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Children and Youth Services Review

journal homepage:

Service needs of children exposed to domestic violence: Qualitative findings
from a statewide survey of domestic violence agencies☆

Kristen A. Berg1, Anna E. Bender, Kylie E. Evans, Megan R. Holmes⁎, Alexis P. Davis2,
Alyssa L. Scaggs, Jennifer A. King
Center on Trauma and Adversity at the Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, United States


Intimate partner violence
Child maltreatment
Family violence
Trauma-informed care


Objective: Each year, more than 6% of all U.S. children are exposed to domestic violence and require inter-
vention services from agencies that serve affected families. Previous research has examined detrimental biop-
sychosocial consequences of domestic violence exposure during childhood and the importance of effective
prevention and intervention services for this population. However, less research has explored diverse inter-
vention professionals’ own perspectives on the needs of the domestic violence-exposed children they serve.
Method: This study employed an inductive approach to thematic analysis to investigate intervention profes-
sionals’ reflections and advice regarding the service, policy, and research needs as well as overall strategies to
better protect children exposed to domestic violence.
Results: Respondents articulated four primary themes of (a) building general education and awareness of the
effects of domestic violence exposure on children; (b) the need for trauma-informed care; (c) the salience of
cultural humility in serving affected families; and (d) essential collaboration across service domains.
Respondents discussed these themes in the context of four key systems of care: the clinical or therapy, family,
school, and judicial systems.
Conclusions: Future research should integrate the voices of affected children and families as well as examine
models for effectively implementing these recommendations into practice settings.

1. Introduction

More than a quarter of children are projected to witness domestic
violence (also known as intimate partner violence) in the United States
by the time they reach age 18, with an estimated 6.4% of all children
exposed each year (Finkelhor, Turner, Ormrod, Hamby, & Kracke,
2009). Domestic violence exposure induces substantial economic
burden nationwide, incurring over $55 billion in aggregate lifetime
costs, including increased healthcare spending, increased crime, and
reduced labor market productivity (Holmes, Richter, Votruba, Berg, &
Bender, 2018). Children who have been exposed to domestic violence
are at higher risk for a range of behavioral and mental health problems

compared with non-exposed children (e.g., Fong, Hawes, & Allen, 2019;
Kitzmann, Gaylord, Holt, & Kenny, 2003; Vu, Jouriles, McDonald, &
Rosenfield, 2016; Wood & Sommers, 2011).

A variety of social service agencies, domestic violence service pro-
viders, and other systems of care provide essential services to families
impacted by domestic violence. While a growing body of literature has
examined service gaps and practitioner perspectives from domestic
violence service agencies specifically, less research has examined do-
mestic violence-specific agencies in tandem with those that frequently
collaborate with domestic violence agencies to address systemic service
gaps and/or provide other necessary treatment for trauma. Our study
contributes to building this knowledge by surveying such agencies
Received 13 April 2020; Received in revised form 24 August 2020; Accepted 24 August 2020

☆ Funded through The HealthPath Foundation of Ohio. The contents of this publication do not necessarily reflect the views or policies of the funders. This
information is in the public domain. Readers are encouraged to copy and share it, but please credit the authors. Funded through The HealthPath Foundation of Ohio.
The contents of this publication do not necessarily reflect the views or policies of the funders. This information is in the public domain. Readers are encouraged to
copy and share it, but please credit the authors.

⁎ Corresponding author at: Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-7164, United

E-mail address: [email protected] (M.R. Holmes).
1 Present affiliation: Center for Health Care Research and Policy, The MetroHealth System, 2500 MetroHealth Dr., Cleveland, OH 44109, United States.
2 Present affiliation: Florida Policy Institute, 1001 N Orange Ave., Orlando, FL 32801, United States.

Children and Youth Services Review 118 (2020) 105414

Available online 28 August 2020
0190-7409/ © 2020 Elsevier Ltd. All rights reserved.


across the state of Ohio to generate an assessment, from providers’ own
perspectives, regarding gaps in service provision and policies crucial to
promoting resilience among families and children exposed to domestic

1.1. Prevalence

Domestic violence (DV) refers to physical violence, sexual violence,
stalking, and/or psychological aggression perpetrated by a current or
former intimate partner (Centers for Disease Control and Prevention,
2016). The CDC’s National Intimate Partner and Sexual Violence Survey
(NISVS) estimates that more than 10 million adults each year in the
United States are physically assaulted by current or former intimate
partners, with more than 1 in 4 women (27.3%) and more than 1 in 10
men (11.5%) victimized by DV at least once in their lives (Breiding
et al., 2014). Research suggests that DV is more prevalent among
couples with children, placing children at risk for both direct and in-
direct witnessing of violence (McDonald, Jouriles, Ramisetty-Mikler,
Caetano, & Green, 2006). Children who witness DV may see or hear the
violence, attempt to intervene in or stop the violence, or perceive the
aftermath of violence such as notice bruising or tension within the
household (Cross, Mathews, Tonmyr, Scott, & Ouimet, 2012). In the
state of Ohio, the current study’s site, an estimated 163,000 children are
exposed to DV annually and 657,000 before the age of 18 (U.S. Census
Bureau, 2015).

1.2. Negative effects of childhood domestic violence exposure

Children’s exposure to DV has been linked to a number of deleter-
ious outcomes across a range of developmental domains. DV exposure
has predicted more internalizing (e.g., anxiety and depressive symp-
toms) and externalizing (e.g., hyperactivity and aggression) behaviors
in youth, social and emotional impairments, poorer cognitive outcomes,
and impaired physiological functioning due to hyper-activated stress
responses (Koolick et al., 2016; Perkins & Graham-Bermann, 2012;
Saltzman, Holden, Holahan, 2005; Vu, Jouriles et al., 2016). Affected
youth also demonstrate higher rates of bullying and dating violence as
both perpetrators and victims (Choi & Temple, 2016; Jouriles, Mueller,
Rosenfield, McDonald, & Dodson, 2012; Moretti, Obsuth, Odgers, &
Reebye, 2006; Voisin & Hong, 2012). These negative sequelae have
been observed across developmental stages from infancy to adoles-
cence, with DV-exposed youth exhibiting poorer outcomes compared
with their nonexposed counterparts (Howell, Barnes, Miller, & Graham-
Bermann, 2016).

The detrimental effects of children’s witnessing DV have been lar-
gely conceptualized by developmental traumatology and emotional
security models. Witnessing the assault of a caregiver at the hands of
another caregiver is particularly threatening to children’s sense of
safety and well-being. DV signals caregivers’ distress and unhappiness,
the possibility of family dissolution, and/or the possibility of a care-
giver’s serious harm or death (Davies et al., 2002). Witnessing threat to
the integrity or life of a caregiver destabilizes a child’s foundational
sense of stability integral to emotional well-being, dysregulates chil-
dren’s stress response systems over time, and increases risk of post-
traumatic stress symptomatology (Davies & Martin, 2013; De Bellis &
Zisk, 2014). Such trauma can impair children’s developing brains and
physiologies, increasing vulnerability to adverse behavioral, physical,
cognitive, and socioemotional functioning (De Bellis, 2001; De Bellis &
Zisk, 2014).

1.3. Co-occurrence of child maltreatment and domestic violence

Children who witness DV are also at increased risk of poly-
victimization (i.e., experiencing multiple forms of victimization such as
DV exposure with child abuse and/or neglect; Finkelhor, Turner,
Hamby, & Ormrod, 2011). A national survey found that 33.9% of youth

who witnessed DV during the past year were also maltreated during the
same time period, compared with 8.6% of youth who reported only
child maltreatment (Hamby, Finkelhor, Turner, & Ormrod, 2010). In
the state of Ohio, approximately 4 in 10 DV-exposed children also ex-
perience maltreatment. The Ohio Department of Job and Family
Services (2016) reported that 39,401 cases in State Fiscal Year
2014—or 43% of all child maltreatment cases—had a notation of
“Concern of Domestic Violence.”

Considering the high rate of co-occurrence, child welfare workers,
DV service providers, and law enforcement personnel are all critical in
identifying and serving children. However, studies of these providers’
perceived knowledge and competence at addressing co-occurring mal-
treatment and DV have found discrepancies. For example, research has
found that DV service providers and child welfare personnel were more
likely to identify and address DV exposure and child maltreatment,
respectively, with limited skills and training around identifying their
co-occurrence (Coulter & Mercado-Crespo, 2015; Hazen et al., 2007;
Kohl, Barth, Hazen, & Landsverk, 2005). Such evidence suggests com-
partmentalized provider training focused on intervention services for
families who are, statistically, likely to be dually affected.

1.4. Complex needs of families who experience domestic violence

Families affected by DV, and often co-occurring child maltreatment,
experience complex needs consequent of multiple interrelated family
traumas. Adults and children exposed to DV are likely to present with
symptoms of complex trauma or impairments across regulatory and
interpersonal domains (Cook et al., 2017; Pill, Day, & Mildred, 2017).
Symptoms of complex trauma, spanning from emotional dysregulation
to cognitive and physical difficulties, manifest in unique presentations
not necessarily aligned clearly with diagnostic criteria and require more
individualized treatment (Cook et al., 2017; Pill et al., 2017; van der
Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). DV-affected fa-
milies tend to also experience substance use (Afifi, Henriksen,
Asmundson, & Sareen, 2012; Macy, Giattina, Parish, & Crosby, 2010),
homelessness (Pavao, Alvarez, Baumrind, Induni, & Kimerling, 2007),
and interruptions in children’s education (Kiesel, Piescher, & Edleson,
2016). Each of these concerns reflects another domain of service pro-
vision in a complex web of presenting needs; however, the ability of
agencies to offer such multigenerational and comprehensive services
requires additional staffing, training, and logistical considerations.

1.5. Service systems that interface with families affected by domestic

Such complex needs demand collaborative, interactive, and co-
ordinated systems of care. Historically, DV agencies were established to
provide advocacy and wraparound services (e.g., crisis care, safe
shelter, legal interventions, counseling) for affected families (Macy
et al., 2010a; Panzer, Philip, & Hayward, 2000; Zweig & Burt, 2007).
However, in the aftermath of a DV incident, families may also interface
with law enforcement, child welfare, school, or medical systems. Re-
cognizing the need for a cross-system collaborative response, the
seminal Greenbook practice guidelines were published in 1999 by the
National Council of Juvenile and Family Court Judges (NCJFCJ), urging
the field to reduce service fragmentation and coordinate system re-
sponses to children dually exposed to DV and maltreatment (Schechter
& Edleson, 1999). Several cooperative response models have since been
implemented, including the Safe Start Initiative (Kracke & Cohen,
2008), Handle with Care programs (Bushinski, 2018), coordinated
community response teams (Banks, Dutch, & Wang, 2008), and Family
Justice Centers (Murray, Wyche, & Johnson, 2020). Despite the colla-
borative progress of these initiatives, research documents a history of
divergent philosophies and service approaches across agencies involved
(Gordon, 1988; Humphreys & Absler, 2011; McKay, 1994). For ex-
ample, child welfare approaches often identify the child as the victim

K.A. Berg, et al. Children and Youth Services Review 118 (2020) 105414


and the non-offending caregiver as implicitly culpable. In contrast, DV
agencies primarily focus on the non-offending caregiver as the victim.
The paradigm differences reflected in these two systems, as well as
other networks of care, complicate collaborative efforts that would best
promote family safety and healing from trauma (Appel & Kim-Appel,
2006; Holmes, Bender, Crampton, Voith, & Prince, 2019).

1.5.1. Challenges faced by service providers
In addition to challenges to creating and enacting a collaborative

model of care, providers face multiple other barriers to effectively
identifying and serving families affected by DV. Providers report in-
adequate training and skills around inclusively serving subpopulations
(based on race/ethnicity, sexual orientation, urbanicity, disability
status, immigrant status, etc.), rendering those affected families under-
served (Helfrich & Simpson, 2006; Lehrner & Allen, 2009; Messing,
Ward-Lasher, Thaller, & Bagwell-Gray, 2015). Families have also re-
ported barriers to engagement such as fear and distrust of the child
welfare, legal, and justice systems (Alaggia, Regehr, & Jenney, 2012;
Baker, Cook, & Norris, 2003; Lichenstein & Johnson, 2009). When fa-
milies do engage with services, providers articulate limitations around
enacting trauma-informed practices—those grounded in recognizing
and responding to the cognitive, psychological, socioemotional, and
physical consequences of trauma (Leitch, 2017)—to most effectively
mitigate the effects of DV exposure (Laing, Irwin, & Toivonen, 2012;
Trevillion et al., 2012). Furthermore, providers report challenges
around funding to continually meet the needs of families and offer
ongoing training and education for staff (Stover & Lent, 2014).

1.6. Current study

While there is research that examines collaborative approaches to
serving families affected by DV, to the authors’ knowledge, no study has
synthesized open-ended responses both from diverse professionals who
directly serve families who have experienced DV, and more peripheral
service systems that interface with those primary agencies.
Additionally, this study explored perspectives of providers across an
entire state, illuminating and assessing the needs of families and service
providers across diverse communities. This study employed an in-
ductive approach to thematic analysis to explore the following research
questions across one state: (a) What do providers experience as the most
prevalent service needs for children and youth exposed to domestic
violence? (b) What do providers experience as the most prevalent
policy needs for children and youth exposed to domestic violence? (c)
What do providers experience as the most prevalent research needs for
children and youth exposed to domestic violence? (d) What do provi-
ders report are the best strategies for protecting children and youth
exposed to domestic violence? and (e) What do providers report are the
best strategies for reducing the negative effects of domestic violence
exposure for children and youth?

2. Method

An electronic statewide survey that solicited open-ended responses
was conducted to engage directors of Ohio-based agencies providing
services for children exposed to DV. The purpose of the survey was to
examine how DV-exposed children were being served by agencies (e.g.,
types and delivery format of services offered, ages of children served,
which evidence-based or promising programs were offered) and to seek
information and ideas on how to better serve this population. Data were
collected over a 4-month time period in 2016. This study was approved
by the Institutional Review Board of a private Midwestern university.

2.1. Participants and setting

The Shelter and Program Referral List on the Ohio Domestic
Violence Network website (

html) was first used to locate relevant agencies in the state that pro-
vided DV services, resulting in a list of 205 agencies. After removing
duplicate agencies that were listed in more than one county, a total of
75 agencies were included as the initial sample. Using an internet-based
search, agency directors’ contact information was identified. From
October 2016 to November 2016, directors were contacted by the re-
search team via postal letter, email, and telephone and invited to
complete the electronic Qualtrics survey (survey items described
below). In November 2016, to maximize participation, outstanding
respondents were invited to participate in a short-version form of the
survey. All agencies invited to participate in the survey were sent
weekly reminder emails.

Two particular questions on the survey requested that directors list
(a) other agencies to which they referred children or youth who needed
services not provided by their agency and (b) other agencies within
their communities that provided trauma services to children or youth
that they had not listed. Through November 2016, responses to these
questions yielded an additional 47 agencies, which resulted in a total of
122 agencies across the state that could potentially provide services for
youth affected by DV. Of the 122 agencies, 17 were excluded due to the
study researchers being either unable to identify the agency itself or
being unable to find sufficient contact information with which to ex-
tend an invitation to participate in the survey, resulting in a total
sample of 105 agencies that were asked to complete the survey. Out of
those, 59 completed the entire survey (56.2%), 19 completed a portion
of the survey (18.1%), 5 declined or refused to complete the survey
(4.8%), and 22 did not respond to the study team’s calls or emails re-
garding the survey (20.9%). A total of 78 respondents (74.3%) either
completed or partially completed the survey. Among those, 44 (41.9%)
provided qualitative responses to at least one of the survey’s open-
ended questions and those data were used to synthesize the results
presented in this study.

2.2. Survey items

The survey included questions about whether agencies offered ser-
vices for children and their non-offending caregivers, whether the
agency was able to meet the current demands for children or youth
exposed to DV, whether respondents considered their agency to be
trauma-informed, the types of services the agencies provided, and the
specific evidence-based or promising programs used with children and
youth. In addition, agencies were asked to respond via extended, open-
ended response to the following questions: As the state of Ohio assesses
statewide needs as they relate to DV-exposed children or youth, (a)
what recommendation would you make about where to focus particular
attention in terms of need related to services?; (b) what recommenda-
tion would you make about where to focus particular attention in terms
of need related to policy?; (c) what recommendation would you make
about where to focus particular attention in terms of need related to
research?; (d) What do you think needs to be done to better protect
children or youth who are exposed to DV?; and (e) What ideas do you
have about reducing negative effects of DV on Ohio’s children or youth?
A total of 44 agency respondents offered responses to at least one of
these extended questions.

2.3. Analysis approach

All extended text responses from agencies were downloaded from
the electronic survey as text files and then uploaded into NVivo qua-
litative data analysis computer software, version 11.4.2. Agencies’
collective set of responses were inductively coded by two doctoral-level
research assistants using Braun and Clarke’s (2006) approach to the-
matic analysis in order to examine both the semantic and conceptual
patterning across agency participants’ responses. The coders in-
dependently first analyzed verbatim responses with a combination of in
vivo and open coding in order to inventory the range of individual

K.A. Berg, et al. Children and Youth Services Review 118 (2020) 105414


concepts expressed by participants. Separately, the coders then sorted
the in vivo and open codes into emergent categories by conceptual si-
milarity and then organized those emergent categories into broader,
internally cohesive themes. The coders then reconvened to review,
compare, and combine their two resulting coding schemes and re-
conciled conceptual discrepancies. This generated one cohesive the-
matic scheme by which participants’ responses to the extended response
survey questions were classified and organized, as discussed below.

3. Findings

3.1. Descriptives

Table 1 provides descriptive information about the 44 agency pro-
viders in the current study. The total number of children reported to
have received services in the State Fiscal Year 2016 was 85,213. Of
note, because some children interact with multiple systems, it is pos-
sible that some children may have been double counted using the four
sources of data. Because data were de-identified, it is not possible to
know the extent of possible double counting.

The majority of the sample (47.7%) identified themselves as ex-
ecutive directors while 4.6% self-identified as clinical directors and
9.1% specifically as DV program directors or coordinators. Just over

18% reported as other directors (e.g., visitation director, shelter di-
rector, child advocacy center director), and almost 7% reported as other
coordinators (e.g., advocacy coordinator, general coordinator). Another
7% self-identified as other professionals such as administrative assistant
or legal advocate. Approximately 45.4% of agencies reported that in
addition to offering services for children, they also offered services to
support the non-offending caregivers who were parenting the children.
Over 60% indicated being able to meet current demands for DV-ex-
posed youth to a large or very large extent, though 20% reported
meeting children’s needs at a small or very small extent. In total, 84% of
respondents considered their agencies to be trauma-informed and 59%
indicated their agencies to be using at least one evidence-based or
promising intervention or prevention program.

3.2. Thematic analysis findings

Across extended response survey questions, agency providers of-
fered four key recommendations to: (a) build general education and
awareness surrounding the consequences of children’s exposure to IPV;
(b) implement a trauma-informed care framework across child-serving
systems; (c) integrate culturally-humble practices across and within
systems; and (d) collaborate across systems. Providers made these re-
commendations in reference to four primary contexts of the clinical or
therapy system (i.e., any behavioral or mental health services for DV-
exposed children), family system (i.e., any points of intervention for the
family as a whole, such as parenting classes, counseling or support for
non-offending parents, or visitation services), school system (i.e., sup-
portive services for DV-exposed children in educational settings and
schoolwide prevention or intervention curricula), and judicial system
(i.e., child welfare services as well as family and criminal court sys-
tems). Table 2 displays an abbreviated summary of key study findings.

3.2.1. Education
Providers (43%) discussed the importance of promoting general

education and awareness for service providers, school personnel, par-
ents, and the broader community on how children are affected by
witnessing DV. Advice for better protecting DV-exposed children in-
cluded suggestions such as requiring annual trauma-focused training
and continuing education credits for all professionals working with
children affected by trauma. Responses particularly emphasized the
importance of providing general education and awareness within the
family system surrounding DV and its detrimental effects on children.
As one provider suggested, “the best way to protect the child is to
educate the parent about the effects of domestic violence on their
children.” Another provider qualified, however, that such information
should be carefully and thoughtfully delivered to parents in order to be
accessible and thus useful:

Increase education available to parents about domestic violence and
how it really relates to their children, but in an engaging way, as most
of the information that is delivered today is still targeted toward victim-
blaming and is unreceptive to the parent.

Other providers highlighted opportunities for schools to integrate
socioemotional health-focused curricula to promote early education,
starting in childhood, about healthy relationship dynamics. Some of-
fered examples of curriculum content, including: healthy relationship
skills, general emotion coping skills, ways through which to identify
and express emotions healthily both in the self and in others, emotional
intelligence, meditation and mindfulness, safe dating behaviors, and
sex-positive and enthusiastic consent-focused sexual health education.
Alluding to the preventive capacity of socioemotional education on
children’s current and later relationships, one provider suggested that
schools could offer “education for children beginning in elementary
school regarding healthy relationships.” Another detailed:

Teach more social and emotional skills in school instead of just
academic topics, [and] cover healthy relationship skills, sexual health,
etc. Include different coping skills built into the curriculum. Some

Table 1
Characteristics of comprising study agencies (n = 44).

N %

Respondent job responsibility a

Executive Director 21 47.7
Clinical Director 2 4.6
DV Program Director or Coordinator 4 9.1
Other Director 8 18.2
Other Coordinator 3 6.8
Other 3 6.8
Missing 6 13.6

Services also offered to non-offending parent
Yes 20 45.4
No 2 4.5
No answer 22 50.0

Extent to which able to meet current demands for DV-exposed

Very small extent 3 6.8
Small extent 6 13.6
Moderate extent 7 15.9
Large extent 16 37.2
Very large extent 11 25.0
No answer 1 2.3

Would expand service area or services if additional funding were

Yes 39 88.6
No 5 11.4
No answer 0 0

Consider agency to be trauma-informed
Yes 37 84.1
No 6 13.6
No answer 1 2.3

Types of services offered
Individual counseling for children
Age birth to 2 4 9.1
Age 3 to 5 9 20.4
Age 6 to 12 10 22.7
Age 13 to 18 13 29.6

Community outreach 24 54.6
Safety planning 24 54.6
Material resources (transportation, children’s clothing, food, etc.) 23 52.3

Uses at least 1 evidence-based or promising intervention or
prevention program

No 2 4.5
Yes 26 59.1
No answer 16 36.4

a Multiple respondents reported more than one job responsibility, rendering
these categories (with the exception of “missing”) not mutually-exclusive.

K.A. Berg, et al. Children and Youth Services Review 118 (2020) 105414


schools have implemented meditation rooms instead of detention halls
with great results.

Beyond the family and school systems, multiple responses called for
broad community-wide education. For example, one provider suggested
that the state unroll a “public health campaign, to the same level as
[those about] drugs and smoking, about the impact of violence on
children in Ohio.” Another articulated the crucial role of such education
in “taking away the belief that only certain people are affected by do-
mestic violence and trauma.”

Providers spoke to the role of active research and its dissemination
in promoting education and awareness of the long-term effects of DV,
and intervention and prevention knowledge for professionals working
with affected families. Providers offered specific research topic ques-
tions of interest such as “What [should] relationships with fathers who
batter mothers look like?” or “What is the correlation between domestic
violence and issues with child learning?” Continued research related to
the Adverse Childhood Experiences (ACEs) study (Felitti et al., 1998)
and work by professionals like Dr. Bruce Perry (2009) were …

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