Domestic Violence and Maternal and Child Health: New Patterns of Trauma, Treatment, and Criminal Jus

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The three study samples were pooled together and were categorized into whether the participants received substance abuse treatment either in prison or aftercare 0 or in both settings 1. A lifetime number of traumatic events variable was created with a count of the number of traumatic events the participants endorsed at the baseline assessment.

For the purpose of consistency, these items were then categorized into more general forms of traumatic events i. The scores ranged from 0 to 4, with 0 indicating endorsement of none of the given traumatic events and 4 indicating endorsement of all four of the listed traumatic events. Number of arrests was based on how many times the participant reported having been arrested in her lifetime for two studies TISAT and LOFFDI and a count of how many times the participant reported having been arrested and charged for particular offenses as provided in a list for GRTP.

Prior mental health treatment was measured using questionnaire items that asked whether the participant had received outpatient or inpatient treatment for an emotional or mental health problem.

Other variables included demographics such as age; race; education; employment; and whether the respondent had children, and, if so, the number of children she had. Follow-up measures were used as dependent variables in all analyses i. A distinct form of robust regression 2 was used for each dependent variable. Because the number of drugs variable was a count measure, a negative binomial regression yielded incidence rate ratios IRRs to estimate effects.

For psychiatric status, a logistic regression with odds ratios ORs was used because the scores were standardized and were then converted to a binary measure. The self-efficacy measure, which consisted of raw scores, was analyzed using an ordinary least squares regression yielding coefficients for effect size. Interaction effects between the number of lifetime traumatic events endorsed and the treatment setting were tested to examine whether more exposure to trauma had differential effects on the outcomes for those who received substance abuse treatment in both settings i.

The interaction term was created by multiplying the continuing care 0,1 variable by the number of traumas variable. Statistical controls included baseline values for the outcomes number of substances used at baseline, psychiatric status at baseline, and baseline self-efficacy scores , respectively. In addition, the number of prior arrests at baseline and the number of children the participant had at baseline were included as scales. The demographic factors used as covariates i. To further control for differences across study participants at baseline, we used the matching procedure of propensity scores to control for self-selection and other inequalities e.

A propensity score is the conditional probability of receiving a treatment i. An advantage of propensity scores is that if two subjects have the same propensity score, one subject in the treated group and one subject in the control group, then one could interpret that these two subjects were randomly assigned to each group—that is, they were equally likely to be in either the treatment group or control group.

Because three treatment groups prison only, aftercare only, and prison plus aftercare were simultaneously available, multinomial logits were used to construct the propensity scores Baser, This is a commonly used method in which the effect of treatment i. The participants reported an average of 2. The average self-efficacy score for the sample was 2. More details on characteristics of the total sample and each treatment group are provided in Table 3. There were no statistically significant differences in demographic or background characteristics across treatment groups prison or aftercare vs.

The three proposed hypotheses were supported by the results of the multivariate regressions. Table 4 shows results from the regression models for each outcome: IRRs for number of substances used, ORs for psychiatric status, and coefficients for self-efficacy scores. Significant covariates for polysubstance use included its baseline measure, number of arrests, whether respondents were incarcerated at the follow-up interview, age, and number of children.

In the predicted counts for number of substances used see Figure 1 , the bar patterns indicate that those who experienced fewer numbers of trauma events used fewer substances regardless of continuing care. However, as the number of trauma events increased, those who received continuing care either maintained or decreased the number of substances used.

In turn, those with a higher number of trauma events who did not receive continuing care had significantly higher counts of substances used in comparison to those who received continuing care. For the predicted probabilities of psychiatric severity see Figure 2 , the bar patterns show that the probability of high psychiatric status increased for those who did not receive continuing care and decreased for those who received continuing care for higher numbers more than two of trauma events.

Predicted self-efficacy scores see Figure 3 showed that those with fewer numbers of trauma events i. However, those with two or more trauma events who received continuing care had significantly higher self-efficacy scores. Predicted counts for number of substances used for those who received continuing care and those who did not, by the number of trauma events endorsed.

Predicted probabilities of high psychiatric severity status for those who received continuing care and those who did not, by the number of trauma events endorsed. Predicted self-efficacy scores for those who received continuing care and those who did not, by the number of trauma events endorsed. This study found that criminal justice—involved women who received continuing care treatment in both prison and aftercare and who had a history of exposure to more trauma fared better than those who received treatment in a single setting.

As a main effect, the number of traumatic events was associated with a higher number of substances used, more severe psychiatric scores, and lower self-efficacy scores at follow-up.

Acknowledging a persistent truth: domestic violence in pregnancy

However, if participants received both prison and aftercare treatment, these associations were mitigated. It is important to note that the relationships between trauma exposure and the outcomes examined were similar across trauma levels 1—4 in the continuing care condition, whereas in the comparison group there was more variability in the outcomes dependent on the degree of trauma exposure.

Besides continuing care, protective factors against polysubstance use included the number of prior arrests and number of children. Number of arrests as a predictor had a weak effect in that it approached the level of no association i.

The finding that a higher number of lifetime arrests measured at baseline was associated with lower numbers of substances used at follow-up cannot be explained theoretically, nor has it been found in the prior literature. Perhaps there is a spurious relationship in which a third factor may be affecting both, but examining this association would be beyond the scope and purpose of the current study. Another consistent predictor against polysubstance use was being a parent Robbins et al. Risk factors for polysubstance use included the baseline measure of number of substances used and whether the participant was incarcerated at follow-up.

The effect of age, in which those who were older were more likely to have a higher rate of number of substances used, was weak and neared no association i. As expected, psychiatric severity at follow-up was closely tied to prior psychiatric severity and prior mental health treatment. Similar to the effect of age on polysubstance use, age had a very weak effect on psychiatric status. In light of these links, this study contributes to the existing literature by highlighting the role of continuing care as a moderator of the detrimental effects of a history of trauma on substance use and mental health outcomes.

Yet further research is needed to determine when continuing care is warranted, compared with other interventions, and for whom. Future examinations could address particular types of trauma profiles e. Such research would help to explain the treatment conditions that are optimal for differing clinical profiles of women offenders, including those who may benefit from shorter or less intensive interventions.

Although community supervision has received evidence in support of its protective effects on recidivism Georgiou, , some have noted that mandated treatment and criminal justice oversight lead to higher chances of arrest and return to custody. Proponents of pure public health argue that this type of punitive approach is less effective than engagement with treatment counselors Marlowe, Moreover, risks of rearrest and reincarceration are outweighed by the higher risk of increased likelihood of relapse postrelease when individuals face environmental stressors and reentry challenges, such as poor social support and inadequate economic resources.

Numerous studies have shown that individuals newly released from prison who relapse are at especially high risk for overdose and death Binswanger et al. In this regard, the protective effect of transition to structured drug treatment programs, referral to medication-assisted treatment, community-based resources and recovery support including self-help groups , and family support is critical Binswanger et al. Strengths associated with this study include the use of a pooled sample of women offenders from multiple criminal justice treatment settings, which increases statistical power due to a larger sample size and a more diverse sample.

Although a pooled sample provides more statistical power, it also presents limitations stemming from measurement issues and issues associated with integrating diverse samples. The use of the outcome variable number of substances limits insight into severity or frequency of use. This outcome is representative of polysubstance use, which has been shown to be associated with the prevalence of psychiatric symptoms e. Moreover, in the current study, on average, participants indicated using two substances at follow-up, whereas substance abuse treatment programs typically endorse abstinence from any substance use as the goal of treatment.

Therefore, as a predictor of mental health disorders, poly-substance use as an outcome can provide insight into gradual steps toward achieving abstinence, 7 which can be an iterative and lengthy process that may not be achieved in 6 months. Another potential limitation of the current study is the pooling of prison and aftercare populations.

One can argue that these populations are different demographically and tend to have varying outcomes. However, because we controlled for demographic characteristics in the regression models, which took into account averages across the samples, heterogeneity was accounted for by covariance. In addition, the propensity scoring techniques also addressed preexisting group differences that may have influenced outcomes.

Moreover, pooling samples from programs that used different modules of trauma-informed services poses the issue that not all participants received the exact same intervention, and therefore outcomes may vary because of these content-specific differences. However, prior studies have used the technique of pooling samples from multisite studies of trauma-informed interventions, including integrating data from 14 sites using varying trauma-specific components e.

All of the women in this study sample received some form of substance abuse treatment either in prison or in aftercare that included a trauma-specific intervention within the context of gender-responsive treatment. In particular, continuing care is most effective in enhancing psychological and substance use outcomes for women who have suffered more and different types of traumatic events. Furthermore, the findings also imply that, for some groups of women offenders, substance abuse treatment interventions in prison would be more beneficial if they were linked to continuing care, and aftercare programs would also maximize benefits if they were preceded by in-custody interventions.

To optimize benefits and to obtain long-term results, treatment for women offenders ought to be comprehensive and long term in addition to being trauma focused. This study focused on the effects of trauma-informed interventions at different points in the criminal justice process prison vs. Although study findings are suggestive of the beneficial effects of continuing care for some women, future research is needed to determine the specific mechanisms and conditions under which it is or is not beneficial. In addition, the role of trauma in factors that influence treatment motivation and participation could clarify other indirect effects of traumatic exposure on substance use and mental health outcomes.

Moreover, because this study pooled multiple samples, and there was variation in the specific content and treatment exposure across the study sites, a more direct comparison of women who do and do not receive aftercare could provide additional insights. TI, under subaward with Walden House, Inc.

National Center for Biotechnology Information , U. Author manuscript; available in PMC Feb Grella and Nena P. Abstract Using secondary data analysis of 3 separate trauma-informed treatment programs for women offenders, we examine outcomes between those who received both prison and community-based substance abuse treatment i. The following hypotheses are tested: Study Samples Sample 1: Gender-Responsive Treatment in Prison GRTP The first sample, the GRTP sample, was originally part of a randomized controlled study in the Valley State Prison for Women, where half of the participants received gender-responsive substance abuse treatment that included a trauma-informed intervention Beyond Trauma; Covington, , a ; see Messina et al.

Open in a separate window. Trauma History A lifetime number of traumatic events variable was created with a count of the number of traumatic events the participants endorsed at the baseline assessment. Baseline Covariates Number of arrests was based on how many times the participant reported having been arrested in her lifetime for two studies TISAT and LOFFDI and a count of how many times the participant reported having been arrested and charged for particular offenses as provided in a list for GRTP.

Analyses Follow-up measures were used as dependent variables in all analyses i. Multivariate Models on Outcomes at Follow-Up The three proposed hypotheses were supported by the results of the multivariate regressions. Number of substances used at baseline; Model 2: Psychiatric severity score at baseline; Model 3: Self-efficacy score at baseline. Strengths and Limitations Strengths associated with this study include the use of a pooled sample of women offenders from multiple criminal justice treatment settings, which increases statistical power due to a larger sample size and a more diverse sample.

Conclusion All of the women in this study sample received some form of substance abuse treatment either in prison or in aftercare that included a trauma-specific intervention within the context of gender-responsive treatment. Alcohol Health and Research World. The relative ability of different propensity score methods to balance measured covariates between treated and untreated subjects in observational studies. Prediction of sexual, emotional, and physical maltreatment and mental health outcomes in a longitudinal cohort of adolescent women.

Toward a unifying theory of behavioral change. Social foundations of thought and action: A social cognitive theory. Bandura A, Locke EA. Negative self-efficacy and goal effects revisited. Journal of Applied Psychology. Propensity score matching with multi-level categories: Benight CC, Bandura A. Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy.

Behaviour Research and Therapy. Gender differences in depression and anxiety among alcoholics. Journal of Substance Abuse. Risk factors for all-cause, overdose and early deaths after release from prison in Washington state. Drug and Alcohol Dependence. Return to drug use and overdose after release from prison: A qualitative study of risk and protective factors. Release from prison—A high risk of death for former inmates.

TRAUMA EXPOSURE

New England Journal of Medicine. Research, practice, and guiding principles for women offenders. Women offenders and gendered effects of public policy. Review of Policy Research. A person-centered analysis incorporating gender responsive factors. Criminal Justice and Behavior. The California treatment expansion initiative: Aftercare participation, recidivism, and predictors of outcomes. Bureau of Justice Statistics. Correctional populations in the United States, Carson EA, Golinelli D.

A healing journey for women. A program for treating addiction. A trauma informed approach. Journal of Psychoactive Drugs. The simultaneous analysis of multiple data sets. Propensity scores in cardiovascular research. The therapeutic community for addictions: An evolving knowledge base. Journal of Drug Issues. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: Effects of posttraumatic stress disorder and child sexual abuse on self-efficacy development.

American Journal of Orthopsychiatry. Early sexual abuse and lifetime psychopathology: A co-twin control study. Mothering from the inside: Social supporters and drug use enablers: A dilemma for women in recovery. Substance abuse and dependence in prisoners: The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale.

Does increased post-release supervision of criminal offenders reduce recidivism? Evidence from a statewide quasi-experiment. International Review of Law and Economics. Another study found that hospitalizations caused by violence were more common among pregnant women using cocaine as compared with non-drug-exposed pregnant women Bauer et al.

Studies on violence during pregnancy in the general population show prevalence rates ranging from 0. Although a causal relationship between exposure to violence during pregnancy and adverse perinatal outcomes has not been clearly demonstrated, pregnant women who experience abuse are more likely than are non-abused women to have conditions that place their fetuses at risk. In addition, pregnant women experiencing violence are at a higher risk of becoming victims of homicide than are pregnant women not experiencing violence Campbell et al.

It is clear that substance-abusing pregnant women who experience violence are at a significant risk of developing a variety of negative sequelae. However, not much is known about this population. Thus, the purpose of this study was to describe the prevalence of exposure to violence among pregnant women receiving substance abuse treatment at an inner-city treatment facility.

Their sociodemographic and clinical characteristics as well as their service needs were evaluated. The results of this study may provide information essential for the creation of clinically effective identification, evaluation, and treatment programs for pregnant women experiencing violence to providers and policymakers. Several factors contributed to this decision: First, most studies have found that violence against women is most often perpetrated by current or former sexual partners.

However, substance-abusing women are frequently exposed to violence by perpetrators other than their partner. Using the IPV or traditional domestic violence concept exclusively would omit abuse perpetrated by others e. Second, violence against women involves a continuum of behaviors including intense criticisms and demeaning remarks, restraint of normal activities and freedoms, jealous control, denial of access to other persons or resources, threats and intimidation, sexual coercion and assault, rape, physical attacks, and even homicide Pagelow, ; Walker, Study participants were pregnant substance-abusing women admitted between September and July to a comprehensive treatment facility in Baltimore for their first treatment episode.

All women began treatment with a 7-day residential component. During this time, women participated in group counseling, including a single minute psychoeducational group session focusing specifically on the intersection of violence and substance abuse. Immediately after the group session, women were asked to complete the Violence Exposure Questionnaire VEQ , a screening tool developed to evaluate current and lifetime exposure to violence.

The VEQ expanded the AAS to assess seven domains physical abuse, sexual abuse, emotional abuse, perceived safety of patient, presence of weapons in the home, community violence exposure [self and child ren ], and perceived need for help regarding issues related to violence exposure. To determine their exposure to physical abuse, we asked the patients if they had been hit, slapped, kicked, or physically hurt by someone. To determine their exposure to sexual abuse, we asked them if anyone had forced them to have sex.

For each of the types of abuse, we asked the patients about their lifetime history and history of abuse during their current pregnancy. In addition, the relationship of a victim to her perpetrator s —father, mother, ex-partner, current partner, or others—was assessed for each report of past or current abuse.

In an attempt to determine if the women also engaged reciprocally in violent behaviors, we asked the following questions: Particularly, firearms are involved in a high percentage of homicides in the home Bailey et al. The VEQ contains two questions regarding exposure to violence in the community: Finally, the VEQ evaluates whether mothers perceive a need for help in the form of counseling, family therapy, etc. Data analyses were carried out using a SAS computer software Version 8. For continuous variables, mean values and standard errors were calculated and comparisons were made using t tests.

Seven hundred fifteen pregnant women completed the VEQ as part of a standard intake treatment assessment protocol at the program. Fifty-nine percent of the women reported an independent living arrangement. The lifetime prevalence rate of any type of violence ever physically, sexually, or emotionally abused ranged from The prevalence rate of exposure to any type of violence during the current pregnancy was Rates of specific types of violence during the current pregnancy ranged from Four percent of the women reported all three types of abuse during their pregnancy.

Sexual partners were the primary perpetrators of lifetime physical Parents especially mothers were also frequent perpetrators of physical and emotional abuse. Sexual abuse was more frequently perpetrated by abusers other than the partners e. Approximately one third Twenty-five percent of the women who reported episodes of physical aggression with their partner stated that these fights occurred in front of their children.

Introduction

More than half Twenty-six percent of the women reported having a weapon available at home usually a knife or gun that was identified as a potential weapon. Reports of lifetime violence in the community were also high. Women identified emotional effects on the children i. Women frequently attributed effects in more than one area to the exposure to violence. This study documented high rates of lifetime and current exposure to violence among a population of substance-dependent pregnant women entering substance abuse treatment, as assessed by the VEQ.

Physical, emotional, and sexual abuse histories were frequently reported with high rates of co-occurrence. Usually, the perpetrator was the partner or someone closely related to the victim i. The prevalence rate of physical violence during pregnancy in this sample Although the rates of violence that we found are high, we nonetheless believe that they represent underestimates of the true scope of the problem.

Exposure to violence among substance-dependent pregnant women and their children

We have clinically observed that women frequently deny exposure to violence upon program admission, only to disclose abuse subsequently during their treatment. It is also possible that substance-dependent women may accept some abusive aspects of their life as normal or may experience psychosocial pressure to deny a history of abuse. Some of the women involved in these episodes may not perceive these situations as an abusive event perpetrated by their partner.

Therefore, it may not be surprising to find higher rates of abuse later on in treatment when substance-abusing pregnant women become aware of their abusive relationships and feel more comfortable disclosing to therapists the reality of their everyday lives. The finding that 7. Sexual abuse has been associated with multiple health risks for mothers and infants, including sexually transmitted diseases e. In addition, substance-abusing pregnant women who report both sexual and physical abuse during pregnancy present with high levels of psychological distress Velez et al. Routine screening for sexual abuse in substance-abusing pregnant women is imperative so that appropriate services and safety plans can be established for the victims, their existing children, and their newborns.

The VEQ may serve as a screening tool given that it was very well accepted by this study population and facilitated development of individualized intervention plans.

Intervention strategies for pregnant drug-dependent women experiencing violence differ depending on the relationship of a perpetrator to a victim. However, it is notable that, in this sample, many perpetrators of violence against women during their current pregnancy were reported to be persons other than their current or ex-partner i. In the case of sexual abuse during current pregnancy, more than half This has negative implications for women in their ability to access shelters for women experiencing violence.

Also, even serious emotional abuse by a partner or another person is rarely a criterion for acceptance into a shelter or other domestic violence services. Many of the women in this sample stated that their emotional abuse was more disturbing than their physical abuse. Interestingly, a relatively low percentage of women in this sample reported feeling unsafe at home This may be caused by the frequently unstable domiciliary arrangements of this population. Feeling unsafe at home may imply a literal interpretation that may not apply to a woman who either is homeless or has transient housing accommodations.

They are also at increased risk of developing alcohol and drug problems in later life as well as becoming either batterers or victims in adulthood Anda et al. In addition to the violence experienced at home, women and their children from this sample reported experiencing significant rates of community violence. Exposure to violence may have a significant negative impact on developmental and adaptive functioning in children.

Although this study was designed to characterize violence exposure among pregnant drug-dependent women, the potential effects of exposure to violence among their children should not be underestimated. Clearly, such children require further investigation. Studies indicate that the most important resource protecting children from the negative effects of exposure to violence is a strong relationship with a competent, caring, stable adult, most often a parent.

The present study data should be interpreted with caution because methodological limitations must be considered. First, this is a cross-sectional study and may only reflect the current situation of the patients and what they can recall, which may in turn be affected by memories of a traumatic event. Second, the data are based on self-report, which may or may not reflect the true situation of victimization. Third, the results are from a sample of substance-abusing pregnant women seeking drug treatment, which may be different from those from the general population.

In addition, this study reports findings based on a single screening for violence exposure during the first week of treatment as opposed to screening at a predetermined gestational age or repeated screening over time. There may be a cohort effect given that women of more advanced gestational age have had more chances of being exposed to violence than those who are just beginning their pregnancy or vice versa. Some of the strengths of the study include the relatively large sample size, the fact that data were collected in a relatively short period, and the application of an instrument developed to assess the prevalence and characteristics of violence exposure among pregnant substance-abusing women, for which there is no precedent.

Administering the questionnaire after a structured group session that defined abuse and terms used to describe different types of abuse seems both a potential limitation and a strength.

1. Introduction

Although the group session helped define the terms used in discussing abuse and helped build trust that allowed the women to respond affirmatively to some of the items, it may also have produced higher rates of item endorsement than would be seen without it. In summary, substance-abusing pregnant women and their children reported high rates of exposure to all types of violence.

This exposure has significant health consequences for the women, children, and fetuses involved. The data reported here support the importance of routine screening for lifetime and current exposure to violence among substance-abusing pregnant women.

Providers must understand and teach the complex relationships among substance abuse, exposure to violence, and mental health. The process of recovery for each pregnant substance-abusing woman experiencing violence must incorporate treatment for IPV issues both for herself and for her children. Treatment facilities for substance-abusing pregnant women should be prepared to address exposure to violence among their clients. Further research should be conducted to design and evaluate treatment models for violence exposure as a component of substance abuse treatment and to understand the effects of physical, sexual, and emotional abuse during pregnancy on both substance-dependent mothers and their unborn children.

National Center for Biotechnology Information , U. J Subst Abuse Treat. Author manuscript; available in PMC Mar 4. The publisher's final edited version of this article is available at J Subst Abuse Treat. See other articles in PMC that cite the published article. Abstract This study examined the prevalence of exposure to violence among drug-dependent pregnant women attending a multidisciplinary perinatal substance abuse treatment program. Introduction Violence toward women is a major public concern with ramifications for both the public health and criminal justice systems.

Materials and methods 2. Participants Study participants were pregnant substance-abusing women admitted between September and July to a comprehensive treatment facility in Baltimore for their first treatment episode. Results Seven hundred fifteen pregnant women completed the VEQ as part of a standard intake treatment assessment protocol at the program. Open in a separate window.

Episodes Percentage Lifetime physical fights with current partner Discussion This study documented high rates of lifetime and current exposure to violence among a population of substance-dependent pregnant women entering substance abuse treatment, as assessed by the VEQ. Violence during pregnancy and substance use. American Journal Public Health. Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression.

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