatment, prevention, and deterrence strategies: Cross-problem research (such as the relationship between substance abuse and family violence); Studies of family dynamics and processes that interact with family violence; Cost analysis and service system studies that describe the existing set and distribution of services focused on different forms of family violence; Social setting issues that warrant study because of their implications for the design of treatment, support, prevention, and deterrence strategies. Challenges To Effective Evaluations In recommending this research agenda, the committee recognizes that such research is complicated by a number of factors. Service providers and researchers are realizing that family violence is an interactive, dynamic, and complex problem that requires approaches across multiple levels of analysis (individual, family, community) and multiple service systems. The presence or absence of policies and programs in one domain may directly affect the implementation and outcomes of service strategies in another. Services also interact with the characteristics of the client: some people need more support or stronger sanctions, depending on their histories and life circumstances; others need only a limited amount of assistance, treatment, or sanction to improve.

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--> The lack of collaboration between researchers and service providers has impeded the development of appropriate measures and study designs in assessing the effectiveness of programs. It has also discouraged research on the design and implementation of service interventions and the multiple pathways to services that address the causes and consequences of family violence. To improve evaluations of family violence interventions and to provide a research base that can inform policy and practice, major challenges must be addressed. These challenges include issues of study design and methodology, as well as logistical concerns, that must be resolved in order to conduct rigorous research in open service systems in which many factors are not under the control of the research investigator. Meeting these challenges will require collaborative partnerships among researchers, service providers, and policy makers to generate approaches and data sources that are useful to all. The establishment and documentation of a series of consensus conferences on relevant outcomes, and appropriate measurement tools, will strengthen and enhance evaluations of family violence interventions and lead to improvements in the design of programs, interventions, and strategies. The development of the next generation of evaluation studies will benefit from the building blocks of knowledge that have been put into place over the past 15 years. This research base, and the convergence of the field around such issues as the recognition of the interactive nature of the service system in different institutional settings, the existence of multiple subgroups of offenders, the need for research experimentation to guide treatment and prevention efforts, and the use of multiple measures of program outcomes suggest that a richer and deeper understanding of family violence interventions lies within reach in the decade ahead.