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Protecting the Child and the Family: Integrating Domestic Violence Screening Into a Child Advocacy Center
Mary L. Pulido and Divya Gupta Violence Against Women 2002 8: 917 DOI: 10.1177/107780102400447069 The online version of this article can be found at: http://vaw.sagepub.com/content/8/8/917

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VIOLENCE AGAINST Pulido, WOMEN Gupta / / PROTECTING August 2002 THE CHILD AND THE FAMILY

Protecting the Child and the Family

Integrating Domestic Violence Screening Into a Child Advocacy Center

MARY L. PULIDO
The New York Society for the Prevention of Cruelty to Children

DIVYA GUPTA
Albert Einstein College of Medicine

This article presents preliminary data gathered from the pilot study of a domestic violencescreening tool conducted at a child advocacy center. Female caretakers of children who were being evaluated for sexual or physical abuse were screened. Of the caretakers, 67% reported a history of emotional abuse, 64% physical abuse, and 47% sexual abuse. Also, 20% of the women reported physical abuse during pregnancy, 8% reported sexual abuse, and 40% reported emotional abuse. Given the high incidence of the coexistence of child abuse and domestic violence in these families, child abuse evaluations need to assess for family safety.

This article presents preliminary data gathered from a pilot study of a domestic violencescreening tool conducted at the Child Protection Center (CPC) of the Division of Community Pediatrics at Montefiore Medical Center. The CPC is a fully certified child advocacy center (CAC) in the Bronx of New York City. As a CAC, it coordinates a multidisciplinary response to serious cases of child physical and sexual abuse by using a team of medical providers, social workers, police officers, assistant district attorneys, and child protective service workers. Joint forensic interviews are conducted in one location, with all parties present, to expedite the medical, investigative, and prosecutorial procedures and to ensure the immediate safety of the child. As a pediatric specialty clinic in child abuse evaluation, the CPC has evaluated more than 13,000 cases of physical abuse, sexual abuse, and physical neglect since 1984.
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The complexity and severity of the abuse cases seen at the CPC require immediate interagency evaluative efforts and case management among the New York City Administration for Childrens Services, the district attorneys office, the police department, and other agencies. Time is a critical factor in protecting a childs safety and well being, as well as for prosecuting sex offenders and perpetrators of physical abuse. An important benefit of the CAC multidisciplinary team approach is the reduction of stress to the family and child. Children exposed to repeated questioning about the trauma that they endured often recant their statements, become anxious or withdrawn, and experience other psychological effects of posttraumatic stress. The CPC has provided office space on-site to the district attorneys office, the special victims squad of the New York Police Department, and the New York City Administration for Childrens Services to ensure immediate services to abused children and their family members. Until recently, the encounter at the CPC focused on the childs safety. However, during the past 3 years, the CPC has regularly evaluated cases presenting with co-morbidity of child abuse and domestic violence. It was estimated that in 60% of the cases seen at the CPC, both types of violence were present in the home setting. The clinical team would become aware of the issue in one of several ways. The child would disclose family violence during the forensic interview, the caretaker would disclose during the psychosocial assessment of the childs history, or the caretaker and/or child would be afraid to leave the CPC after the child disclosed the abuse, and on further questioning, domestic violence was disclosed. Aware of the growing evidence of the correlation of child abuse and domestic violence, the CPC began to focus on incorporating domestic violence screening into its forensic assessments so that the clinical multidisciplinary team could protect the family from abuse. In 1997, the CPC launched its first domestic violence initiative, Victims of Violence, and began a screening and referral process for women in Montefiore Medical Centers obstetrics/ gynecology clinic. The CPC also provided in-service training for medical center employees in the identification, assessment, and treatment needs of battered women. The CPC also published a reference manual, Safe Connections (Hesse, 2001), to describe resources available to domestic violence survivors. The project

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was funded through the New York State Office of Children and Family Services. This new emphasis on moving the focus of the forensic investigation from protecting only the child to protecting the family resulted in the development of a tool to screen for domestic violence at the CPC in 2001. The CPC sought to redirect the resources of the multidisciplinary team from child-focused evaluations to family-focused investigations, so that all aspects of violence affecting the child could be addressed. Specific questions were addressed in the domestic violence screening study: Are child abuse victims exposed to domestic violence in their households? Have the caretakers of the children who are being evaluated for child abuse experienced sexual, physical, or emotional abuse and/or abuse during pregnancy? Does the health status (physical and emotional) of the caretaker affect her ability to prevent her child(ren) from being abused? A description of the tool, preliminary data analysis, limitations of the study, and recommendations for future research will be described in this article. Given the high incidence of domestic violence identified during the child abuse evaluation, the goal of the CPC will be to move from planning for the safety of the child to planning for the safety of the entire family unit. LITERATURE REVIEW In the past two decades, many researchers have sought to explore the complexities of the existence of multiple types of violence within families and the difficulty in elucidating the links between direct and indirect exposure to violence and a childs health. A national family violence survey indicated that each additional act of violence toward a spouse increases the probability of the abusive partner also being abusive to the child, particularly if the perpetrator is the father (National Center for Injury Prevention and Control, 1985). The hallmark study of Stark and Flitcraft (1988) reported that among the 116 children seen in a hospital for suspected abuse and neglect, 45% of their mothers had histories indicative of domestic violence. Various authors have reported that in 30% to 70% of cases, child abuse and domestic violence coexist in the same family unit (Beeman, Hagemeister, & Edleson, 2001; Duffy, McGrath, Becker, & Linakis, 1999; Edleson,

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1999; McKay, 1994). Several mechanisms exist that explain how children are abused in the context of adult domestic violence. These include accidents during violence that was meant to harm the partner, children intervening on behalf of their mothers, intended child abuse by the mothers batterer, abuse of children by battered women, violence during pregnancy, and child witnesses of domestic violence (McKay, 1994; Mills et al., 2000). Children are not always the primary targets of violence by batterers. Often, they are bystanders and are accidentally hit, or they attempt to intervene and are struck (McKay, 1994). A study of 139 children presenting to the emergency room of an urban medical center with injuries resulting from family violence showed that 48% of the children were younger than 2 years old (Christian, Scribano, Seidl, & Pinto-Martin, 1997). The same study showed that 59% of injured children younger than 2 years old were being held in their mothers arms at the time of injury. Of the adolescents, 78% were injured while attempting to intervene. Bowen (2000) reported that domestic violence occurred in 54% of the homes of children being evaluated for sexual abuse and that 28% of mothers reported being physically abused and 42% sexually abused as children. The American Academy of Pediatrics (1998) issued a policy statement, indicating that pediatricians should screen and intervene on behalf of battered women to actively prevent child abuse. Studies have reported that most pediatricians have received training on child abuse and neglect but not on working with abused mothers (Duffy et al., 1999; Wright, Wright, & Issac, 1997). Reasons given for not addressing issues of abused women include lack of formal training and pediatricians not viewing the health of women as their responsibility. However, Linares et al. (1999) reported that simply asking women if they have been granted an order of protection against anyone can reveal a violent history and could help identify children at risk of abuse and neglect. Violence against pregnant women is another mechanism that connects child abuse and domestic violence. Studies have reported the prevalence of violence during pregnancy as anywhere from 0.9% to 20.1% (Cokkinides, Coker, Sanderson, Addy, & Bethea, 1999; Gazmararian et al., 1996). Women report that pregnancy can often trigger violence or escalate existing violence

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against them. Pregnant women have greater demands on their time and health, thus placing more stress on a relationship. Pregnancy can also isolate women from their support systems, leaving them more vulnerable to the batterer (Noel & Yam, 1992). Violence has been shown to escalate as the pregnancy advances and is targeted toward the abdomen. Pregnant women who report physical violence have been found more likely to deliver by cesarean section, deliver lowbirth weight infants, and have an increased rate of miscarriage, kidney infections, premature labor, and trauma due to blows to the abdomen (Campbell, 1992; Cokkinides et al., 1999). Perhaps, the most troubling correlation between child abuse and domestic violence is that women who are abused may abuse their children. From a feminist perspective, battered women abuse and neglect their children because they are entrapped in their relationship. Therefore, by providing means to empower these women, they will cease the abuse of their children (Peled, 1997; Stark & Flitcraft, 1988). However, it must be recognized that abused women are not a homogeneous group. Some women may unintentionally place their children in danger because they cannot leave an abusive relationship due to the fear of increasing separation assault, fear of separation and loss of custody of children, lack of financial resources, and lack of community and institutional resources (Magen, 1999; Wilson, 1998). Variable access to health care, especially mental health services, is another reason why emotionally troubled, abused women might be neglectful in their parenting roles (Culross, 1999). Safety planning is a critical aspect of advocacy and empowering women to align their resources and support systems to make gradual progress to leave the abusive partner or to protect themselves and the children in the violent relationship (Eisenstat & Bancroft, 1999; Wilson, 1998). Children who witness domestic violence may also experience its effects. Children who grow up in violent households have been reported to suffer from posttraumatic stress disorder, have greater dysfunction with social and professional relationships, exhibit the extremes of aggressive or docile behaviors, and have poorer school and work performances. These children often find themselves being the abuser or enduring abuse in their own personal relationships (Knapp, 1998; McKay, 1994).

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Despite the overlap between child maltreatment and battered women, treatment services have remained separate. Similarly, research in these two fields has developed independently and not under the collective of family violence. Beeman et al. (2001) reported data on 172 families of whom 55.2% had both child maltreatment and domestic assault reports. The conflict among the response of child protective services, the battered womens movement, the health care system, and the courts to coexisting child abuse and domestic violence exists largely because of the separate developments of these movements, seeking different goals and serving different clients. Child protective services workers are equipped to deal with the best interests of the child, which often necessitate removal of the child from the home, blaming the mother for not protecting her children, and in some cases, criminal allegations against the mother. The battered womens movement seeks to address the needs of adult women whose rights and safety have been violated and to address their needs for independence and physical safety (Peled, 1997; Stark & Flitcraft, 1988). There is a tendency to focus on the needs of women and not on the needs of both mothers and their children, both of whom are clearly at risk. In the past few years, there has been a concerted move to integrate services for abused children and abused women. In the 1980s, Boston was one of the first sites to integrate services provided by the public child welfare agency, department of social services, and the advocacy project for battered women, AWAKE (Whitney & Davis, 1999). In Michigan, since 1993, the collaboration between the domestic violence prevention and treatment board, Families First, and childrens protective services (since 1995) has allowed these professionals to address and reframe the issues of family violence and provide services to both abused children and battered women (Findlater & Kelly, 1999). More recently, efforts to integrate service provision have been made by means of training child protective services, battered womens advocates, and the larger community in detecting and addressing the needs of battered women and their children (Mills et al., 2000). Challenges faced by these groups in reframing the definitions of family violence have been similar to those outlined in this review (Findlater & Kelly, 1999; Magen, Conroy, McCartt Hess, Panciera, & Levy Simon, 2001; Mills et al., 2000; Whitney & Davis, 1999).

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Domestic violence and child abuse and neglect are public health issues that are often interrelated. As such, it is critical for health care workers, social welfare institutions, and the legal system to work in collaboration to provide services to all those affected by violence. METHOD
THE DOMESTIC VIOLENCESCREENING TOOL

The CPC developed a 41-item questionnaire that covered the following topics: caretaker demographics, support systems, past relationships and domestic violence incidence, pregnancy information and domestic violence incidence, current relationship status and domestic violence incidence, and caretakers perception of her health and safety. The interviewer completed a summary section after the session with a client. The demographic section included questions on age, ethnicity, marital status, educational level, number and age(s) of child(ren), and relationship to child(ren) being evaluated at the CPC. The support section sought the following information: source(s) of income, source(s) of support if the caretaker needed help, and number of individuals the caretaker considered friends. The section regarding present and past domestic violence incidents included the following questions: Have you ever had an order of protection? Has anyone ever hurt you emotionally (called you names, threatened to hurt you, intimidated you, prevented you from seeing your family and friends, forced isolation)? Did this person ever abuse your children? Information on the caretakers age, the identity of the perpetrator, and the frequency and duration of abuse was collected. Similar questions were repeated for the next two sections, which focused on physical abuse and sexual abuse. Physical abuse was described to the caretaker as being hit, shoved, slapped, kicked, bitten, or hurt with an object/weapon. Sexual abuse was described as stranger or date rape, being forced to engage in sex when she did not want to, being made to perform sexual acts that made her uncomfortable, and being prevented from using contraception.

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A section was added to the questionnaire regarding abuse during pregnancy. The CPCs experience has indicated that the period of pregnancy may offer an opportune time to break the cycle of domestic violence (Pulido, 2001a). Questions asked of the caretakers include the following: Have you ever been pregnant? Did anyone hurt you while you were pregnant? Emotional, physical, and sexual abuse were discussed. The perpetrator, frequency, and duration of the abuse were discussed. The caretaker was also asked if the perpetrator ever abused her child(ren). Health and safety concerns were also covered. The caretaker was asked to rate her emotional and physical health and her current stress level. Depression, suicidal ideation, and use of alcohol and other drugs were discussed. Safety planning was covered with every caretaker who was screened.
PILOTING THE SCREENING TOOL

The CPC developed a script for the clinicians who were interviewing caretakers to introduce the concept of screening for family safety concerns. Most families who are using CACs are under great duress, and the screen was introduced as a way of ensuring womens safety after they left the CPC. The multidisciplinary team tried several methods of incorporating the screen into the clinic schedule to ensure that it was not disruptive to the forensic examination process. The caretaker needed privacy and time to speak with the interviewer about domestic violence issues. The CPC found that the best time to introduce the topic was immediately after the psychosocial assessment of the child, after the caretaker had been asked indepth questions about the child abuse allegation. The caretaker would then be interviewed privately by a bilingual case manager, while the child was undergoing the forensic interview process. Following the screening process, the information gathered about domestic violence concerns was incorporated into the family assessment, and a comprehensive plan was developed to address all issues.

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SAMPLE SELECTION

The respondents consisted of female caretakers who were accompanying a child for a child abuse forensic evaluation between January 2001 and April 2001. Cases were included in this sample if the caretaker was a biological, foster, or adoptive parent. Only patients who agreed to participate were screened. (Only one caretaker refused to participate.)
DATABASE DEVELOPMENT

The CPC used SPSS version 10.0 to develop a database for analyzing the information gathered in the screening process. RESULTS
RESPONDENT DEMOGRAPHICS

In all, 59 female caretakers were screened at the CPC between January 2001 and April 2001 (see Table 1). The mean age was 35 years. The age range of those screened was 19 to 75 years. The majority of the women were Latino (39% Puerto Rican, 8% Dominican). African American women accounted for 30%, West Indians 4%, Asian Americans 4%, and Caucasians 10%. Educational levels varied. The majority of the women had not completed high school (42%). Otherwise, 15% had graduated from high school, 30% had attended college, and 12% had graduated from college and/or attended graduate school. The majority of the women (83%) were the biological parent of the child who was undergoing the child abuse evaluation at the CPC. But 7% were adoptive parents, 7% were foster parents, and 4% were relatives. Of the women, 40% listed public assistance as their primary source of income, 37% were employed full or part time, 9% were dependent on their partners employment, and 7% received disability social security income. The other respondents listed child support and other as financial support.

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VIOLENCE AGAINST WOMEN / August 2002 TABLE 1 Demographics of Female Caretakers (N = 59)

Variable Race/ethnicity Latina African American Caucasian Caribbean Islander Asian Islander Education Less than high school High school graduate or graduate equivalency degree Some college College graduate or graduate school Relationship to child evaluated at the Child Protection Center Biological parent Adoptive parent Foster parent Relative Sources of family income Public assistance Self-, full-, or part-time employment Partners employment Disability/social security income

n 31 18 6 2 2 25 9 18 7 49 4 4 2 24 22 5 4

% 52 30 10 4 4 42 15 30 12 83 7 7 4 40 37 9 7

HISTORY OF ABUSE

Of the women surveyed, 68% reported a past history of emotional abuse, 64% reported a past history of physical abuse, and 48% reported a past history of sexual abuse. Also, 20% of the women reported that they had been physically abused during pregnancy, 41% reported being emotionally abused during pregnancy, and 9% reported being sexually abused during pregnancy.
CURRENT ABUSE AND USE OF RESTRAINING ORDERS

As Table 2 shows, 12% of the women stated that they were currently in an abusive relationship. Of these, 5% reported physical abuse, 5% reported emotional abuse, and 2% reported sexual abuse. Restraining orders had been obtained by 45% of the women who were surveyed. The restraining orders were against their ex-partners, ex-husbands, and current husbands.

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TABLE 2 History of Abuse Among Caretakers (N = 59) Variable Incidence of past domestic violence Emotional abuse Physical abuse Sexual abuse Incidence of current domestic violence Emotional abuse Physical abuse Sexual abuse Incidence of violence during pregnancy Emotional abuse Physical abuse Sexual abuse History of use of restraining orders against ex-partners, ex-husbands, and current husbands n 40 38 28 3 3 1 24 12 5 27 % 68 64 48 5 5 2 41 20 9 45

ABUSE OF CHILDREN

Of the women surveyed, 10% stated that the perpetrator of their abuse had also physically abused their children, 17% stated that the perpetrator had emotionally abused their children, and 7% reported that the perpetrator had sexually abused their children. Also, 55% of the women stated that their children had witnessed them being abused by the perpetrator, and 27% of these women also reported that they had witnessed their parents engage in violent altercations while they were children.
HEALTH STATUS OF THE SURVIVOR

The majority of the women (61%) stated that they were in good physical health, 32% in fair health, and 7% in poor health (see Table 3). Emotional health was reported as good by 50%, fair by 30%, and poor by 20%. Of the women, 44% reported feeling depressed frequently, and 17% felt depressed always. Also, 37% stated that they were not depressed, and 25% of the women reported that they had attempted suicide.

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TABLE 3 Health Status of Survivor (N = 59) Variable Physical health Good Fair Poor Emotional health Good Fair Poor Self-reported depression Always Frequently Never Previous suicide attempt n 36 19 4 29 18 12 10 27 22 15 % 61 32 7 50 30 20 17 44 37 25

CASE STUDIES

The following case studies are examples of the painful abuse that permeates the lives of these women and their children. They emphasize the need to incorporate domestic violence screening into CACs. A 27-year-old mother of three children came to the CPC so that one of her children could be evaluated for sexually acting out behavior. During the course of the interview, she disclosed a history of battering by the father. The battering also occurred during her pregnancies and included unwanted forced sexual activity, punching, kicking, and derogatory remarks about her appearance. He threatened her into submission and told her that he would flee with the children if she took action against him. A 35-year-old female with three children reported that when she was a teenager, she was emotionally, physically, and sexually abused by an uncle. She had an order of protection against her childrens father due to daily emotional and frequent physical and sexual abuse. He also emotionally, physically, and sexually abused her while she was pregnant because he did not want children. He also frequently hit their oldest son. She reported that her ex-partner would beat her and then make her children hit her also and call her names. This client reported that she had suicidal and

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homicidal thoughts (directed toward her children) and that she had tried to commit suicide in the past. A25-year-old woman with two children reported multiple incidents of emotional, physical, and sexual abuse. She had an order of protection against an ex-partner and was emotionally and physically abused by both of her childrens fathers. She had been in and out of the shelter system and had received domestic violence assistance from family members, police, neighbors, and a local domestic violence agency. Her sons father had also emotionally and physically abused her son on many occasions and had been incarcerated for several years. She reported feeling very anxious and depressed because her sons father had been released from prison and was threatening to harm her and her son. A 34-year-old female with five children who was currently in a relationship reported having an order of protection against her childrens father due to frequent emotional and physical abuse. On one occasion, he held a loaded shotgun to her face. She had him arrested, and he served 30 days before being released on bond. She is currently in a nonabusive relationship and reported that she does have a safety plan for herself and her children in the event of any further abuse.
STUDY LIMITATIONS

Due to the purposive nature of the sample, the results of this study are limited in their generalizability to the general population. They are of interest to pediatric child abuse clinics, CACs, and child protective service agencies that regularly interview abuse victims. This was the first time that this questionnaire was used in a CAC. Therefore, it would be desirable for other CACs to use this survey so that comparisons can be made. Finally, this study reports on a limited sample size of 59 participants. DISCUSSION AND CONCLUSION It is clear that the development and implementation of a domestic violencescreening questionnaire assisted in the identification of families in which women were experiencing domestic violence. The goal of identifying all types of family violence that could affect the child abuse victim was aided by this effort. The

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significant correlation of cases that presented with domestic violence and child abuse serves to reinforce the growing awareness of the need to protect the family as opposed to just focusing on the identified child victim. The high incidence of disclosure rates of past and present domestic abuse should be noted. All the study participants disclosed their abuse on their first visit to the clinic. The presence of the multidisciplinary team may have made caretakers feel more supported in their ability to disclose. That their child was being evaluated for abuse may have aided them in their ability to disclose their own abuse. Disclosure may also be due to several other factors, such as the family-centered care approach used at the CPC and that the clinicians who were screening had received extensive domestic violence assessment training and were sensitive to the womens safety needs. Training for providers to enable them to more competently interview women about histories of interpersonal violence is important. The multidisciplinary response that is available at CACs can be a tremendous asset in dealing with cases that present with domestic violence and child abuse. The CPC conducted a series of training sessions for the police, district attorneys, and child protective service workers who are part of the team, so that service provision to these families could be coordinated. Medical centerbased CACs have an added advantage of being able to immediately address the physical and psychological needs of both battered women and child abuse survivors. There is no easy way to do this work. It takes a significant investment of time and energy. Collaboration and support of a multidisciplinary team of service providers is essential. The mental health needs of the caretakers were significant in the rates of depression and history of past suicide attempts. Staff conducting domestic violence screening should be aware of available resources to cover both emergency psychiatric services and long-term therapy referral. The impact of this issue on the ability of women who are experiencing severe depression to protect their children warrants further research. The CPC found that asking a caretaker if they have ever had a restraining order opened the door to a further discussion of the incidence of violence. It may be easier for the woman to discuss this issue as she has already taken steps to combat the violence in

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her life. It is recommended that this question be added to a providers intake assessment of all female patients, as it may present an opportunity to engage the woman in a discussion about domestic violence issues. All providers who are screening for family violence need to be aware of the advocacy that must continue at the city, state, and federal levels so that adequate funding for services is available to help survivors of trauma. Families involved in domestic violence often require emergency and long-term transitional shelter, employment services, access to medical and mental health care, and assistance navigating the legal systems to protect the family from future violence. Demand also exceeds capacity for services for the perpetrators of the abuse. There must be a concerted effort by advocates from the child abuse and domestic violence arenas to promote legislation and policy to address these issues. Our understanding of the connection between child abuse and domestic violence is growing but is still limited. A research agenda that will enable us to gain a better understanding of the pervasiveness of violence in families and to determine the effectiveness and the scope of services needed to address their safety is needed. Interventions and services that protect the child and the family must be explored. REFERENCES
American Academy of Pediatrics. (1998). Policy statement: The role of the pediatrician in recognizing and intervening on the behalf of abused women. Pediatrics, 101, 1091-1092. Beeman, S. K., Hagemeister, A. K., & Edleson, J. L. (2001). Case assessment and service report in families experiencing both child maltreatment and woman battering. Journal of Interpersonal Violence, 16, 437-458. Bowen, K. (2000). Child abuse and domestic violence in families of children seen for suspected child abuse. Clinical Pediatrics, 39, 33-40. Campbell, J. C. (1992). Addressing battering during pregnancy: Reducing low birth weight and ongoing abuse. Seminars in Perinatology, 19, 301-306. Christian, C. W., Scribano, P., Seidl, T., & Pinto-Martin, J. A. (1997). Pediatric injury resulting from family violence. Pediatrics, 99, e8. Cokkinides, V. E., Coker, A. L., Sanderson, M., Addy, C., & Bethea, L. (1999). Physical violence during pregnancy: Maternal complications and birth outcomes. Obstetrics and Gynecology, 93, 661-666. Culross, P. L. (1999). Health care system responses to children exposed to domestic violence. The Future of Children, 9, 111-121. Duffy, S. J., McGrath, M. E., Becker, B. M., & Linakis, J. G. (1999). Mothers with histories of domestic violence in a pediatric emergency department. Pediatrics, 103, 1007-1013.

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Edleson, J. L. (1999). The overlap between child maltreatment and woman battering. Violence Against Women, 5, 134-154. Eisenstat, S. A., & Bancroft, L. (1999). Domestic violence. New England Journal of Medicine, 341, 886-892. Findlater, J. E., & Kelly, S. (1999). Reframing child safety in Michigan: Building collaboration among domestic violence, family preservation, and child protection services. Child Maltreatment, 4, 167-174. Gazmararian, J. A., Lazorick, S., Spitz, A. M., Ballard, T. J., Saltzman, L. E., & Marks, J. S. (1996). Prevalence of violence against pregnant women. Journal of the American Medical Association, 275, 1915-1920. Hesse A. (2001). Safe connections. Bronx, NY: Child Protection Center, Montefiore Medical Center Knapp, J. F. (1998). The impact of children witnessing violence. Pediatric Clinics of North America, 45, 355-364. Linares, L. O., Groves, B. M., Greenberg, J., Bronfman, E., Augustyn, M., & Zuckerman, B. (1999). Restraining orders: A frequent marker of adverse maternal health. Pediatrics, 104, 249-257. Magen, R. H. (1999). In the best interests of battered women: Reconceptualizing allegations of failure to protect. Child Maltreatment, 4, 127-135. Magen, R. H., Conroy, K., McCartt Hess, P., Panciera, A., & Levy Simon, B. (2001). Identifying domestic violence in child abuse and neglect investigations. Journal of Interpersonal Violence, 16, 580-601. McKay, M. M. (1994). The link between domestic violence and child abuse: Assessment and treatment considerations. Child Welfare League of America, 73, 29-39. Mills, L. G., Friend, C., Conroy, K., Fleck-Henderson, A., Krug, S., Magen, R. H., et al. (2000). Child protection and domestic violence: Training, practice, and policy issues. Children and Youth Services Review, 22, 315-332. National Center for Injury Prevention and Control. (1985). The co-occurrence of intimate partner violence against mothers and abuse of children. Retrieved from http://www.cdc.gov/ ncipc/factsheets/dvcan.htm Noel, N. L., & Yam, M. (1992). Domestic violence: The pregnant battered woman. Nursing Clinics of North America, 27, 871-884. Peled, E. (1997). The battered womens movement response to children of battered women: A critical analysis. Violence Against Women, 3, 424-446. Pulido, M. (2001a). Pregnancy: An opportunity to break the cycle of domestic violence. Journal of Health and Social Work, 26(2), 120-124. Stark, E., & Flitcraft, A. H. (1988). Women and children at risk: A feminist perspective on child abuse. International Journal of Health Services, 18, 97-118. Whitney, P., & Davis, L. (1999). Child abuse and domestic violence in Massachusetts: Can practice be integrated in a public child welfare setting? Child Maltreatment, 4, 158-166. Wilson, C. (1998). Are battered women responsible for protection of their children in domestic violence cases? Journal of Interpersonal Violence, 13, 289-293. Wright, R. J., Wright, R. O., & Issac, N. E. (1997). Response to battered mothers in the pediatric emergency department: A call for an interdisciplinary approach to family violence. Pediatrics, 99, 186-192.

Mary L. Pulido, MAT, CSW, currently serves as the executive director of the New York Society for the Prevention of Cruelty to Children. She was the executive director of the Child Protection Center at Montefiore Medical Center, Bronx, New York, from 1996 to 2001. She is the principal investigator for the Administration

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on Children, Youth, and Families (U.S. Department of Health and Human Services) on neglect prevention among teen mothers. She is currently pursuing her doctorate in social welfare at the City University of New York, where a focus of her research has been domestic violence and child abuse intervention, and trauma due to terrorism. Divya Gupta, MD, is a graduate of the Albert Einstein College of Medicine in the Bronx, New York. She completed her undergraduate studies at Cornell University in biological sciences. She has coordinated domestic violence interventions at the Child Protection Center at Montefiore Medical Center since 1999. She also serves as an emergency room advocate for women who have been sexually assaulted and sits on the board of Medical Students for Choice. She plans to pursue a career as an obstetrician and gynecologist.