key: cord-0898938-mobky5kz
authors: Risser, Lauren; Berger, Rachel P.; Renov, Veronica; Aboiye, Fatimah; Duplessis, Virginia; Henderson, Cynterria; Randell, Kimberly A.; Miller, Elizabeth; Ragavan, Maya
title: Supporting children experiencing family violence during the COVID-19 pandemic: IPV and CPS provider perspectives
date: 2022-03-25
journal: Acad Pediatr
DOI: 10.1016/j.acap.2022.03.011
sha: a42c13a75c3ff534993ec534c4b2dbecd06ff623
doc_id: 898938
cord_uid: mobky5kz

OBJECTIVES: : Children experiencing family violence (child abuse and neglect and exposure to intimate partner violence) are at a particularly elevated risk for compounding challenges during the COVID-19 pandemic. In this study, we interviewed intimate partner violence (IPV) advocates, child protective services (CPS) caseworkers, and IPV and CPS administrators on the needs of children experiencing family violence during the pandemic. METHODS: : We conducted semi-structured interviews with IPV advocates, CPS caseworkers, and IPV and CPS administrators. Recruitment occurred through emails to national and state listservs, networks of the study team, and word of mouth. Interviews were completed through Zoom, took 45 to 60 minutes and were audio recorded. We used a mixed deductive-inductive content analysis approach. RESULTS: : Fifty-nine IPV advocates, 35 IPV administrators, 21 CPS workers and 16 CPS administrators participated in this study. Four themes emerged from this work. Participants discussed the role of social isolation, school closures, and distance learning on children experiencing family violence. They also noted child custody and visitation challenges, particularly in the context of abusive partners using custody to control IPV survivors and limitations to virtual visitation more broadly. Compounding challenges were described for children from marginalized communities due to structural-level inequities. Collaboration was discussed by participants from both IPV and CPS sectors. CONCLUSION: : This study is one of the first to describe the way the COVID-19 pandemic has impacted children experiencing family violence. Future studies should triangulate these results with children, families, and other child-serving providers

 This study examines the perspectives of child protective services workers and intimate partner violence advocates about the compounding challenges faced by children experiencing family violence during the COVID-19 pandemic. Informed by these results, we provide recommendations for child-serving providers

Children, defined as those under age 18 years, have been deeply impacted by the COVID-19 pandemic. [1] [2] [3] [4] Despite lower rates of symptomatic COVID-19 illness and mortality, 5 children have experienced significant secondary impacts of the pandemic. These include school closures, decreased physical activity, violence exposure, mental health symptoms, and parent/caregiver, poverty, stress, job loss, illness, and death. 3, 4, [6] [7] [8] [9] [10] [11] Those providing services to children, including pediatric healthcare providers, have an important responsibility to support children and caregivers during this ongoing and relentless pandemic.

Children experiencing family violence, including child abuse and neglect (CAN) and exposure to intimate partner violence (IPV), are at particularly elevated risk for negative impacts of the pandemic. Before the pandemic, one in five US children was exposed to IPV 12 and one in seven experienced CAN annually. 13 Experiencing family violence can have myriad and lifelong negative physical, behavioral, and developmental health impacts on children. 13, 14 Recent work has demonstrated links between the pandemic and family violence. [15] [16] [17] [18] [19] [20] While individual studies have shown mixed results in terms of changes in IPV frequency and severity during the pandemic, a systematic review of 32 studies 20 and a meta-analysis of 18 studies 15 showed overall increases in IPV during the pandemic (medium effect size of 0.66 for the meta-analysis). 15 Further, studies have elucidated the unique challenges IPV survivors faced during the pandemic, particularly when shelter-in-place orders were enacted. [21] [22] [23] The relationship between and CAN appears to be more complicated although still significant. 17 For example, studies have shown decreased CAN reports to Child Protective Services (CPS) 18 and decreased emergency department visits for CAN 19 in 2020 compared to 2019; however, the percentage of hospitalizations as a result of ED visits for CAN increased. 19 Another study examining the perspective of home visiting providers found 87% of participants thought maltreatment risk had increased during the pandemic. 24 Further, children experiencing family violence who identify as Black, American Indian or Alaska Native (AIAN), Latine, LGBTQ, and those living in poverty have experienced compounding challenges due to pre-existing structural inequities, family violence, and the pandemic. 8, [25] [26] [27] Therefore, addressing family violence during the pandemic is critical to support child health and well-being, particularly for children from marginalized communities.

Individuals working at IPV and CPS agencies directly support children and caregivers impacted by family violence and play important roles in advocating for family safety and wellbeing. IPV agencies provide a range of services to IPV survivors and their children including counseling, legal advocacy, and shelter. 28 CPS is a government agency that investigates child maltreatment, determines if abuse or neglect has occurred, and intervenes, if needed, with the goal of promoting children's safety. 29 Therefore, staff at IPV and CPS agencies are optimally positioned to share the experiences and challenges of children connected to their services who are experiencing family violence during the pandemic. To that end, we performed qualitative interviews to explore the perspectives of IPV advocates, CPS caseworkers, and CPS and IPV administrators on the needs of children experiencing family violence (specifically CAN and exposure to IPV) during the pandemic.

This manuscript draws upon results of a larger qualitative study of family violence during the pandemic. 23; 30,31 We interviewed IPV advocates, CPS caseworkers, and IPV/CPS administrators to examine the experiences of families connected with these agencies and to elucidate the programs and services agencies implemented to support families during the pandemic. IPV advocates have advanced training in responding to IPV and provide direct services to survivors. CPS caseworkers respond to CAN reports and meet with families regularly to facilitate service provision and ensure the safety of children. While administrators do not work directly with survivors or families, they advocate for policy and practice changes at local, regional, state, and national levels and make decisions regarding programming and other resource allocation. In the larger study, we also examined the experiences of adult IPV survivors during the pandemic, and strategies IPV and CPS agencies used to support families and frontline workers; these findings are published elsewhere. 23;30,31 The University of Pittsburgh Institutional Review Board deemed this study exempt.

To meet inclusion criteria, an interviewee had to: 1) self-identify as a(n) IPV advocate, CPS caseworker, or IPV/CPS administrator; 2) be aged 18 or older; 3) speak and understand English; and 4) work in the United States. Recruitment occurred through word-of-mouth, emails, and calls to our team's professional networks, emails to national listservs through our partner Futures Without Violence for IPV advocates and administrators, and emails to various state listservs for CPS caseworkers and administrators.

We developed interview questions aligned with our research objectives. Interview guides also included questions related to our broader study objectives. Appendix 1 includes a sample of questions from our larger interview guide most relevant to this article, including one question we added mid-way through data collection. In the interview guide, we explicitly asked participants to think about children experiencing family violence (IPV and CAN) rather than children more broadly.

Interviews lasting 45 to 60 minutes were conducted from June 2020 to March 2021 by members of the study team all of whom underwent qualitative methods training and completed practice interviews prior to starting data collection. Participants provided verbal consent prior to beginning the interview and received $30 for participating. Interviews were conducted until thematic saturation was reached (i.e., no new data emerged), 32 when we were able to recruit a representative sample, and when all individuals who expressed interest were able to participate.

Verbatim transcriptions of the interview audio files were uploaded to the Dedoose qualitative coding software. 33 We used a mixed deductive-inductive content analysis approach, starting with a priori codes aligned with our research questions (e.g., effect of COVID-19 on children) and then creating inductive codes based on emerging data. 34 The coding team included the first, third, and final authors, in addition to trained research assistants. Two team members coded each transcript, which was reviewed by a third coder. The coding teams met weekly to discuss discrepancies in coding, develop consensus, and discuss emerging content areas. Our full team met monthly to review patterns in the data and elucidate key content on this study topic. We also shared codes with our monthly community partner council, comprising national IPV and child welfare organizations, to help us finalize our themes. Table 2 .

Social isolation during the pandemic impacted the safety of children experiencing family violence Interviewees from both IPV and CPS sectors described how increased isolation was particularly challenging for children experiencing family violence, as children have lost access to supportive, safe spaces outside of the home. This can result in witnessing IPV or experiencing CAN to which they may not have previously been exposed. As an IPV advocate (#17) shared:

Survivors do an incredible job of protecting their children, to the best of their ability, and I think that a lot of the safeguards have been taken from survivors, so kids can't go to camp anymore, they can't go to school. They're more likely to hear and to witness the abuse that one parent is engaging in with the safe parent.

Participants also shared that isolation during the pandemic altered safety plans to reduce the risk of harm: Further, interviewees shared that schools are often one of the first places to notice signs of abuse. An IPV administrator (#28) shared, "Our public schools have largely been closed.

They are starting to reopen a bit…there has not been an opportunity for anybody outside to look in to see if a child is struggling. Sometimes, [violence] becomes uncovered through noticing something's off with a child, and then offering a parent help." Schools also provide a sense of community and strength, which participants shared was missing for children and important to recreate: "around December for Christmas, there is a school that would come, and they would do a holiday party for our kids. A lot of our kids are really missing that sense of community. We try to find ways to create that, but obviously, it's not the same" (IPV Advocate #42).

Custody and visitation challenges in the context of family violence and the pandemic Participants shared several unique challenges created by the pandemic around custody and visitation when IPV and/or CAN are present. IPV advocates noted how abusive partners used the pandemic to try to change custody agreements or limit survivors from seeing their children: Participants shared that many of the families they served were also impacted by poverty.

These families had limited resources prior to the pandemic, making the economic challenges that accompanied COVID-19 even more difficult to navigate. As one CPS caseworker (#12) shared:

[Parents] could be working at the fast-food restaurants, grocery stores, bus drivers. If they call offthey can't pay rent. If they don't have childcarewe're going to have neglect concerns that kids are being left home alone. If they call off of workthey're gonna get fired and they're not going to be able to make their rent. You can see those challenges that parents have around work, which is then also exposing them to more people, exposing them to higher rates of the virus.

An IPV administrator (#22) shared how digital inequities were specifically impacting AIAN communities where they worked: "I think the inequities across the state have only been exaggerated, including Indigenous people having limited access to a lot of resources, particularly internet. When we're talking about education of survivors' children, that's a huge issue."

In general, individuals representing IPV and CPS agencies shared similar perspectives, particularly around social isolation and school closures. However, for custody concerns, IPV staff focused primarily on how abusive partners used COVID-19 to manipulate custody and CPS staff described broader custody challenges during the pandemic due to virtual visitation, particularly for parents whose children had been removed from their custody.

Given the shared experiences of IPV and CPS agencies during the pandemic, collaboration between the agencies offers opportunities to learn from and support each other as well as the families that they serve. A CPS administrator (#9) shared the importance of collaboration, "All these different agencies intertwine, and there's no one overseeing that collaboration. Thankfully, in this field, we are aware that we need this collaboration to work together, and as experts we've found ways to collaborate within our community."

To our knowledge, this is among the first studies to explore perspectives of IPV and CPS agency staff regarding impacts of the pandemic on children experiencing family violence. Participants provided unique insights into the challenges COVID-19 presented for these children as well as opportunities to better support children and their families.

Many of the challenges facing children, such as increased isolation and school closures, were pervasive during the pandemic 35 as well as other past crises (i.e., Hurricane Katrina) 36 and not unique to children experiencing family violence. However, family violence exacerbated these challenges, which compounded the negative impacts of the pandemic for this group of already vulnerable children. As noted by Holland et al.,

preventing and responding to public health crises (including emergency preparedness plans) should incorporate efforts to mitigate secondary impacts of the crisis, such as increased mental health needs, substance use, and violence. 37 Such prevention efforts must include information specific to children experiencing family violence.

Our study highlights the need to expand supports for children and their caregivers in the context of pandemics and public health emergencies, particularly for marginalized communities who have experienced compounding challenges during this pandemic. 8;25-27 Participants in this study noted how children from marginalized communities experienced structural inequities rooted in racism, homophobia, transphobia, and poverty further perpetuating cycles of family violence. Thus, child-serving providers and policymakers should ensure that families' experiences and expertise are integrated into service provision and that structural level solutions are amplified rather than focusing on punitive measures against individual parents or caregiver. At the individual/family level, the pandemic has created unique challenges around custody and visitation. In the context of IPV, prior work has documented abusive partners' use of custody agreements as a mechanism of coercive control. IPV survivors have described how child-related judicial processes may revictimize them and allow the abusive partner to maintain control. 38, 39 Further, abusive partners may use child custody to control IPV survivors in multiple settings, including pediatric healthcare. 40 Our study extends this past work by noting how the pandemic increased opportunities for abusive partners to maintain control over custody and limit visitation. Further, this study underscores the challenges of virtual visitation more broadly for children separated from their parents. Past research shows the developmental and health impacts of family separation. 41, 42 Our study suggests the importance of developing safe ways for in-person visitation during public health emergencies.

These findings should be considered with several limitations in mind. We interviewed staff from IPV and CPS agencies rather than directly interviewing families.

While these individuals work closely with children experiencing family violence, additional work is needed to hear directly from children and caregivers. Further, these interviews were conducted from June 2020 to March 2021, which only reflects a short time period of the pandemic. The experiences of families were unlikely to be stable throughout the pandemic especially as distancing measures were relaxed and vaccines became widely available. As the pandemic continues, experiences of family violence and the social service and public health responses will continue to evolve. Additionally, while we conducted significant outreach through national networks, this study relied on convenience sampling and may not be generalizable. However, the intent of qualitative research is not to generalize but to elucidate nuanced and heterogeneous concepts and experiences.

While not a limitation, neither IPV or CPS participants identified the need for better coordination between IPV and CPS agencies despite noting the importance for collaboration across different service sectors more broadly, especially as part of being prepared for future crises; however, interviewees were not probed for this information.

Efforts to better elucidate potential barriers and missed opportunities for such collaboration are needed. 18 Research Implications "When we're talking about families whose support system is in the high-risk categoryit could be grandparents. It could be more elderly aunts, uncles, cousins that could be assisting the family with childcare, watching the kids while parents go to work or helping get to school and home…If there is a fear and you want to stay away from those folks to keep them isolated so that they don't get sick, your support system is lost…that has created a bigger challenge on meeting the needs of some of our families." -CPS administrator #12 "We had the abusive stepdad and she was able to remove herself from the situation, that was her safety plan. She knew what to do. At the same time, it's trying to find a safe place for them to go when they can't go to a friend's house. When they can't go to a certain family member's house because they might be immunocompromised or elderly." -IPV advocate #44 School closures and distance learning created stress for children experiencing family violence "A lot of our reports are made by mandated reporters such as teachers, social workers, principals… once they took the kids out of school and weren't seeing them on a daily basis… [the kids] didn't have the opportunity to go to the social worker at school and talk to them about what's going on in the home" -CPS caseworker #2

"Families who are in shelters don't always have wi-fi. Then it's difficult for children to go to school there at the shelter. Parents are transporting them to community centers to be able to do that. Shelters sometimes are not in the most convenient location. That's another challenge. I think that one's the biggest challenge right now if school continues to be online is it's not easy for all parents to be able to be there for them, especially when they're going through all this trauma, all this abuse." -IPV advocate #41 Custody and visitation challenges in the context of family violence and the pandemic "The biggest impact [of the pandemic] would be on our visitations with our parents since a lot of our parents do not quarantine or are unable to quarantine like a lot of other people canthey are very transient. They are homeless at times and staying with multiple different people. Some of our children that we have come into care are medically fragile." -CPS administrator #14 "[Navigating visitation]is something that survivors are already struggling with…I think especially as things change in the pandemic, there might be increased pressure on survivors to have increased contact with someone who's abusive or having to have them navigate the brunt of the challenges that come about visitation and thereby potentially exposing them to more difficulty or harm or exposing the kids to more difficulty." -IPV advocate #32 Compounding of structural inequities for children experiencing family violence "I think… about the political landscape and how that's really emotionally impacted Black and Brown and LGBTQ youth, too. I think that's just been an emotional burden and added burden to their families, which increases any family stress that's going on, which increases violence that's going on." -IPV advocate #43 "A lot of parents are feeling overwhelmed with having to worry about their kids falling behind…[IPV agency] has done a lot of individual troubleshooting, but I feel like there needs to be a broader solution…Because you know who's not getting served, right? It's the kids of color, black and brown kids in the city, in the neighborhoods." -IPV administrator #14 "How do we educate their children? They don't have computers.

Think about having three children, school-age children, in different grades in your home trying to do their homework. That means three computers. A lot of families don't have three computers. We saw that a lot in the marginalized communities. Some of the teleservices, the telemedicine, the tele-mentalhealth, the tele-resources for safety planning, they didn't have access to that, and especially if they spoke multiple languages or languages that weren't quite as common." -IPV advocate #6 Collaboration "I think about the work that I'm doing personally, as part of the [agency], I've had more contact with zero-to-three safe baby courts, for instance, and looking at domestic violence and how that impacts and effects families and providing practice guidance around that. Those are relationships that started before COVID that are ongoing and have expanded." -IPV administrator #11

Children's Hospital Association. Children and COVID-19: State Data Report

COVID-19-Associated Orphanhood and Caregiver Death in the United States. Pediatrics

The Impact of Coronavirus on Households Across America -RWJF

Parental Social Isolation and Child Maltreatment Risk during the COVID-19 Pandemic

Provisional Mortality Data -United States

Stress and parenting during the global COVID-19 pandemic

Supporting Adolescents and Young Adults Exposed to or Experiencing Violence During the COVID-19

Supporting Intimate Partner Violence Survivors and Their Children During the COVID-19 Pandemic

Impact of COVID-19 pandemic lockdown on movement behaviours of children and adolescents: a systematic review

Sounding the Alarm for Children's Mental Health During the COVID-19 Pandemic

Examining the impacts of the COVID-19 pandemic on family mental health in Canada: findings from a national cross-sectional study

Children's Exposure to Intimate Partner Violence and Other Family Violence. National Survey of Children's Exposure to Violence.Office of Juvenile Justice and Deliquency Prevention

Intimate partner violence: identification and response in pediatric health care settings

Domestic violence during the COVID-19 pandemic: Evidence from a systematic review and metaanalysis

Alarming trends in US domestic violence during the COVID-19 pandemic

COVID-19 and violence against children: A review of early studies

An increasing risk of family violence during the Covid-19 pandemic: Strengthening community collaborations to save lives

Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic -United States

Domestic Violence During the COVID-19 Pandemic: A Systematic Review

Survivors' Experiences of Intimate Partner Violence and Shelter Utilization During COVID-19

Everyone is Living in the Same Storm, but our Boats are all Different": Safety and Safety Planning for Survivors of Intimate Partner and Sexual Violence During the COVID-19 Pandemic

The Impact of the COVID-19 Pandemic on the Needs and Lived Experiences of Intimate Partner Violence Survivors in the United States: Advocate Perspectives

Evaluating child maltreatment and family violence risk during the COVID-19 Pandemic: Using a telehealth home visiting program as a conduit to families

Racial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged <25 Years

Syndemics: A cross-disciplinary approach to complex epidemic events like COVID-19

Psychosocial Effects of the COVID-19 Pandemic and Mental Health among LGBTQ+ Young Adults: A Cross-Cultural Comparison across Six Nations

Domestic violence and sexual assault services: Inside the black box

Department of Health and Human Services, Administration for Children and Families

The Impact of the COVID-19 Pandemic on Intimate Partner Violence Advocates and Agencies

The impact of the COVID-19 pandemic on child protective services caseworkers and administrators. Child abuse & neglect, 105431

How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field methods

Web Application for Managing, Analyzing, and Presenting Qualitative and Mixed Method Research Data

Qualitative Research & Evaluation Methods: Integrating Theory and Practice

Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19

Factors influencing the course of posttraumatic stress following a natural disaster: Children's reactions to Hurricane Katrina

Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic

the system had choked me too": abused mothers' perceptions of the custody determination process that resulted in negative custody outcomes