Child Abuse & Neglect 27 (2003) 12311246

Behavioral problems among children whose mothers

are abused by an intimate partner
Mary A. Kernic a, , Marsha E. Wolf a , Victoria L. Holt a , Barbara McKnight b ,
Colleen E. Huebner c , Frederick P. Rivara a,d
a

Department of Epidemiology, School of Public Health and Community Medicine,

University of Washington, Seattle, WA, USA
b
Department of Biostatistics, School of Public Health and Community Medicine,
University of Washington, Seattle, WA, USA
c
Department of Health Services, School of Public Health and Community Medicine,
University of Washington, Seattle, WA, USA
d
Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
Received 13 November 2002; received in revised form 3 December 2002; accepted 14 December 2002

Abstract
Objectives: To determine the association between childrens exposure to maternal intimate partner
violence (IPV) and behavior problems as measured by the parent report version of the Child Behavior
Checklist (CBCL).
Methods: The study population was comprised of 167 2- to 17-year-old children of Seattle women
with police-reported or court-reported intimate partner abuse. The CBCL normative population served
as the comparison group. Risk of behavior problems was calculated among the exposed children, in the
presence and absence of a history of reported child maltreatment, relative to the normative population.
Multiple logistic regression served as the primary method of analysis.
Results: Children exposed to maternal IPV were more likely to have borderline to clinical level scores
on externalizing (i.e., aggressive, delinquent) behavior (RR = 1.6, 95% CI: 1.2, 2.1) and total behavioral
problems (RR = 1.4, 95% CI: 1.1, 1.9) compared to the CBCL normative sample after adjusting for age
and sex. Children who were exposed to maternal IPV and were victims of child maltreatment were more
likely to receive borderline to clinical level scores on internalizing (i.e., anxious, depressed) behaviors
(RR = 2.6, 95% CI: 1.5, 3.6), externalizing (i.e., aggressive, delinquent) behaviors (RR = 3.0, 95% CI:
1.9, 4.0) and total behavioral problems (RR = 2.1, 95% CI: 1.2, 3.2) compared to the CBCL normative
sample after adjusting for age and sex.

Corresponding author address: Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth
Avenue, Seattle, WA 98104-2499, USA.
0145-2134/$ see front matter 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chiabu.2002.12.001

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M.A. Kernic et al. / Child Abuse & Neglect 27 (2003) 12311246

Conclusions: Exposure to maternal IPV is significantly associated with child behavioral problems both
in the presence and absence of co-occurring child maltreatment. Appropriate attention to the mental
health of children living in households with IPV is needed.
2003 Elsevier Ltd. All rights reserved.
Keywords: Intimate partner violence; Child witness; Domestic violence; Child behavior; Child abuse; Child
maltreatment

Introduction
At least 1.5 million children are exposed to their mothers abuse by an intimate partner in the
United States each year (Greenfeld et al., 1998; Tjaden & Thoennes, 1998; US Census Bureau,
2000). Prior research suggests that children living in households in which their mothers are
abused are at increased risk of behavioral problems, but many of these studies are weakened by
several methodologic problems. Descriptive studies of children exposed to maternal intimate
partner violence (IPV) were the first to indicate a high degree of behavioral distress (e.g.,
depression, anxiety, aggressive behaviors, and post-traumatic stress) among this group, but the
lack of comparison groups made these observations inconclusive (Kilpatrick & Williams, 1998;
Levine, 1975; Moore, 1975; OKeefe, 1994; Penfold, 1982; Smith, Berthelsen, & OConnor,
1997; Stagg, Wills, & Howell, 1989; Wildin, Williamson, & Wilson, 1991). Analytic studies
that have examined this association are also inconclusive. A common approach has been to use
Achenbachs Child Behavior Checklist (CBCL) to compare levels of internalizing behaviors
(depressive, withdrawn, or anxious behaviors), externalizing behaviors (aggressive, delinquent
behaviors), and social competence (competence in school, social situations, and involvement in
activities) among children in households experiencing IPV relative to children from non-violent
households (Fantuzzo et al., 1991; Jaffe, Wolfe, Wilson, & Zak, 1986a; Jaffe, Wolfe, Wilson,
& Zak, 1986b; OKeefe, 1994). Although many studies found a significant association between
childrens exposure to maternal IPV and internalizing and externalizing behaviors (Fantuzzo
et al., 1991; Jaffe et al., 1986a, 1986b; OKeefe, 1994), other studies have found no such
association (Jaffe, Wolfe, Wilson, & Zak, 1985; Wolfe, Jaffe, Wilson, & Zak, 1985; Wolfe,
Zak, Wilson, & Jaffe, 1986), an association only with externalizing behaviors (Sternberg
et al., 1993), or an association only with internalizing behaviors (Christopoulos et al., 1987;
Cummings, Pepler, & Moore, 1999; Holden & Ritchie, 1991). Studies that have evaluated
the association between exposure to maternal IPV and total behavioral problems (includes
internalizing, externalizing behaviors as well as social, thought and attentional problems) have
consistently shown a positive association (Christopoulos et al., 1987; Cummings et al., 1999;
Davis & Carlson, 1987; Holden & Ritchie, 1991; Hughes, Parkinson, & Vargo, 1989; Kolbo,
1996; Moore & Pepler, 1998; Wolfe et al., 1985). Findings with regard to social competence
have been more mixed with roughly half the studies showing deficits in social competence
among children exposed to their mothers abuse by an intimate partner (Davis & Carlson,
1987; Fantuzzo et al., 1991; Jaffe et al., 1986b), one showing an effect but only among current
shelter residents (Wolfe et al., 1986) and the remainder finding no such effect (Christopoulos
et al., 1987; Hughes et al., 1989; Jaffe et al., 1986a; Wolfe et al., 1985).

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1233

Despite the agreement of most studies that children exposed to their mothers abuse are
at increased risk of at least some type of behavioral disturbance, the validity of much of the
previous work in this field is compromised by the inability to account for the co-occurrence
of child abuse (Christopoulos et al., 1987; Cummings et al., 1999; Gleason, 1995; Hinchey &
Gavelek, 1982; Holden & Ritchie, 1991; Jaffe et al., 1985, 1986a, 1986b; Jouriles, Murphy,
& OLeary, 1989; Kilpatrick & Williams, 1998; Kolbo, 1996; OKeefe, 1994; Rosenbaum
& OLeary, 1981; Westra & Martin, 1981; Wolfe et al., 1985). Additionally, most studies
have typically sampled from battered womens shelters, affecting both generalizability to
the broader population of children exposed to maternal IPV and challenging validity on the
grounds that behavioral disturbance among this population may be at least in part attributable
to the disruption associated with relocation to a shelter (Christopoulos et al., 1987; Davis &
Carlson, 1987; Holden & Ritchie, 1991; Hughes et al., 1989; Jaffe et al., 1985, 1986b; Mathias,
Mertin, & Murray, 1995; McCloskey, Figueredo, & Koss, 1995; OKeefe, 1995; Rossman &
Rosenberg, 1992; Wolfe et al., 1985, 1986).
This study was designed to explore the relationship between exposure to maternal IPV and
child behavior problems and to address the limitations of previous studies in several ways. First,
child maltreatment data were collected on the IPV-exposed group, allowing us to calculate
estimates of the risk of behavioral problems associated with exposure to maternal IPV both in
the presence and in the absence of child maltreatment. Second, city-wide police-reported data
on IPV incidents were used to allow for greater external validity. Finally, we collected data on
the duration of exposure to maternal IPV, allowing us to confirm that IPV exposure occurred
in advance of the outcome period of interest.

Methods
Subjects
The IPV-exposed group consisted of dependent children whose mothers were victims of
police-reported or court-reported intimate partner violence in Seattle, Washington, and who
participated in the Womens Wellness Study (WWS) described in detail elsewhere (Wolf, Holt,
Kernic, & Rivara, 2000). Briefly, the WWS study population consisted of 448 Seattle women
18 years and older who were victims of abuse by a male intimate partner that resulted in
a police-reported incident or a filing of a protection order between 10/15/97 and 12/31/98.
Sampling of Womens Wellness participants was through stratified random sampling based on
history of police involvement and protection order status. Eligible children were aged 217
years upon their mothers entry into the WWS and lived with their mother at least part-time
during the 12 months prior to her enrollment.
Upon entry to the WWS, 186 of the women (41.5%) had children between 2 and 17 years
of age who had lived with them during the prior 12 months or more. In families with several eligible children, one child was randomly chosen as the index child using an assignment
scheme based on the ranking of computer-generated random numbers. Of the 186 eligible
children, 14 (7.5%) were excluded because CBCL outcome data were provided on a child
other than the assigned index child, or it was unclear if the CBCL was provided for the

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correct child. Additionally, 5 (2.7%) mothers refused to fill out a CBCL. Thus, the final
sample size was 167 IPV-exposed children, which was 89.3% of those known to be eligible. Data on child maltreatment were collected on the IPV-exposed group from reports of
physical abuse, sexual abuse, or severe neglect to the Seattle Police Department (primarily
through Child Protective Services). A child was considered positive for child maltreatment
if any report of abuse was found to warrant investigation, regardless of the outcome of that
investigation. This broader definition was used in order to provide a more sensitive measure
of child maltreatment given the difficulty in prosecuting cases of alleged abuse. Using this
definition, 24 of the 167 IPV-exposed children (14.4%) were also found to be victims of child
maltreatment.
The standardized normative samples for the Achenbachs CBCLs for ages 23 years and
ages 418 years served as the comparison group (Achenbach, 1991a, 1991b). The CBCL
normative samples (n = 2736) were used in the development and standardization of the
CBCL by its authors and were sampled to be representative of the US population in terms of
socioeconomic status (SES), ethnicity, region, and urban-suburban-rural residence. The study
protocol was approved by the University of Washingtons Human Subjects Committee.
Child behavior outcomes
The Child Behavior Checklist was completed by mothers of the participating IPV-exposed
children upon entry to the Womens Wellness Study. Eighty-six percent of the interviews were
completed via telephone by trained interviewers, and the remainder were self-administered
and returned by mail.
The CBCL is a well-standardized, extensively used psychometric instrument with high
reliability and validity. We used the established age- and sex-specific cutoff scores for each
of the CBCL scales as reported by Achenbach (1991a, 1991b). These authors established
the cutoff scores as those that best distinguished the non-referred children of the normative
sample from the clinically referred children. Scores above the cutoff, therefore, provide an
indication that the exhibited behavioral problems are sufficiently atypical to be of clinical
concern, and have been shown to correlate well with clinical diagnoses of behavioral problems
and external risk factors associated with behavioral dysfunction (Jensen & Watanabe, 1999;
Kasius, Ferdinand, van den Berg, & Verhulst, 1997). The proportion of children scoring in
the borderline or clinical range on each CBCL scale (internalizing behaviors, externalizing
behaviors, social competence, and total behavioral problems) served as the primary outcomes
of interest. Within the normative population, scores in the clinical range represented the upper
10th percentile for behavioral subscales and the lower 2nd percentile for the social competence
subscale. An additional 8 and 3% of each age-sex group within the normative population
fell within the borderline clinical range on the behavioral subscales and social competence
subscales, respectively. Although internalizing, externalizing, and total behavioral scales were
designed for assessment with children ranging in age from 2 to 18 years of age, the social
competence scale was designed to be used among children aged 618 years. We, therefore,
limited our analysis of social competence to children within this age group (n = 70 for children
exposed to maternal IPV only and n = 13 for children exposed to maternal IPV and child
maltreatment).

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1235

Maternal intimate partner violence

Conflict Tactics Scalerevised. To assess the type and severity of maternal intimate partner
violence, we used the revised version of the Conflict Tactics Scale (CTS2). The Conflict Tactics
Scale is a 27-item instrument designed to capture information on the occurrence and frequency
of specific acts of reasoning, negotiation, psychological, physical, and sexual abuse used within
the context of an intimate relationship. Using the CTS2, we were able to categorize presence
or absence of physical abuse, psychological aggression, and sexual coercion during the 1 year
prior to the index episode of abuse that led to the mothers enrollment in the parent study
(Straus, Hamby, Boney McCoy, & Sugarman, 1996). Although we used all items of the CTS2
for physical abuse (12 items) and psychological abuse scales (8 items), we shortened the sexual
abuse scale to include one minor and one severe item out of the potential 3 minor and 4 severe
items from this scale. We chose to shorten this scale to lessen the emotional burden to subjects
caused by answering questions that would unnecessarily capture explicit details about sexual
abuse events. The two items we used captured the two major themes captured by this scale
simply without added detail. These themes include use of sexual abusive acts not involving
the use of physical force and sexual abusive acts involving physical force. To describe further
the abuse history, we added individual items to the questionnaire to elicit information on the
duration of physical abuse (0, 6, 712, 1324, 2560, >60 months) and duration of emotional
abuse (0, 6, 712, 1324, 2560, >60 months).
Covariates
Additional data collected by maternal report on the IPV-exposed group included the childs
age and sex, household income, parental occupation, number of parents in the household,
mothers symptoms of depression, maternal alcohol abuse, and severity and duration of maternal IPV.
Maternal depression. We used the 20-item Center for Epidemiologic Studies of Depression
Scale (CES-D) to assess maternal depressive symptoms (Radloff, 1977). Participants were
asked to report responses to CES-D items for the 1-week period prior to the interview. Responses were based on a 4-point Likert scale ranging from rarely or none of the time to
most or all of the time. Depression was categorized as a dichotomous yes/no variable using
a CES-D total cutoff score of 16 or greater. The CES-D has been reported to have high internal consistency and to discriminate well between inpatient and general population samples
(Radloff, 1977; Schulberg et al., 1985).
NET alcohol screen. The 3-item NET (Normal-Eyeopener-Tolerance) scale was used to measure problem drinking among mothers in the year prior to the index incident of intimate partner
abuse (Bottoms, Martier, & Sokol, 1989). The scale comprises two dichotomous (yes/no) questions to measure self-opinion on whether each mother felt she was a normal drinker and
whether she ever drank in the morning to steady her nerves or in response to a hangover. The
purpose of the third question was to arrive at a measure of alcohol tolerance by questioning
the number of drinks required to feel intoxicated. Problem drinking was defined as having an

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M.A. Kernic et al. / Child Abuse & Neglect 27 (2003) 12311246

affirmative response to either of the first two questions or a tolerance level at or above three
drinks. This measurement scheme for the NET has been found to compare favorably with other
brief screening measures. Russell et al. (1994) report sensitivity of 71% and specificity of 86%
for this measure relative to a gold standard measure of risk drinking based on the Bowman,
Stein, and Newton (1975) interpretation of the timeline follow-back procedure (Russell et al.,
1994).
Socioeconomic status. Family socioeconomic status was defined using the Hollingshead 9-step
scale for parental occupation (Hollingshead, 1975). To be comparable to the SES data available
for the CBCL normative sample, we used the higher of the two parental occupation scores if
both parents were employed, and grouped SES data into lower (occupation score of 13.5),
middle (46.5), and upper (79) SES levels.

Analysis
Multiple logistic regression was used to compute the relative risk estimates of behavior
problems associated with a childs exposure to maternal abuse by an intimate partner, in the
presence and the absence of child maltreatment, relative to the CBCL normative sample. Because child maltreatment data were not available on the CBCL normative sample, we treated
child maltreatment (coded as a dichotomous yes/no variable) as a second level of exposure
among children exposed to maternal IPV, and considered all normative children to be unexposed to child maltreatment. Separate risk estimates were calculated for children exposed
to maternal IPV who were not victims of child maltreatment and those who were exposed
to both maternal IPV and child maltreatment. Because most of our outcomes were not rare
occurrences, we used the odds ratio correction methods described by Zhang to provide a more
reliable measure of the relative risk (Zhang & Yu, 1998). We tested for significant differences
in the effect of IPV by age and sex and found that odds ratios did not vary significantly by
either factor; therefore, we calculated summary odds ratios for each level of exposure after
adjusting for age and sex. Likelihood ratio statistics were used to determine the statistical
significance of the exposureoutcome relationship. We categorized the childs age, race, and
socioeconomic status to be comparable to the categories used to describe the CBCL normative
sample (Achenbach, 1991a, 1991b).
To examine the contribution of type, severity, and duration of maternal IPV to each outcome of interest, we added the following categorical variables to a model that contained
age, sex, child maltreatment, and a dichotomous maternal IPV exposure variable: severity
of maternal IPV-related physical abuse (none, minor, severe) and emotional abuse (none,
minor, severe) in the year prior to WWS enrollment, and duration of maternal IPV-related
physical abuse and psychological aggression. Duration of maternal IPV (<6, 712, 1324,
2560, >60 months) was reported by the subjects mothers. We did not assess the contribution
of these factors to the rarer outcome of poor social competence due to insufficient sample
size.
To evaluate whether confounding by socioeconomic status among the IPV-exposed children
could explain the associations between IPV and behavior problems, we performed a subanaly-

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1237

sis that assessed the prevalence of behavior problems within subgroup of IPV-exposed children
living in higher income households (annual incomes $35,000; n = 36) relative to all children
in the comparison group.

Results
Study population
IPV-exposed and CBCL comparison children differed in terms of sociodemographics
(Table 1). The IPV group was more likely to be of non-White race, and of lower socioeconomic
status than the CBCL normative population. Additional data available on the IPV-exposed
group indicated that 78.5% of their mothers experienced physical abuse in the past year, with
the majority of those having experienced severe acts of physical violence (Table 2). Almost
all mothers of IPV-exposed children reported having experienced some form of psychological
aggression in the past year, and 80.8% experienced severe psychological aggression. Additionally, more than three quarters of the study mothers reported a history of either physical and/or
emotional abuse of at least 1 years duration, with more than half of those having experienced
this abuse for 5 years or more. Concurrent problems of depression and alcohol abuse were
identified among many of the women. Almost 60% showed symptoms of severe depression
Table 1
Demographic characteristics of IPV-exposed and CBCL comparison children
IPV-exposed (n = 167)

CBCL comparison (n = 2736)

n (%)

n (%)

Age (years)
23
411
1218

33 (19.8)
97 (58.1)
37 (22.2)

368 (13.5)
1200 (43.9)
1168 (42.7)

Sex
Female
Male

79 (52.7)
88 (47.3)

1407 (51.4)
1329 (48.6)

Race/ethnicitya
White
Black
Hispanic
Other

48 (30.4)
52 (32.9)
22 (13.9)
36 (22.8)

2018 (73.8)
444 (16.2)
180 (6.6)
94 (3.4)

Hollingshead parental occupational statusa

Upper
33 (19.8)
Middle
84 (50.3)
Lower
50 (29.9)

953 (34.8)
1193 (43.6)
590 (21.6)

Characteristic

Sample sizes for the CBCL comparison group were estimated from published data that were rounded to the
nearest whole percent.

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M.A. Kernic et al. / Child Abuse & Neglect 27 (2003) 12311246

Table 2
Additional characteristics of IPV-exposed children (n = 167)
Characteristic

n (%)

Mothers education
Less than high school
High school graduate
Some college/post-high school
College graduate/advanced degree

20 (12.0)
48 (28.7)
73 (43.7)
26 (15.6)

Single parent household

88 (47.3)

Severity of maternal IPV-related physical aggression

None
Minor
Severe

36 (21.6)
29 (17.4)
102 (61.1)

Severity of maternal IPV-related psychological aggression

None
Minor
Severe

3 (1.8)
29 (17.4)
135 (80.8)

Duration of maternal IPV-related physical abuse (years)

<1
1 to <5
5

51 (32.9)
54 (34.8)
50 (32.3)

Duration of maternal IPV-related emotional abuse (years)

<1
1 to <5
5

44 (27.0)
56 (34.4)
63 (38.7)

Maternal depressive symptoms

None (CES-D score <16)
Minor (CES-D score 16 and <27)
Severe (CES-D score 27)

27 (16.2)
40 (24.0)
100 (59.9)

Maternal alcohol problems (NET score 1)

42 (25.8)

Reported child maltreatment

24 (14.4)

(CES-D cutoff of 27 or greater), and over 25% were positive for at least one indicator of
alcohol abuse on the NET.
Internalizing behavior
The relative risk of borderline to clinical levels of internalizing behavior problems associated with exposure to maternal IPV without concomitant child maltreatment was slightly but
nonsignificantly elevated (RR = 1.3, 95% CI: .91.7) (Table 3). Children exposed to both IPV
and child maltreatment were more than twice as likely to have a borderline to clinical level
score on the internalizing behavior scale compared to CBCL comparison children (RR = 2.6,
95% CI: 1.53.6).

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1239

Table 3
Relative risk of borderline to clinical level CBCL scores among IPV-exposed children by child maltreatment history
relative to CBCL comparison children
CBCL scale

Internalizing behaviors
Externalizing behaviors
Poor social competenceb
Total behavioral problems

Exposed to maternal
IPV only (n = 143)

Exposed to maternal IPV and

child maltreatment (n = 24)

n (%)

RRa

95% CI

n (%)

Rra

95% CI

33 (23.1)
42 (29.4)
5 (7.1)
37 (25.9)

1.3
1.6
1.2
1.4

.91.7
1.22.1
.52.9
1.11.9

11 (45.8)
13 (54.2)
0
9 (37.5)

2.6
3.0
0
2.1

1.53.6
1.94.0

1.23.2

Relative to normative children after adjusting for age and sex.

Social competence measured only among subjects aged 618 years (n = 70 for those exposed to maternal IPV
only, n = 13 for those exposed to maternal IPV and child maltreatment, and n = 2116 for normative group).
b

Externalizing behavior
In contrast to the findings regarding internalizing behavior problems, children in both
IPV-exposed groups were significantly more likely to score in the borderline to clinical level
range on the externalizing behavior scale. We found children exposed to IPV only to be 1.6
times as likely (95% CI: 1.22.1) and children exposed to both IPV and child maltreatment to
be 3.0 times as likely (95% CI: 1.94.0) to score in the borderline to clinical level range on
externalizing behaviors relative to CBCL comparison children.
Poor social competence
We found no evidence of a significant association between poor social competence and
exposure to maternal IPV (RR = 1.2, 95% CI: .52.9). None of the children exposed to both
maternal IPV and child maltreatment received social competence scores in the borderline to
clinical range.
Total behavioral problems
Children exposed to maternal IPV, without concomitant child maltreatment, were 40%
more likely to have a total behavioral problem score within the borderline to clinical range
than CBCL normative children (RR = 1.4, 95% CI: 1.11.9). Children who experienced both
IPV and child maltreatment even more likely to receive scores indicating a high level of total
behavioral problems (RR = 2.1, 95% CI: 1.23.2).
Analysis of the contribution of type, severity, and duration of maternal abuse
In evaluating the contribution of type, severity, and duration of IPV on childrens behaviors,
we found only duration of physical abuse added to the effect of IPV exposure. Children exposed
to long-term maternal physical IPV were significantly more likely than those with shorter
term exposure to exhibit borderline to clinical levels of total behavioral problems (Table 4).

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Table 4
Relative risk of borderline clinical to clinical level score for total behavioral problems among IPV-exposed children
relative to CBCL normative children by duration of physical abuse and child maltreatment history
Duration of
maternal IPV
<6 months
6 months to 1 year
>1 to <5 years
5 years or more

Exposed to maternal
IPV only (n = 132)a

Exposed to maternal IPV and

child maltreatment (n = 23)a

n (%) with outcome

RRb

95% CI

n (%) with outcome

RRb

95% CI

7 (21.2)
1 (7.1)
11 (26.8)
17 (38.6)

1.1
1.1
1.5
2.9

.52.3
.34.1
.72.9
1.65.2

2 (25.0)
2 (66.7)
1 (16.7)
3 (50.0)

1.7
1.8
2.3
4.5

.64.8
.47.7
.86.7
1.612.6

Excludes those subjects missing data for duration of maternal IPV (n = 11 for those exposed to maternal IPV
only; n = 1 for those exposed to maternal IPV and child maltreatment).
b
Relative to normative children after adjusting for age and sex; test for trend p = .03; model estimates are based
on dummy variable version of duration of maternal physical IPV; using Zhang correction for RR approximation
by an OR with a common outcome.
a

Furthermore, relative risk estimates were greater for exposed children with a history of child
maltreatment than for children exposed to maternal IPV only at each level of maternal IPV
duration.
Contribution of socioeconomic status
In a subanalysis that limited our IPV-exposed group to children from households with incomes of at least $35,000, the proportion of children with scores in the borderline to clinical
level range on all four CBCL scales was as high or higher than that for the sample as a whole.
We found that after removing children at risk of behavioral difficulties due to socioeconomic
disadvantage from our analysis (IPV-exposed children from households with <$35,000 annual
income), high problem scores were still common within the remaining, relatively socioeconomically advantaged group. Specifically, within this subset, 25.0, 27.5, 14.3, and 30.0% of
non-abused IPV-exposed children scored in the borderline to clinical range on the internalizing,
externalizing, social competence, and total behavioral scales, respectively.

Discussion
Using the CBCL normative sample as a reference group, we found significant positive
associations between childrens exposure to maternal IPV and borderline to clinical level
scores on the CBCL scales that measure externalizing behaviors and total behavioral problems.
These findings confirm those of prior work, but importantly, do so in the context of a more
representative sample from which we were able to provide risk estimates separately for IPV
children with or without concomitant child maltreatment relative to the normative population
(Fantuzzo et al., 1991; Jaffe et al., 1986a, 1986b; OKeefe, 1994; Rossman & Rosenberg,
1992). Among children who were also victims of child maltreatment, relative risk estimates
were of greater magnitude and were significantly elevated for internalizing behaviors as well.

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1241

The association that we found between childrens exposure to maternal IPV and internalizing
behaviors was consistent with prior studies in that the relative risk estimate was elevated, but it
did not achieve statistical significance in the absence of a joint exposure to child maltreatment
(Christopoulos et al., 1987; Cummings et al., 1999; Fantuzzo et al., 1991; Holden & Ritchie,
1991; Jaffe et al., 1986a, 1986b; OKeefe, 1994). We did not find a significantly greater
proportion of exposed children to have poor social competence. In agreement with the studies
that have reported on total behavioral problems associated with childrens exposure to maternal
IPV, we found a significantly greater proportion of children to score within the borderline to
clinical range on the total behavioral problems scale of the CBCL (Christopoulos et al., 1987;
Davis & Carlson, 1987; Holden & Ritchie, 1991; Hughes et al., 1989; Jaffe et al., 1986b;
Kolbo, 1996).
Our calculations of crude relative risks for clinical level behavioral problems based on
previously published studies indicate our estimates of association are more conservative than
those reported previously (Christopoulos et al., 1987; Davis & Carlson, 1987; OKeefe, 1994;
Sternberg et al., 1993; Wolfe et al., 1985). We were able to calculate estimates of the crude
relative risks for clinical level internalizing behaviors and clinical level externalizing behaviors
associated with IPV exposure from three prior studies. We found the estimates from these prior
studies to be 1.3, 3.3, and 5.7 for internalizing behaviors and 1.9, 2.1, and 4.5 for externalizing behaviors (Christopoulos et al., 1987; OKeefe, 1994; Sternberg et al., 1993). The crude
relative risk we obtained from the present study when we limited our outcome to clinical level
internalizing behavior scores was 1.3, identical to that of Sternberg et al. Our estimate increased
slightly to 1.4 with the inclusion of children who were also victims of child maltreatment. The
relative risk for clinical level externalizing behaviors obtained in our study was 1.5 for children
exposed to IPV only and 1.8 for the group as a whole (with and without child maltreatment).
Because two of the three earlier studies did not provide data allowing for the calculation of
separate relative risk estimates by child maltreatment status, we would expect these estimates
to be elevated compared to relative risk estimates obtained from our analysis of non-abused
IPV-exposed children. However, our relative risk estimates were still lower than those of prior
studies that did not account for child maltreatment, even after combining non-abused and
abused IPV-exposed children in our calculations. Because the shelter populations represented
by earlier studies tended also to have much higher prevalence of child maltreatment among
IPV-exposed children compared with the general population used in our study, the estimates
from prior studies would be expected to remain elevated by comparison because they are
more heavily weighted with child maltreatment victims than our sample. For example, estimates of the prevalence of child maltreatment among the IPV-exposed populations utilized
in these studies have ranged between 26 and 97%, compared to 14% found in the current
study (Christopoulos et al., 1987; Davis & Carlson, 1987; Hughes, 1988; Hughes et al., 1989;
Kolbo, 1996). There are two likely explanations for the lower child maltreatment estimates
found in our study. First, our estimates of child maltreatment are likely conservative compared
to those that would have been obtained by maternal report. Second, many of the characteristic
differences in shelter populations relative to general populations of IPV families also place
shelter populations at much greater risk of co-occurring child maltreatment.
The results from studies using shelter populations are likely not generalizable to the majority
of IPV-exposed children for other reasons as well (Edleson, 1999). Several factors related to

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living at a battered womens shelter may negatively affect childrens behavior and therefore
result in upwardly elevated estimates of risk of childrens behavioral problems relative to the
general population of IPV-exposed children. These include being in an actively abusive phase
of the relationship, being exposed to more severe violence, having fewer financial and social
resources, and experiencing acute distress due to relocation (Wolfe et al., 1986).
We were also able to calculate crude relative risk estimates for clinical level total behavioral
problems from two additional prior studies of children from battered womens shelters (Davis
& Carlson, 1987; Wolfe et al., 1985). From the data provided from these earlier studies, we
calculated crude relative risk estimates of 2.5 and 7.0 for non-abused IPV-exposed and abused
IPV-exposed children combined. This compares to crude estimates from our study of 1.8
when limiting to non-abused IPV-exposed children and 1.9 when including both abused and
non-abused IPV-exposed children. Over 50% of the IPV-exposed children in the study with
the relative risk of 7.0 were also victims of child maltreatment. Additionally, selection bias
may have been a problem for this study in that mothers chose which of their children served
as the study subject in families with more than one child. Lending credence to this concern,
some women from our study volunteered to study interviewers that they wished to report on
the behavior of one of their other children rather than the randomly assigned child we sampled
because they believed that child was more affected by the abuse. We avoided this bias by
maintaining the random sampling scheme.
There has been an ongoing discussion in the literature about the possibility of maternal
depression contributing to bias in reports of child behavior. However, no consistent pattern has
arisen to substantiate these concerns. In support of the validity of our maternally reported findings, we found, in a related study of school-aged children of WWS participants, significantly
more externalizing problem behaviors based on school records of academic suspension and
frequent absenteeism among IPV-exposed children relative to comparison children (Kernic
et al., 2002).
Although our sample was more broadly representative of children of abused women than
samples drawn from battered womens shelters, it was nonetheless limited to children of
women whose abuse was reported to the police or court system. It is conceivable that the
effects of intimate partner abuse on children differ by whether that abuse is reported, which
would necessarily affect the generalizability of our results. Results from the National Crime
Victimization Survey (NCVS) suggest that reporting an incident to the police is more likely
among IPV victims whose abuse results in injury (55% of injured victims reported to the
police vs. 46% of non-injured) (Bachman & Saltzman, 1995). If reported IPV is more severe
than unreported IPV, and severe IPV negatively impacts childrens behavior more than less
severe IPV, our estimates of child behavior problems may be greater than those that would be
observed had families of unreported IPV also been included in our sample.
A related limitation of this study is the possibility of misclassification of exposure. Neither
maternal IPV nor history of child maltreatment was available on the CBCL normative sample.
In the analyses reported here, we assumed no exposure to either of these factors in the normative
sample, when, in truth, some of these children are likely to have had one or both exposures. This
type of misclassification would result in a slight underestimate of the risk of adverse behavioral
outcomes associated with childrens exposure to their mothers abuse by an intimate partner.
For example, we calculated, using an observed estimate of police-reported IPV in Seattle (i.e.,

M.A. Kernic et al. / Child Abuse & Neglect 27 (2003) 12311246

1243

33.5 per 1000 women-years) and the NCVS estimate that 50% of IPV is reported to police,
that our risk estimate for externalizing behaviors was underestimated by approximately 5%
due to this type of misclassification.
In this study, we used the CBCL normative sample rather than a local comparison group for
which socioeconomic status could be directly assessed. Because no published data are available
for the frequency of clinical level scores among the CBCL normative sample by socioeconomic
status, we were limited in our ability to adjust for socioeconomic status in our analyses. As a
result, our estimates were potentially elevated since the IPV-exposed sample was of lower SES
than the CBCL normative sample, and lower SES has been associated with poorer performance
on the CBCL (Raadal, Milgrom, Cauce, & Mancl, 1994). However, confounding by SES is an
unlikely explanation of our significant results since we found comparable or higher proportions
of IPV-exposed children to score in the borderline to clinical level ranges on each CBCL scale
when we limited our analysis to IPV-exposed children from households with annual incomes
of $35,000 or more. Additionally, lower SES may be a consequence of IPV (for instance,
victimized mothers have separated from their abusers), therefore, controlling for SES would
be inappropriate. We chose explicitly not to adjust for factors, such as maternal depression or
alcohol abuse, which might have been a consequence of abuse. This choice was made because
it was our intention to measure the entire effect of maternal IPV on child behavior rather than
its effect above and beyond mediating factors such as these.
These findings provide significant evidence of the association between childrens exposure
to maternal IPV, with or without a history of reported child maltreatment, and the occurrence of
behavioral problems. An important direction for future research will be to focus on the identification of factors that serve to mediate the relationship between IPV exposure and behavioral
problems, thereby directing research on the development of effective interventions with these
children. Our results indicate that appropriate attention to the mental health needs of children
exposed to IPV, with or without the presence of child maltreatment, is strongly warranted.

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Rsum
Objectifs: Examiner sil y a une relation entre le fait pour des enfants davoir t exposs la violence
entre leur mre et un partenaire intime (IPV) et la prsence de troubles de comportement mesurs par
le tmoignage parental au Child Behavior Checklist (CBCL).

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Mthode: La population tudie tait constitutie de 167 enfants de 2 17 ans dont les mres rsidant
Seattle avaient signal des abus la Police ou au Tribunal. La population normale du CBCL a servi
de groupe de comparaison. Le risque de problmes de comportement a t calcul auprs des enfants
exposs, selon la prsence ou labsence de signalements pour mauvais traitements par rapport la
population normale. La mthode principale danalyse a t la rgression multiple.
Rsultats: Les enfants exposs la violence subie par leur mre (IPV) ont sembl plus susceptibles de
prsenter des scores de niveau limite cliniquement vidents pour le comportement extrioris (I.E.
agressif ou dlinquant) (RR = 1.6, 95% CI: 1.2, 2.1) ainsi que des comportements globalement
problmes (RR = 1.4, 95% CI: 1.1, 1.9) par comparaison avec lchantillon normal au CBCL aprs
correction pour lage et le sexe. Les enfants exposs et qui ont t victimes de mauvais traitements
ont sembl plus susceptibles de prsenter des scores de niveau limite cliniquement vidents pour les
comportements internaliss (anxit, dpression) (RR = 2.6, 95% CI: 1.5, 3.6), extrioriss (agressif,
dlinquant) (RR = 3.0, 95% CI: 1.9, 4.0) et les problmes gnraux de comportement (RR = 2.1, 95%
CI:1.2, 3.2) par comparaison avec lchantillon normal aprs correction pour lage et le sexe.
Conclusion: Etre expos la violence subie par leur mre de la part dun partenaire intime est associ
de faon significative des problmes de comportement quil y ait eu ou non en meme temps chez
ces enfants des mauvais traitements. Il faut donc accorder de lattention la sant mentale des enfants
vivant dans les foyers o il y a IPV.

Resumen
Objetivo: Determinar la asociacin entre la exposicin de los nios a episodios de violencia domstica
(VD) y los problemas de conducta medidos con la versin para padres del CBCL.
Mtodo: La muestra del estudio se compuso de 167 madres de nios/as de entre 2 y 17 a9 A os que
vivan en Seattle y que haban notificado a la polica o a la justicia un episodio de violencia domstica.
Las puntuaciones normativas del CBCL sirvieron como grupo de comparacin. Se calcul el riesgo de
presentar problemas de conducta entre los nios expuestos en relacin a la puntuacin de la poblacin
normativa y teniendo en cuenta la presencia o ausencia de una historia de notificaciones de maltrato
infantil. El principal mtodo de anlisis fue la regresin logstica mltiple.
Resultados: Los nios expuestos a VD tenan ms tendencia a presentar puntuaciones lmite o clnicas
en conducta (e.j., delincuencia y agresiones) externalizada (RR = 1.6; 95% CI: 1.2, 2.1) y en el total de
problemas de conducta (RR = 1.4, 95% CI: 1.1, 1.9) comparados con las puntuaciones de la muestra
normativa en el CBCL despus de haber ajustado el gnero y la edad. Los nios que fueron expuestos
a VD y fueron vctimas de maltrato infantil tenan ms tendencia a presentar puntuaciones lmite o
clnicas en conducta (e.j., ansiedad y depresin) internalizada (RR = 2.6; 95% CI: 1.5, 3.6), conductas
externalizadas (RR = 3.0; 95% CI: 1.9, 4.0) y en el total de problemas de conducta (RR = 2.1, 95%
CI: 1.2, 3.2) comparados con las puntuaciones de la muestra normativa en el CBCL despus de haber
ajustado el gnero y la edad.
Conclusiones: La exposicin a la violencia domstica est significativamente asociada con problemas
de conducta en la infancia tanto en presencia como en ausencia de maltrato infantil. Se necesita una
atencin adecuada a los problemas de salud mental de los nios que viven en hogares donde se produce
exposicin a situaciones de violencia domstica.