Resolved: Intimate Partner Violence in a Child’s Home is a Form of Maltreatment and Should Generally be Reported.

• How should we address the situation of children living in homes with intimate partner violence?
• Even if children are not directly harmed, we know they suffer poor outcomes from these environments. Should this be considered a form of maltreatment?
• Does this situation fall under our obligation to report to child protective services?

This is a common dilemma faced by many mandated reporters, with compelling arguments on both sides of the issue. To shed light on these complexities, we organized a debate featuring four highly qualified national experts who argued for and against the resolution: "Intimate Partner Violence in a Child’s Home is a Form of Maltreatment and Should Generally be Reported." Initially presented at the national meeting of the Helfer Society, we hope this debate advances the discussion on these challenging situations.

The Host: Dan Lindberg is a member of Kempe’s Child Protection Team and an Emergency Physician 

The Debaters: 

FOR The Resolution: Dr. John Melville is the Director of the Division of Child Abuse Pediatrics at the Medical University of South Carolina, where the law mandates reporting of IPV exposure.  

Dr. Antonia Chiesa is the Director of Integrated Healthcare Services at the Kempe Center and the Principal Investigator of the Kempe Care Network, which improves the care of potentially abused children across Colorado.    

AGAINST The Resolution: Dr. Gunjan Tiyyagura is a pediatric emergency physician in New Haven, where she helped develop an integrated care model of care for IPV survivors and their children. 

 Dr. Nina Livingston is a Child Abuse Pediatrician in Hartford, where she partners with her state coalition against domestic violence and is a co-author of the AAP clinical report on IPV and the Pediatrician 

Transcript

00:00:00:00 - 00:00:20:16
Unknown
You're listening to Radio Kent. We value the sense of community that connects people and helps them find ways to move forward. Join us on our journey to prevent child abuse and neglect.

00:00:20:18 - 00:00:46:13
Unknown
Well, welcome and welcome back. This is Radio Camp. I'm Dan Lambert with the Camp Center for the Prevention and Treatment of Child Abuse and Neglect. Thanks for joining us today. I'm taking over hosting duties for Kendal Marlow for this episode of Radio Camp, where we'll be using a new format for the podcast. Today, we're hosting a debate to highlight a common but difficult situation faced by many mandated reporters.

00:00:46:15 - 00:01:11:20
Unknown
What do we do when a child is living in a home where there's intimate partner violence specifically? What do we do when it comes to reporting to Child Protective Services? I think we'd all agree that the worst outcomes of abuse aren't always associated with the physical trauma itself. But should the presence of intimate partner violence in a home be reported to Child Protective Services just as other forms of maltreatment?

00:01:11:22 - 00:01:41:19
Unknown
This is an important topic and it's really controversial. Different states and different juristic sons have come to different conclusions when it comes to their requirements for reporting child maltreatment. And so in order to try to get to an answer, we've recruited for world class child maltreatment experts to debate the following resolution. Resolved. Intimate partner violence is a form of child maltreatment, and it should generally be reported to Child Protective Services.

00:01:41:21 - 00:02:05:26
Unknown
We are so proud to have recruited four extraordinarily qualified debaters arguing for the resolution will be Dr. Antonia Keyser and Dr. John Melville. Dr. Keyser is an associate professor of pediatrics here at the Kemp Center and a leader of the Camp Care Network, which improves the care of potentially abused children all across Colorado. Her partner today is John Melville.

00:02:05:28 - 00:02:37:16
Unknown
Dr. Melville is the director of the Division of Child Abuse Pediatrics at the Medical University of South Carolina and the director of the South Carolina Child Advocacy Medical Response System. On the other side, arguing against the resolution will be Dr. Gunjan Tioga and Dr. Neil Livingston. Dr. Tioga is a pediatric emergency physician in New Haven, where she helped develop an integrated model of care for IPV v survivors and their children.

00:02:37:19 - 00:02:59:23
Unknown
Her partner is Dr. Nina Livingston. Dr. Livingston is a child abuse pediatrician in Hartford, where she partners with her state Coalition against Domestic Violence and is a coauthor of the American Academy of Pediatrics Clinical Report on Intimate Partner Violence and the Pediatrician. Today's episode will be a bit longer than our usual episodes, so let's get right to it.

00:02:59:25 - 00:03:27:18
Unknown
We're using an Oxford debate format in round one. Each debater will make an opening statement, followed by round two, where I will ask questions of the debaters in turn. Finally, in round three, each debater will make a very brief closing statement. So without further ado, let's welcome Dr. Antonia Keyser to the microphone for her opening statement. Well, thank you so much.

00:03:27:20 - 00:04:03:27
Unknown
And I'm here today to argue that exposure to intimate partner violence, which I'll refer to as IPV at times, is a form of child maltreatment and should be mandated by law for report. And let me lay out that irrefutable evidence now in the United States, nearly one in five children witnessed violence between their parents or caregivers. This is a staggering statistic that translates to a national public health crisis and is creating invisible scars every day.

00:04:03:29 - 00:04:39:00
Unknown
IPV creates a toxic environment. Homes filled with fear and insecurity. A home which should be a child's haven for safety and love turns into a battleground and jeopardizes the child's mental and emotional well-being. This extends beyond the physical altercations that we often associate with domestic violence, and certainly those effects of physical violence are undeniable. But it's the psychological trauma to children that is equally devastating and results in long lasting harm.

00:04:39:02 - 00:05:16:12
Unknown
Children who witness violence are more likely to suffer from anxiety, depression and other serious behavioral problems. It causes emotional distress that can have profound impact on their development and hinder their ability to form healthy relationships or achieve their full potential. These behavioral health implications are rooted in injury to the brain and self. Those invisible scars I mentioned earlier studies have revealed a disturbing correlation between exposure to domestic violence and altered brain development in children.

00:05:16:14 - 00:05:44:00
Unknown
Changes that can actually be seen on MRI, including lower brain volumes for children exposed to interpersonal violence. Other study. Other studies show of effects to areas of the brain that are involved with processing, sensory perception and the transfer of information between hemispheres. These alterations can have lasting effects on how a child perceives the world, interacts with others, copes with stress, manages emotions.

00:05:44:02 - 00:06:12:16
Unknown
These are the invisible scars that are present throughout life and don't just disappear in adulthood. There is a frightening link between childhood exposure to violence and a multitude of mental health disorders later in life, including but not limited to depression, PTSD, substance abuse. The potential consequences to children and society are far too grave to ignore. But let's switch gears.

00:06:12:18 - 00:06:40:16
Unknown
Switch gears, and let's talk about those more obvious concerns of physical safety. Children who witnessed violence in the home are at a much greater risk of experiencing physical abuse themselves. Upwards of four times the risk in some studies. In the most extreme examples, it should be noted that in 20% of child homicide cases, the victim lived in a home where domestic violence was present.

00:06:40:19 - 00:07:11:29
Unknown
Almost half of women who report IPV during pregnancy also report non IPV child abuse by the child's third month. These statistics speak for themselves. Children living in homes with IPV are at a much higher risk of harm, and a hands off approach simply cannot be justified when the child safety and well-being are at stake. The physical and emotional damage left in the wake of IPV is clear.

00:07:11:29 - 00:07:48:11
Unknown
It is abuse and we must respond accordingly. Mandatory reporting is our pathway to activate resources and to intervene in situations where children are at risk. Specially trained professionals can provide support to children and victims of IPV. Early intervention will prevent further abuse and help children cope with the trauma they've experienced. These service services can include things like trauma, informed therapy, safety, planning, violence, specific resources that are going to help break the cycle of violence.

00:07:48:13 - 00:08:24:10
Unknown
Now, some may express concerns regarding the effectiveness of mandatory reporting or even the quality of responses from Child Protective Services. And I grant these are valid areas for discussion, but they do not negate the urgent need to intervene in situations of interpersonal violence. We must strive to improve the system and simultaneously take steps to protect vulnerable children. In conclusion, exposure to interpersonal violence is an undeniable and serious form of child abuse.

00:08:24:12 - 00:08:57:00
Unknown
It has far reaching physical and emotional health consequences. These facts necessitate a strong legal framework to protect vulnerable children. Exposure to IBD, IPV is child maltreatment and demands a mandatory reporting system safeguard the well-being of our most vulnerable citizens. And thank you for your time. Thank you. Dr.. That was outstanding. I think the gantlet has been thrown down.

00:08:57:02 - 00:09:09:27
Unknown
So with that in mind, I'd like to welcome Dr. Gungeon Tiger to present the first opening statement against the resolution.

00:09:09:29 - 00:09:34:03
Unknown
Thank you very much. You've heard about what intimate partner violence is and that it can be harmful to children in many ways. We will spend our time showing you why universal reporting to Child Protective Services for IPV is a bad idea. And what we should be doing instead. First, we want to start by discussing a landmark case to frame our discussion.

00:09:34:05 - 00:09:59:03
Unknown
This case was entitled Nicholson versus Williams. Shoreline. Nicholson was beaten by her daughter's father and sought medical care for her injuries. Her daughter was in her crib in another room and her son was at school during the attack. During this process, a report was made to Child Protective Services for child exposure to intimate partner violence. As a result, CPS removed the children, alleging that Ms..

00:09:59:03 - 00:10:41:02
Unknown
Nicholson was unable to protect her children. A Class A battered mothers and their in their children challenged New York City's policy of removing children from homes, from mothers who would expose their children to domestic violence by being victimized in their presence without showing harm to the child or considering the context within which that exposure took place. The New York District Court thus decided that this was an unconstitutional practice and further recommended that CPS agencies must demonstrate that a child endured harm as a direct result of IPV exposure to substantial IPV exposure related maltreatment.

00:10:41:04 - 00:11:13:21
Unknown
So we want to argue to not report all IPV to Child Protective Services because reporting can cause harm. There are unclear benefits of CPS involvement. It may lead to worsening disparities, and the scope of the problem exceeds CPS capacity. I will now explain each one in further detail. So Dowell Dowell intentioned mandatory reporting may discourage survivors from seeking health care and disclosing intimate partner violence.

00:11:13:23 - 00:11:45:07
Unknown
In fact, a study of IPV survivors found that over a quarter of participants were afraid to tell their health care provider about IPV due to the potential reporting to CPS or other governmental institutions. And it may also increase danger for those experiencing IPV. In fact, in a study of 2500 IPV survivors examining the impact of mandatory reporting, greater than 60% of the IPV survivors said the reporting made their situation much worse than before.

00:11:45:10 - 00:12:24:23
Unknown
This included legal system involvement, removal of children and worsening of the actual intimate partner violence. And finally, reporting may discourage providers from addressing intimate partner violence with patients for fear of having to report them against their will. Second, there are unclear benefits of CPS, despite efforts to implement supportive frameworks in the assessment of intimate partner violence. Research shows that there's inconsistent CPS adherence to best practices and guidelines, and the practice on the ground is often at odds with policy directives.

00:12:24:26 - 00:12:59:03
Unknown
For example, investigators still use risk assessment tools that do not separate abused caregiver and perpetrator behaviors. These practices often lead to punitive outcomes for adult survivors. Adult victims or caregivers are often substantiated for failure to protect and subject to consequences like the removal of children and termination of parental rights. Furthermore, research suggests that a CPS investigation does not routinely result in referrals to engagement with needed services for IPV.

00:12:59:05 - 00:13:23:25
Unknown
Only a minority of families get referred. And finally, CPS cases in which IPV is a main concern lead to low rate of out-of-home placement or open services. Potentially implying that while these cases benefit from service referrals to IPV resources, this might be accomplished in some cases outside of the child welfare system.

00:13:23:27 - 00:13:57:03
Unknown
Third, mandated reporting laws will disproportionately affect structurally marginalized families and lead to worsening disparities in cases of IPV exposure. Black children, for example, are more likely to be investigated, transferred to ongoing services, and have cases substantiated. These findings suggest that allegations of neglect involving black youth well more likely to result in continued contact with child welfare systems compared to similar cases involving white dude youth.

00:13:57:05 - 00:14:27:12
Unknown
It is essential, therefore, that as pediatric health care providers, we consider the way oppressive societal policies such as mandatory reporting for all IPV exposure may disproportionately impact IPV survivor experiences and ability to access services. And then finally, we want to talk about the radical impracticality of reporting all IPV exposure. That child exposure to IPV is epidemic through national surveys on child exposure to violence.

00:14:27:12 - 00:14:58:03
Unknown
We know that one in four children in the United States have lifetime exposure to caregiver IPV and CPS systems do not have the capacity to evaluate all of these children. The Minnesota experience is instructive here. In 1999, the Minnesota legislator amended the definition of child neglect to include exposure to family violence. No additional funding was allocated. Referrals expanded rapidly and through seeps into turmoil, with many counties overwhelmed and no able to attend to the higher need cases.

00:14:58:06 - 00:15:24:16
Unknown
Ultimately, a coalition of child welfare and domestic violence advocates successfully lobbied to repeal this change. Flooding our unprepared CPS systems with these cases may harm both those who would be better served in the community and those who truly need help from CPS. So finally, we urge you to vote no because reporting can cause harm. There are unclear benefits of CPS involvement.

00:15:24:18 - 00:16:17:13
Unknown
It will lead to worsening disparities and the scope of the problem exceed CPS capacity. Thank you. Thank you, Dr. Tager. All right. Finally, in arguing in favor of the resolution, I will welcome Dr. John Melville to the microphone during Q. Dr. Jaeger recognizes the importance of this issue as new. We engaging with his child protection professionals. We really need to focus on the child and focused term protection system that is the child protection system that produces the safety of children over the need window.

00:16:17:16 - 00:17:04:01
Unknown
I was told to choose it, stated in the member. No violence is more soundly and permanently harmful to the children who witness the war. Child focused child protection system is a system that is actively protecting children from exposure to domestic violence. No, in the adult medical world, I won't really know where the standard of care the best practice for victims of partner violence is non directive supportive counseling.

00:17:04:03 - 00:17:38:01
Unknown
But overall, it's our best practice because it's the only tool we have. And trauma. It turns out that the don't have the right to choose to live in a violent relationship and there are many, many reasons that they might choose to do so. We do not do not have a right do is to expose children, violent relationship and all the harms.

00:17:38:03 - 00:18:26:22
Unknown
She is mentioned. So as the child protection system, we need to ask does Nondrug do some positive counseling effectively protect children from exposure to the. And the answer has to be no. Griffin interviewed 90 female residents at a domestic violence field. Do you view him taking the ordinary step of leaving the partner and going to shelter over 60% of them and previously been in the soldier and returned to the same partner at least once?

00:18:26:24 - 00:19:12:17
Unknown
33% of people interviewed had returned abusive murder. Five or more times. Despite these dismal statistics, 74% of these victims reported that they were known to no return to their partner this time. And over half, 68% could not even then den avoiding the attacker that might induce him to return to their gruesome partner. This is not news to anyone who works in our field, but it reinforces what we know from the National Domestic Violence Hotline.

00:19:12:20 - 00:19:52:20
Unknown
I believe he moved them and turned them partner. I mean, of seven times in Congress. Come on, you're calling to be the NASCAR leader. A film with been referred to CBS. They zoomed in. Nobody surprised significant. So they could see risk factors throughout the 36 and sterling career. The most significantly was the soon to be significant longitudinal reductions in intimate partner violence.

00:19:52:22 - 00:20:40:01
Unknown
When CBS didn't write certain similarly specific services, we don't mean behind the CBS we need to fix CBS is to respond. I am also very worried about bias and only bullying, child abuse, pediatrics. What we've learned is that we avoid bias. We are more equal, both slow to closing and regularizing details in child induced clinical judgment typically turned into acting on my unconscious biases.

00:20:40:03 - 00:21:27:13
Unknown
The way we make told me it's more equitable is we make it more uniform. My reporting children of all races is when they are exposed to domestic violence, not the ones that we subjectively feel that parents can't handle on their and in. Certainly CPS is going to see intimate partner violence. We wouldn't not for physical abuse or sexual abuse because it was over with to present this harms children as much as physical abuse or sexual abuse.

00:21:27:15 - 00:22:09:18
Unknown
We should report it and we should have ordered CPS responsible to handle it in a way that is fair and protective to children. Thank you. Thank you, Dr. Melville. Well, with our last opening statement, will welcome Dr. Nina Livingston to the microphone, arguing against the resolution. Hello and thank you. To those of you taking some time to consider this important problem with us now that Dr. Taylor has discussed the problems with Universal reporting of all intimate partner violence, which I'll also call IPV.

00:22:09:20 - 00:22:39:22
Unknown
I will spend some time discussing what we should be doing for these families. First, I will talk about mandatory supporting. Then I will discuss reporting harm or threat of harm. And finally, I will talk about system improvements. So what do I mean by mandatory support? First, are IPV services. The literature shows that IPV services are associated with later resolution of IPV and reduced risk of reporting.

00:22:39:24 - 00:23:08:01
Unknown
Unfortunately, studies also show that CPS usually fails to meet these referrals. So whether or not we are making a CPS report or Child Protective Services report, we need to be connecting families to these resources in our mental health services. There is abundant evidence that mental health treatments can improve outcomes for caregivers and children. Some of the best studied for children are child parents, psychotherapy and trauma focused cognitive behavioral therapy.

00:23:08:03 - 00:23:44:21
Unknown
Research shows that CPS rates of referral to mental health services are also poor, and so we also need to be making mental health referrals, whether or not CPS is involved. Third, are parenting support. Effective parenting can improve outcomes after IPV and these services are available through local IPV advocacy agencies. Supports a survivor centered approach. Acknowledges that IPV survivors are often best positioned to assess their own safety and offers universal education to make resources available without a focus on disclosure.

00:23:44:24 - 00:24:11:24
Unknown
And finally, protective factors exist at the level of the child's family and community, and we need to focus on building those for children who have experienced IPV. Now, let's talk about resilience. We acknowledge that experiencing IPV can harm children despite the risks associated with IPV. Many children in these homes are resilient, and there is a broad spectrum of experience for these families.

00:24:11:27 - 00:24:33:11
Unknown
I want to make you aware of the sampling bias in the existing literature on outcomes for children who have experienced IPV. Many children in published studies are CPS involved and or drawn from shelter populations, and such samples frequently represent children who have witnessed severe and recent abuse and do not capture the full spectrum of experience in the community.

00:24:33:14 - 00:25:05:23
Unknown
And finally, a recent systematic review found studies reporting a range of resilient functioning from 20 to 90% with variability most likely reflecting the population sampled. Now let's talk about assessing harm and threat of harm. We recognize that assessing harm can be challenging as caregivers might not provide full information, and it requires individualized assessment. The assessment may include information gleaned to conversations with the caregiver and child social work input and record review.

00:25:05:26 - 00:25:37:25
Unknown
Ask yourself these questions. These as clinicians, how have the children been affected? Is the abusive partner preventing the caregiver from meeting their needs? Have the children been harmed? And are there threats of harm? Answering these questions can help you make a judgment about the need for reporting. They can also guide service referrals for the family. If you assess and judge their report to CPS is indicated, there are best practices to follow in that reporting process.

00:25:37:28 - 00:26:02:23
Unknown
First, it's important to inform the survivor caregiver that a report will be made and offer the opportunity for the survivor to participate in the report. Ideally, you would make a warm handoff to an IPV advocate and refer to appropriate resources recognizing that CPS may not do so. And finally, be mindful of safety issues in documentation and information sharing with attention to who will have access to the record.

00:26:02:25 - 00:26:32:29
Unknown
Our final recommendation is to participate in health system improvements. These include HPV training for mandated reporters, integration of IPV resources and best practice into the electronic health record. Formalize partnerships with IPD agencies so that we can make immediate, warm handoff and even health care based IPV advocacy programs where health care staff are trained as IPV advocates or IPV agency staff are embedded in a health care setting.

00:26:33:01 - 00:27:01:01
Unknown
But don't just take our word for it. Let's take a look at what experts currently recommend. Our colleague, Dr. Jonathan Thackeray, led a group to update the American Academy of Pediatrics clinical report on IPV and the pediatrician in 2023. And I was privileged to be part of that process. The report clearly communicates that IPV alone should not trigger mandated report, but that we must be mindful of state laws that require reporting in certain circumstances.

00:27:01:04 - 00:27:26:24
Unknown
Children without Violence, a national leader in advocacy and health care response to IPV provided this guidance in 2020 to the presence of domestic violence does not necessarily mean a child abuse or neglect report is automatically warranted. And finally, Dr. Raghavan and her colleagues recently conducted a Delphi study with experts in IPV and Child Abuse and Neglect to create expert recommendations on the very question we're considering today.

00:27:26:26 - 00:27:52:04
Unknown
They concluded that participants were in consensus regarding need for reporting when child abuse or neglect was present, and that reporting should not occur for IPV exposure. Only infants Illusion. We ask you to vote no. This resolution oversimplifies a problem that is complex and nuanced and requires individual assessment to determine best practice. In each case. So vote no on mandatory reporting of any IPV in a child's home.

00:27:52:07 - 00:28:40:08
Unknown
And say yes to mandatory supporting an individual assessment. Thank you. That was outstanding. I think we really have quite a few complex issues to hash through. And so let's move to round two where I start to ask questions for each side. Just to summarize the arguments that I heard, that side arguing for the resolution seems to suggest that intimate partner violence in a child's home is certainly dangerous and is a risk factor for other forms of more direct harm to the child that reports to Child Protective Services can prevent future abuse and improve outcomes for children, then we should really have a system that risk respects the risks to children more than the risk to

00:28:40:08 - 00:29:12:24
Unknown
adults, and that we're never going to improve the system if we're not reporting these cases to Child protective Services. What I heard from the side against the resolution is that this is an oversimplification and that reporting in all cases is not the right thing to do, even if there's some cases that certainly need to be reported. They make the case that Child Protective Services in many cases does not help the child and puts the adult victim of intimate partner violence at higher risk for harm that some children do.

00:29:12:24 - 00:29:46:12
Unknown
Okay without reports. The child, the health care system and other mandatory reporters need to get in the game and support these families in ways other than Child Protective Services reports and then expert organizations that have looked at this have not recommended widespread reporting. So with that in mind, it seems like there are a few real areas of clash and I'd like to start by asking Doctor Melville, you said that it's important to put the needs of a child against the decisions of an adult.

00:29:46:14 - 00:30:11:29
Unknown
Is is it really fair to characterize someone who's experiencing intimate partner violence as making a decision to stay in that? Isn't it sort of victim blaming? And what we've heard from survivors in some of these circumstances is that the fact that they're being hit is characterized as child abuse because they're failing to protect their child from the harm that they're experiencing.

00:30:11:29 - 00:30:57:22
Unknown
Is it really a fair way to characterize the situation, to say that these adults are making decisions to put these children at risk? Isn't that just like one into a physical abuse onslaught? I say that the child has experienced physical abuse, a very rarely identified perpetrator or a good guy or a bad guy. I see what the child has experienced and when the child is experiencing exposure to domestic violence, the evidence shows that outside intervention is needed to remedy that.

00:30:57:25 - 00:31:42:07
Unknown
I absolutely agree that punitive actions against the victim and domestic violence are not helpful in the overwhelming majority of cases. What protects the most protective parent is good to the child. What we need is we need a nuanced and effective CPS response, but we need an effective response. And data remain from the Center for Domestic Violence themselves in the kids that we should expect.

00:31:42:09 - 00:32:11:29
Unknown
Non Directive supportive counseling to role in six additional exposures to the school and on average. Okay. Well, doctor, to your girl, let me take the other side case to you. It seems like your side is granting the first part of the resolution that IPV exposure is at least harmful and maybe that it's even a form of child maltreatment.

00:32:11:29 - 00:32:46:23
Unknown
So if you're granting the first part of the resolution, how can you not grant the whole resolution to the question? We believe that IPV is a risk factor for maltreatment itself, just like maternal substance use or just like maternal mental illness. But we still believe that there's a need to perform this individualized assessment, like Dr. Livingston recommended, to assess for harm or threat of harm, just like we would for any maternal risk factor or caregiver risk factor.

00:32:46:26 - 00:33:08:23
Unknown
It's also a I would argue that it's while it may cause harm, there's a lot of resilience factors, there's a lot of safety planning that many caregivers are doing informally. So I think just assessing these cases and the way we assess other cases in which there's maternal risk factors is a right way to go. Before making that decision to report to CPS.

00:33:08:26 - 00:33:32:27
Unknown
Thank you. Well, one other area where it sounds like there's a little consensus is that at least right now, many of these cases, if they got reported to Child Protective Services, would not have the resources or the appropriate response to really help these children, Maybe not all of them, but at least in some cases, it's not going to solve the problem for the child and that may cause some harms to the adults.

00:33:32:27 - 00:33:54:22
Unknown
Now, Dr. Kaiser, your side has argued that we're never going to improve the system if we don't try and make these consults anyway. I guess the question I have is there's two. One is where are these resources to improve the system going to come from? Aren't they inevitably going to be taken from other people served by the Child Protective Services system?

00:33:54:22 - 00:34:24:18
Unknown
Aren't they going to increase the risk of harm to other people? And then number two, how long would you keep making reports if you felt like it wasn't helping the child and it was putting the adult at risk before you decided, okay, that's it's not improving. If it hasn't improved in five years, if it hasn't improved in ten years, would you continue to have mandatory reporting for these cases in hopes that someday the system would improve?

00:34:24:20 - 00:35:01:03
Unknown
Family violence is so damaging to children that I would argue it's really to put a fair amount of child welfare resources to this issue. I would also say that our child welfare system is not the system of 50 years ago. We are already working to improve these responses. Look, for example, at the differential response or alternative response systems that are already in place that recognize the types of issues that you've heard our opponents lay out.

00:35:01:06 - 00:35:41:08
Unknown
Those are systems designed to address, to address a non punitive approach, a more supportive approach to really address the inequities that are talked about in the child welfare system all the time. So there are improvements to practice that are specific to domestic violence that are happening across the nation because child welfare understands all of the nuances that have already been described here and they understand that it's in their purview to address them and in a way that's that's safe and child friendly.

00:35:41:08 - 00:36:23:12
Unknown
So I think we're already there. And I think it's such a serious problem that that it really necessitates the type of resource allocation that you're asking about with regard to reporting. I mean, unfortunately, the law doesn't give me a choice. I'm a mandatory jury reporter. This is child abuse. I have to report. And so I think that if we're going to argue that this is a requirement here and unfortunately, as long as I'm the mandatory reporter, those reports have to get made.

00:36:23:15 - 00:36:51:26
Unknown
And that really is with the goal of of recognition and activating the appropriate response. All right, Dr. Livingston, your side really seems to make a lot of the fact that this is about a universal or routine approach to this. It seems like you certainly would grant that there are some cases where a child living in a home with intimate partner violence is experiencing the sort of maltreatment that requires a report.

00:36:51:29 - 00:37:24:27
Unknown
I guess the question is how do we draw the line? And if we leave it up to individual clinicians to draw the line about what needs a report, do we have to worry about the sort of disparities and biases that the that the other team was bringing up? Thank you for that. Interesting question. It's true that when you're making individualized assessment about any concern for maltreatment, it there is a gray zone.

00:37:24:28 - 00:37:52:28
Unknown
Think about the problem of neglect and how clinicians have to struggle with defining neglect. That is really no different than the kinds of assessments clinicians are already making every day. In other words, recognizing that they're looking at a complex situation and trying to figure out the best way forward for the child and family. What's really tough about intimate partner violence is it's not there's not an easy.

00:37:53:00 - 00:38:24:21
Unknown
There's no easy button here. And in one situation, one avenue might be the best route. In another situation, another avenue might be better. What we need to do is understand which services are really most helpful for families and connect them to those services, whether that happens with CPS involvement or without. So I think we really need to focus on what helps these families and try to get them more of it, with or without CPS involvement, recognizing some of them will be getting investigated and some may not.

00:38:24:21 - 00:38:53:08
Unknown
They just may be in the community, in the community accessing resources. To address your question about disparities in the yes, in every situation where families are getting reported to Child Protective Services services. There is room for bias to worsen disparities. And that's something that we are struggling with across the board in. In every case we face. Okay. Well, thank you very much.

00:38:53:08 - 00:39:16:15
Unknown
I think this is going to end round two and we'll move to round three where we give closing statements for each each team in turn. And to start off the closing statements, we'll turn it back to Dr. Livingston arguing against the resolution.

00:39:16:18 - 00:39:54:28
Unknown
All right. So our opponents have told you a lot about how IPV can be harmful to kids. We agree that children experiencing IPV are at elevated risk for abuse and a host of negative behavioral and mental health outcomes. IPV is an adverse childhood experience and a risk factor for child maltreatment. We are not debating about that. What we are debating today is whether we should report all children with this risk factor to Child Protective Services in an attempt to distract you from the issue at hand.

00:39:55:05 - 00:40:22:22
Unknown
Our opponents have focused on some of the worst harms possible for example, child homicides related to IPV. But the study they cited did not evaluate the impact of Child Protective Service involvement. In any way. Does CPS involvement reduce fatality risk for children living with IPV? A 2016 study designed to determine which CPS services reduce maltreatment fatality provided some useful information.

00:40:22:25 - 00:40:53:03
Unknown
This was an analysis of McCann's data by Douglas at all that included 4.6 million CPS cases with 622 fatalities among them. So very large sample. And the authors demonstrated that physically abused children who received certain services were less likely to die. But for those children, coded as neglect, as are most cases of IPV exposure only, there were no specific CPS interventions that were shown to reduce fatality.

00:40:53:06 - 00:41:21:19
Unknown
When looking at the literature and in clinical practice, it is important to distinguish between those children experiencing physical abuse or other forms of maltreatment in addition to IPV from those experiencing IPV, only our colleagues would have you believe that it is not possible for us to assess for harm or threat of harm to children experiencing IPV, but clinicians assess harm and threat of harm every day and make judgments about which cases must be reported to.

00:41:21:19 - 00:41:51:07
Unknown
CPS Our opponents have also told you that mothers often return to abusive partners, sometimes multiple times. Yes, they do. It is important to consider that leaving is dangerous and that separation is not a panacea. Studies show abuse often continues. Post-Separation, and mothers who separate from abusive partners have to endure their children's court ordered visitation with the abuser, knowing that they are not there to nurture and protect.

00:41:51:10 - 00:42:17:10
Unknown
Talking about prioritizing children over adults ignores the fact that the survivor caregiver is the child's most important resource and that most survivors safety planning for themselves and their children all day, every day. What our opponents have not shown you is any clear evidence that CPS involvement is helpful for families experiencing IPV only. That is because that evidence does not exist.

00:42:17:12 - 00:42:44:24
Unknown
As Dr. Kilgore told you, studies of CPS handling of IPV concerns show that practice is all over the map, with many potential harms and poor rates of referral to helpful services. Studies also show significant rates of persistence of IPV with CPS involvement. So if CPS does not have the power to stop all, IPV may punish the survivor caregiver and are often not referring families to services that help.

00:42:44:27 - 00:43:20:20
Unknown
Why would we refer all IPV to CPS? Do not be led astray. Remember children. Many children are resilient after experiencing IPV. Building protective factors can help and CPS involvement may not improve the situation to maximize benefit and minimize harm. We recommend again in the presence of IPV. Assess for harm or threat of harm. Report the children who cross that threshold and provide supports to all families.

00:43:20:23 - 00:43:58:01
Unknown
Thank you, Dr. Livingston. Okay. Next, we'll have Dr. Melvill arguing in his closing statement for the resolution. I Fear that my friend Dr. Livingston has misquoted me. I did not see the ITV exposure ten or children. I said that it does for children because it is total. I also agree with Dr. Livingston. The HPV is complicated. It requires an individual assessment.

00:43:58:03 - 00:44:33:03
Unknown
It requires the nurse and proper services. I would ask my friend, who is that every to do that? A clinician was spoken to one party in a clinic where the CPS worker who can visit the home, who can talk to the kid who has access to the perpetrators minds, works in his screen, who has access to the law enforcement resources in the state.

00:44:33:05 - 00:45:10:18
Unknown
I agree that we need an individualized assessment. We just differ on who can do it. Dr. Livingston suggested that they did not present any studies showing that CPS helped. I will again go back to the Kimble study with the NASCAR into the showed significant reductions in ATV over 36 months when appropriate referrals for me. I agree with Dr. Livingston.

00:45:10:21 - 00:45:59:09
Unknown
We need a nuanced and careful response, and I believe because it harms children. I just don't think we can run from the clinic because it's not what we do. And I have a few minor fumbles with other arguments on the legacy case. I do not believe, though, because a court judgment means that with this settlement, the head of judgment and the Nickerson case, at least as I read it, that we would have had to do a belt removal, had to do with the end after the individualized assessment moved on to Livingston.

00:45:59:09 - 00:46:39:19
Unknown
So it's know there needs to be an individualized assessment. I agree that the parent is the child's greatest asset, and we need a nuanced and careful assessment and not to move forward. They talked about the Minnesota experience. Again, as I read the history on the law medicine that we really didn't reach. It wasn't repealed. It was soft. And they said, you can do it or you can not do it until we allocate money.

00:46:39:25 - 00:47:30:01
Unknown
And then remember, I wanted the money, but instead, County said all the money they do the kind of response that we talk about and continue to this day under the no field law was mandating reporting of IPV and the response. In summary, ITV and children. I think the harms turner as much as other forms of abuse. We need a system that responds to that effectively, and the use of the system needs to be mandatory.

00:47:30:03 - 00:48:05:06
Unknown
Thank you, Dr. Melville. Okay. With the final closing statement against the resolution, will once more welcome in Tioga to the microphone. Thank you very much for these last 4 minutes. I want to counter some of the important points brought up by our opponents and end by emphasizing some of the points we have discussed earlier in our argument. First, Dr. Melville just pointed out that in Dr. Campbell study knew a large proportion of the families had resolved IPV as a result of Child Protective Services involvement.

00:48:05:08 - 00:48:40:25
Unknown
However, in this same study about 50% had continued IPV and continued IPV within those families. And the improvement in the IPV in in the children's behaviors was all related to referrals to IPV services. So we advocate in some cases when it's possible, why not refer directly to IPV services rather than involve CPS? We also disagree that child and I think I mentioned this before, but that child exposure to intimate partner violence is maltreatment itself.

00:48:40:28 - 00:49:09:21
Unknown
We want to argue that there is when there is harm or a threat of harm. We we must report to CPS as mandated reporters. However, we are not mandated to report all IPV exposure in many states in the United States. And just like the maternal substance use or maternal mental illness which also have associated harm in children, IPV is a risk factor for harm or maltreatment, and we need to consider it a risk factor and not child abuse itself.

00:49:09:24 - 00:49:36:01
Unknown
Finally, I want to also talk about co-occurring physical abuse in the context of IPV. Let me tell you why some of these studies addressing co-occurring IPV and physical abuse are extremely imperfect. Many of the survey studies cited the literature demonstrate that physical abuse occurs in like 30 to 60% of homes with IPV. However, there are many limitations to this work, which include definitions of physical child abuse and the sources of data.

00:49:36:02 - 00:49:58:26
Unknown
Most of these populations are from shelter based populations, not community samples related to the studies assessing the frequency of occult injury in the context of IPV. I can talk about the limitations from firsthand experience. In one of the studies, we assessed the results of occult injury testing after a recognized exposure to IPV among children in whom child abuse pediatricians were consulted.

00:49:58:28 - 00:50:23:18
Unknown
While we demonstrated that almost 60% had injuries identified and about 14% of these were occult, the entire sample consisted of 61 patients for whom a child abuse pediatrician was consulted. So again, a very select and biased population. In contrast, in a second small study of 90 children, less than three years of age who reported to Child Protective Service for IPV exposure, only one had occult injuries.

00:50:23:21 - 00:50:50:16
Unknown
Our data is just currently lacking and we do not have a data on a pure community sample of children exposed to IPV. If young children are injured or involved in IPV incidents, get us a skeletal survey. For older children, we may be able to talk to the children and perform an individualized assessment. Like Dr. Livingston recommended. Suddenly involve CPS once occult abusive injuries are identified or kids disclose harm.

00:50:50:18 - 00:51:16:24
Unknown
But remember, it's not an all or none game. Even if you are not reporting to CPS, you can connect to pediatricians and recommend close follow up. And most certainly you must all link families to IPV Advocacy and mental health services. Remember, most studies demonstrate that even with CPS involvement, referrals to IP based services are uncommon. An improvement in IPV is linked to the receipt of those services.

00:51:16:27 - 00:51:50:10
Unknown
We believe these service referrals can be made without CPS involvement in many cases of exposure, without harm. There's a lot of supporting and healing we can and must do that does not involve CPS. Thank you. Thank you. Dr. T.A.. All right. Well, for the last statement, the last closing statement of the round will welcome Antonio Chiesa to the microphone to give the last statement in support of the resolution.

00:51:50:13 - 00:52:16:10
Unknown
Exposure to intimate partner violence. It's child maltreatment. It causes a lot of psychological harm and puts a child at risk for serious physical harm and even death. 200 kids a year die of IPV abusers abuse, so we should act accordingly. You've heard our opponents assert that reporting to Child Protective Services places the child and caregiver at greater risk.

00:52:16:12 - 00:52:46:03
Unknown
But this position ignores the dangers of not reporting, and leaving a child in an unsafe keeps them vulnerable to all of those emotional and physical scars that I've already described. You have heard our opponents suggest that not being present during abuse means the child is at harm. This common myth has been repeatedly debunked in the literature. The dynamics and impacts are so pervasive that harm is inevitable.

00:52:46:05 - 00:53:11:05
Unknown
And I want to point out that this harm may not just be related to the actions of the perpetrator. In a systematic review on the effects of IPV on parenting by the non of the caregiver, the outcomes are poor, and it further highlights the need for a nuanced and intensive response. You've also heard this worst case legal example, but policies cannot be crafted based on the last worst case.

00:53:11:06 - 00:53:42:17
Unknown
This is a far reaching issue impacting a significant number of families, and policies have to be addressed to address the population at heart at large. John talked a little bit about the Minnesota experiment. Indeed, that that law required dramatically increased the number of reports. How do we ethically ignore this need? And I'll acknowledge the challenge of some child protective services are a problem.

00:53:42:19 - 00:54:10:05
Unknown
But the issue is that that's our current conduit for safeguarding kids and modern day child welfare practices have improved. John mentioned of Olmsted County. Let's also look at Alaska for mandatory reporting laws. IPV were combined with Child Protective Services practice changes and it addressed a lot of these issues that you've heard the day. But those services were put in place for the child and the adult victim.

00:54:10:05 - 00:54:36:19
Unknown
They made it clear that if the family member is removed from the home, it should be the perpetrator and not the victim of violence. It required the system adopt new assessment and intervention protocols that you heard, you know, argue for it encouraged collaboration with domestic violence prevention programs, and it exempted battered women advocates and sexual assault crisis workers from being required to report child protection.

00:54:36:21 - 00:55:13:15
Unknown
When the children and the mother were involved in safety services, additional law changes exempted battered mothers who fled for safety from findings of child abandonment, an increased sense of sentencing consequences for convicted perpetrator when the children were present during a domestic assault, the state put in substantial resources to help train child protection workers to implement the legislation. These are the types of solutions that ensure the quality assessments that you've heard recommended by our opponents.

00:55:13:17 - 00:55:56:12
Unknown
And they address the equity issues that are so important. So even our opponents acknowledge that IPV is harmful for children. Voting yes to this resolution acknowledges the abusive nature of that harm by turning a blind eye to the invisible scars of emotional abuse failed to fulfill that obligation. Reporting creates an opportunity to provide support, support services not just to the domestic violence victims, but also to the children or silently suffering alongside them.

00:55:56:15 - 00:56:21:14
Unknown
Thank you, Dr. Keyser. I wish I had a round of applause and a sound loop that I could play. I think we really owe all the debaters a lot of things for a really nuanced and respectful and informative debate. I know that this is an issue I struggle with in my practice very frequently, and I really appreciate the chance to to hear all these different arguments.

00:56:21:16 - 00:56:42:27
Unknown
Before we sign off, I do want to take a few minutes because a debate can be a very helpful format to elucidate ideas and have a respectful exchange of ideas. And at the same time, child abuse pediatrics can be a very contentious world. And I want to give each of the debaters a chance to participate in a little discussion to clarify that.

00:56:42:29 - 00:57:08:22
Unknown
You know, these positions were taken for the debate. And, you know, I'd hate it for someone to face a defense attorney or somebody who characterizes someone as a very maximalist or universalist approach. So let's take a minute where we can all come off mute and talk a little bit about some of the areas where we actually agree and get out of the format for a debate of the debate for a second.

00:57:08:23 - 00:57:40:26
Unknown
So just to start, let me ask each of each of you, you know, what did you find were the most compelling arguments for the side opposite? What were the things that really made you struggle or made you rethink your position? Yes, sir. Sure. Go ahead, John. So I think the debate was the human knight's most compelling was the concern is the the reporting can increase danger.

00:57:40:29 - 00:58:27:05
Unknown
There's very good evidence the most dangerous time in domestic violence relationship is right before and right after the listing leaves. And I think the there are six years agencies have legislative mandates to inform the alleged perpetrator of the report. And I could very I could very easily see some very bad outcomes as that was not done well. And so I think because the reporting has some risks, that that gives me pause.

00:58:27:07 - 00:58:57:14
Unknown
But on the other hand, you can't hold the government hostage and say, well, if you report, the boys, meet my wife even more. Yeah, I found that argument to be pretty compelling. Q And just since this is a podcast, I'll just share that I'm seeing a lot of nods on the video call. What about Janina? What did you find the most compelling from the other side?

00:58:57:17 - 00:59:28:14
Unknown
I think obviously, as Nina and I prepared, you know, there's so much harm that's associated with intimate partner violence and both Dr. Melville and Dr. Keyser really highlighted the psychological and the physical harms associated with intimate partner violence and I think we both both teams agreed that an individualized assessment needs to be made in these cases that's nuanced and recognizes sort of this spectrum of harm that's associated with intimate partner violence.

00:59:28:14 - 00:59:52:27
Unknown
And I think, you know, currently, I don't know that there's a perfect answer to how we address intimate partner violence as health care providers. And I think it just makes me really think that we need to obviously do better and think about ways in which we provide support when it's through CPS or when it's without CPS, a little bit of better.

00:59:52:29 - 01:00:23:17
Unknown
Yeah, I would second that and I would single out a couple of arguments that I thought were very effective. I love the thing that Dr. Keyser said about invisible scars, because that is a reality for, you know, there's a huge component in of harm that is really about the psychological harm, about the developmental harm and things that are not necessarily visible physical injuries.

01:00:23:19 - 01:00:54:01
Unknown
And I, I agree, too, with what she said about the fact that just just because a child was not present or not physically involved does not mean that there is no impact. So I think that I think is is quite important to recognize and we agree about that. And I also I really took Dr. Melville's point that Child Protective Services, in theory, is better positioned to look globally at risks for the child and has access to all kinds of information in the home and in the police and CPS databases.

01:00:54:01 - 01:01:24:26
Unknown
But it's not available to us at the hospital or at the clinic. So that, I think, is also a compelling argument. And Antonia, any anything you want to add or. Well, I do think I definitely underplayed a risk. And instead, there always is a more nuanced difference between clear harm and risk that does have to be assessed in an individual situation.

01:01:24:29 - 01:02:02:23
Unknown
And I would and I definitely think that impact on what the health care system can do for families is really important, especially as we think of how to to recreate our child welfare practices so that they are more effective, especially when resources are tight. And so I'm a big advocate for thinking what what can other systems do besides, you know, the the referral directly to child welfare, which can have such a profound implications, especially for for minorities in terms of of over surveillance.

01:02:02:23 - 01:02:36:20
Unknown
So I really, really love the idea of, you know, activating the health care system to support families because we're also often seen as a trusted professional who can be less threatening to families and ideally link folks was support services as well. I think. Yeah. I think in general the less punitive of CPS can become, the more effective it will be.

01:02:36:22 - 01:03:16:24
Unknown
I think Drew's talking to somebody who has the power to take your kids away, even if you know, were ever sure that is not going to happen, even if you are absolutely positive, your knowledge suspect you're part of it. How does talking to somebody who has the power to take you into way is a very nerve wracking experience and it does not guarantee pay for their best safety plan.

01:03:16:27 - 01:04:01:14
Unknown
So I would love to see alternative responses. I would love to see an immediate response is perhaps in the domestic violence treatment world, as I think is interesting. But I do think that using nonviolent actors, we do not have the coercive power in the state may and may allow more engagement, may allow more clever action, and may allow more healing.

01:04:01:16 - 01:04:28:02
Unknown
Yeah, I think if we're going to move towards closing on areas where I think we all agree and I thought this was a no brainer, I got some pushback from someone I really respect, but I think that one of the areas where I feel pretty strongly is that CPS has and the whole system that deals with family violence really does need to get more ability to support multiple victims at the same time.

01:04:28:04 - 01:04:49:25
Unknown
And, you know, like Dr. Kiersey just said, not just the health care system, but all mandatory reporters need to think more that when they're making a report, it's not a set it and forget it, pass responsibility to somebody else. But we need to maintain our responsibilities, for example, to say, look, we think this person is the victim, in this person is the perpetrator.

01:04:49:25 - 01:05:16:21
Unknown
When that's true, because we think the worst scenarios that we hear about is people who are experiencing intimate partner violence. And then it's compounded when they're accused of abusing their children by not protecting their child from the exposure, their own violence. And those things can be very he said, she said. And I have a lot of sympathy for an overburdened, under-resourced system that has to make those sorts of high stakes decisions.

01:05:16:23 - 01:05:47:10
Unknown
So helping our current system to address those with resources and with information and with support and really re-inventing the system, I'd like to think that that's the most obvious thing that we can all agree on after a debate like this. Yeah, I would just add to that, Diane. I mean, I agree. I think we need to be collaborating at a high level with Child protective Services because we are touching the elephant in a different place.

01:05:47:10 - 01:06:18:20
Unknown
We have information and we can provide education and insight about these situations and families that may be helpful to the families, emphasizing their strengths, you know, highlighting the victimization of the victimized parent, things that might influence the CPS response in a way that's positive for the family. But I also want to highlight that we need to be really collaborating also with domestic violence advocacy agencies at the community level, the state level and the national level.

01:06:18:20 - 01:06:48:19
Unknown
And we worked a lot in Connecticut with our local domestic violence agencies. They're incredible we engage all and we've really, I think, upped our game in terms of providing direct access to IPV services for the families we're meeting, whether or not CPS is involved with these families. So I really want to put a plug in for that for working with your state coalition or the National Organization Futures Against Violence, because they are a tremendous resource for clinicians on the ground.

01:06:48:22 - 01:07:11:23
Unknown
Yeah. And in fact, you know, one of the best practices for CPS is to call, especially when working with families affected by domestic violence, is to coordinate with intimate partner violence resources, you know, the time of sort of engage ment. And there there's been national initiatives that encourage that, you know, call the Green Book initiative that was, you know, in the early 2000.

01:07:11:23 - 01:07:44:18
Unknown
So I think we that is probably one of the most important things that we can do sort of as advocates for this problem is to really advocate for coordinated and collaborative services for these families. I'll credit my my DV colleagues as really helping me change the way I thought about this issue. I think early in my career as a pediatrician, understandably, I was very Pedes child focused, but they really broadened my view of this issue.

01:07:44:20 - 01:08:13:01
Unknown
And then help me think about it in a way that's I think continues to be safety as an important focus for kids, but also recognizing that safety kids really is in the context of a healthy and helping family. Right. Well, I think that I really appreciate the conversation. This has been super helpful to me. Well, with that, I want to thank all our debaters for such a great and I really want to thank the listeners for joining us and staying till the end to help.

01:08:13:01 - 01:08:42:20
Unknown
It was as informative to you as it was for us. Please join us again for this podcast series in 2024, which will be dropping soon and join us as often as you can. This has been Radio camp. Thank you for listening to radio camp. Stay connected by visiting our web site at Camp Center dot org and follow us on social media.