Intimate partner violence during pregnancy and behavioral problems in children and adolescents: a meta-analysis

Silva, Elisabete P.; Lemos, Andrea; Andrade, Carlos H.S.; Ludermir, Ana B.

doi:10.1016/j.jped.2018.01.007

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Review articles • J. Pediatr. (Rio J.) 94 (5) • Sep-Oct 2018 • https://doi.org/10.1016/j.jped.2018.01.007 copy

Intimate partner violence during pregnancy and behavioral problems in children and adolescents: a meta-analysis^☆ ☆ Please cite this article as: Silva EP, Lemos A, Andrade CHS, Ludermir AB. Intimate partner violence during pregnancy and behavioral problems in children and adolescents: a meta-analysis. J Pediatr (Rio J). 2018;94:471-82. , ^☆☆ ☆☆ Study carried out at Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To evaluate the association of intimate partner violence during the gestational period and the development of externalizing and internalizing behavioral problems in children and adolescents.

Source of data:

A meta-analysis of cohort and case-control studies was performed, using studies selected from electronic databases. Eligible studies included women who experienced intimate partner violence during pregnancy and their children's behavioral problems. These problems encompass two groups: externalizing problems (expressed by hyperactivity, aggressive and challenging behavior, and delinquency) and internalizing problems (represented by depressive moods, anxiety, and somatic symptoms). The risk of bias was assessed by the Newcastle-Ottawa Quality Assessment Scale (NOS) and the quality of evidence by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). RevMan 5.3 software was used for the meta-analysis.

Data synthesis:

Of the 687 eligible articles, only seven met all inclusion criteria and consisted of 12,250 mother/child pairs. The age range of the assessed children varied from 10 months to 16 years. The odds of internalizing problems in children exposed to prenatal violence were two-fold higher (OR = 2.10, 95% CI: 1.17-3.76) and that of externalizing problems were 1.9-fold higher (95% CI: 1.28-2.83), when compared to children of unexposed mothers.

Conclusion:

The results of this study are consistent with the hypothesis that women's exposure to intimate partner violence during pregnancy may be associated with behavioral problems of their children, emphasizing the need for greater understanding about the vulnerability of children to adversity in early ages.

KEYWORDS
Intimate partner violence; Prenatal; Behavioral problems; Child development

Author, year of publication (country of study)	Study period	Type of study	Age of children and mothers	Exposure assessment and evaluation period	Outcome evaluation	Evaluated factors	Newcastle-Ottawa scale^a a Newcastle-Ottawa scale (the score is calculated by the number of *). Case-control studies: Selection: 1. Is the case definition adequate? 2. Case representativeness; 3. Control selection; 4. Control definition. Comparability: 5. Comparability of cases and controls based on study design or analysis. Exposure: 6. Exposure assessment; 7. Same evaluation method for cases and controls; 8. Non-response rate. Cohort studies: Selection: 1. Representativeness of the exposed cohort; 2. Selection of the unexposed cohort; 3. Exposure determination; 4. Demonstration that the outcome of interest was not present at the start of the study. Comparability: 5. Comparability of cohorts based on study design or analysis. Outcome: 6. Outcome evaluation; 7. The follow-up was long enough for the results to occur; 8. Adequacy of cohort follow-up.
							Selection	Comparability	Outcome/exposure
Whitaker et al., 2006³⁰30 Whitaker RC, Orzol SM, Kahn RS. Maternal mental health, substance use, and domestic violence in the year after delivery and subsequent behavior problems in children at age 3 years. Arch Gen Psychiatry. 2006;63:551-60. (United States)	1998-2000	Cohort	Children: 3 years	Questions about physical violence at any time during pregnancy	Child Behavior Checklist (CBCL)	Socioeconomic and demographic factors, use of alcohol, tobacco, and illicit drugs during pregnancy, maternal mental health, child's birth weight	1.A* 2.A* 3.B* 4.A*	5.A* 5.B*	6.B* 7.A* 8.A*
			Mothers: >18 years	1 year after delivery
McFarlane et al., 2014²⁹29 McFarlane J, Maddoux J, Cesario S, Koci A, Liu F, Gilroy H, et al. Effect of abuse during pregnancy on maternal and child safety and functioning for 24 months after delivery. Obstet Gynecol. 2014;123:839-47. (United States)	Period not mentioned. Recruitment of women and children: 13 months Cohort duration: 7 years	Cohort	Children: 18 months-13 years	Severity of Violence Against Women Scale (SVAWS)	CBCL	Socioeconomic and demographic factors, maternal mental health. Compared women with reports during pregnancy and out-of-pregnancy reports	2.A* 3.B* 4.A*	5.A*	6.B* 7.A* 8.A*
			Mothers: 19-37 years	At every 4 months up to 24 months
Flach et al., 2011³3 Flach C, Leese M, Heron J, Feder G, Evans J, Sharp D, et al. Antenatal domestic violence, maternal mental health and subsequent child behavior: a cohort study. BJOG. 2011;118:1383-91. (United Kingdom)	Start: 1991-1992 Data collection: 42 months after the start	Cohort	Children: 42 months	Questions about psychological and physical violence	Revised Rutter Scale	Socioeconomic and demographic factors, Use of alcohol and tobacco in pregnancy, postnatal violence, maternal mental health, child's birth weight	1.A* 2.A* 3.B* 4.A*	5.A* 5.B*	6.B* 7.A* 8.B*
			Mothers: 29 years (mean)	18 weeks of gestation
Martinez-Torteya et al., 2015²⁸28 Martinez-Torteya C, Bogat GA, Levendosky AA, von Eye A. The influence of prenatal intimate partner violence exposure on hypothalamic-pituitary-adrenal axis reactivity and childhood internalizing and externalizing symptoms. Dev Psychopathol. 2015;:1-18. (United States)	Start: 1999-2000 Data collection: from 1 year until 10 years after the start	Cohort	Children: 10 years	Conflict Tactics Scales (CTS) e SVAWS	CBCL	Socioeconomic and demographic factors, maternal life events, mental health, postnatal violence, cortisol in the child's saliva	1.B* 2.A* 3.B* 4.A*	5.A*	6.B* 7.A* 8.B*
			Mothers: 26.8 years (mean)	Interview in the last trimester of pregnancy
Zou et al., 2015¹⁶16 Zou S, Zhang Y, Cao Y, Zhang Y. Correlation of maternal abuse during pregnancy with infant temperament and development. Arch Dis Child. 2015;100:938-43. (China)	2006-2007	Cohort	Children: 10 months	Abuse Assessment Screen (AAS)	Bayley scale	Socioeconomic and demographic factors, Gestational age, Unplanned pregnancy, Previous abortion, Plasma levels of Glu, GABA, and cortisol	1.B* 2.A* 3.B* 4.A*	5.A*	6.B* 7.A* 8.B*
			Mothers: 27 years (mean)	During hospitalization for childbirth
Levendosky et al., 2006²⁰20 Levendosky AA, Leahy KL, Bogat GA, Davidson WS, von Eye A. Domestic violence, maternal parenting, maternal mental health, and infant externalizing behavior. J Fam Psychol. 2006;20:544-52. (United States)	Start: 1999-2000 Data collection: 1 year after the start	Cohort	Children: 1 year	SVAWS	Infant Toddler Social and Emotional Assessment (ITSEA)	Socioeconomic and demographic factors, maternal mental health social support, parental style, postnatal violence	1.B* 2.A* 3.B* 4.A*	5.A*	6.B* 7.A* 8.B*
			Mothers: 26.8 years (mean)	Interview in the last trimester of pregnancy
Tan and Gregor, 2006⁵5 Tan JC, Gregor KV. Violence against pregnant women in Northwestern Ontario. Ann N Y Acad Sci. 2006;1087:320-38. (Canada)	Period not mentioned	Case-control	Children: 3-16 years	Variation of the Abuse Assessment Screen (AAS)	Conners' Parent Rating Scale-Revised: Long Form (CPRS-R:L)	The children were matched by age and gender and no report of physical or sexual violence or witnessing violence in the family. Mothers were matched by age, geographic region, violence during pregnancy, and no physical or sexual violence after the child was 3 years old. Marital status, ethnicity, use of alcohol, or illicit drugs during pregnancy	2.A* 3.A* 4.A*	5.A* 5.B*	6.B* 7.A* 8.A*
			Mothers: Cases: 33.6 years Controls: 35.5 years	Every pregnancy trimester

Population: Children with internalizing and/or externalizing behavioral problems
Exposure: Intimate partner violence during pregnancy
Outcomes	Illustrative comparative risks (95% CI)		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control
Behavioral problems Measured by CBCL and Rutter Scales^a a CBCL, Child Behavior Checklist. Follow-up: 1-10 years	Study population		1.82 (1.28-2.6)	11,677 (4 studies)	⊕⊕⊝⊝ low^c c Two studies evaluated exposure using a non-standard instrument. ,^d d There was inconsistency in the results. p-Value = 0.14 and heterogeneity index of 45%.
	143 per 1000	261 per 1000 (183-373)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	Low
	137 per 1000	250 per 1000 (176-357)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	High
	500 per 1000	910 per 1000 (640-1000)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
Internalizing problems Measured by CBCL and Rutter Scales^a a CBCL, Child Behavior Checklist. Follow-up: 1-10 years	Study population		OR 2.10 (1.17-3.76)^e e The effect size was large (>2).	2943 (4 studies)	⊕⊕⊝⊝ low^c c Two studies evaluated exposure using a non-standard instrument.
	122 per 1000	226 per 1000 (140-343)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	Low
	213 per 1000	362 per 1000 (241-504)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	High
	497 per 1000	675 per 1000 (536-788)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
Externalizing problems Measured by CBCL and Rutter Scales^a a CBCL, Child Behavior Checklist. Follow-up: 1-10 years	Study population^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.		OR 1.90 (1.28-2.83)	2943 (4 studies)	⊕⊕⊝⊝ low^c c Two studies evaluated exposure using a non-standard instrument. ,^f f There was inconsistency in the results. p-Value = 0.08 and heterogeneity index of 50%. Source: Created by GRADE working group - http://www.gradeworkinggroup.org.
	201 per 1000	323 per 1000 (243-416)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	Low^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	296 per 1000	444 per 1000 (350-543)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	High^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.
	364 per 1000	521 per 1000 (423-618)^b b It was adopted as assumed risk in the control, the second highest and second lowest risk of the control group in the included studies.

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[1] * Corresponding author.E-mail:elisabetepsilva@terra.com.br, elisabete.pereira@ufpe.br (E.P. Silva).