The Office for National Statistics (ONS, 2019) has estimated that there were 2.4 million victims of domestic violence aged between 16 and 74 years (1.6 million women and 786 000 men) up to the year ending March 2019. The effects of domestic violence can have a huge impact upon an individual's behavioural and psychological health, such as; ‘substance misuse, depression, suicidality, eating disorders and the development of a combination of mental health disorders’ (Barter and Stanley, 2016: 5). Furthermore, this abuse has an ‘estimated cost of £66 billion in England and Wales, the majority of which (£47 billion) is due to both physical and emotional harms (such as anxiety and depression) incurred by victims (specifically emotional harm such as anxiety and depression), and an estimated cost of 1.3 billion per year to the police and 2.3 billion to the National Health Service, with the remainder cost to the economy due to lost output and reduced productivity at work’ (Rhys et al, 2019: 6).
Evidence suggests that the some of the highest rates of domestic violence and abuse are experienced by adolescents (ONS, 2016), with prevalence rates as high as 45% in England (Fox et al, 2014). Yet, despite this, young people are silent victims of this abuse, and therefore are not visible to services (SafeLives, no date). While in the United Kingdom (UK) there is a plethora of evidence on the effects of domestic violence on adults and the impact on children and professional practice (Radford and Hester, 2007), there has been a paucity of research undertaken on young people's experiences of violence in their intimate relationships (Barter et al, 2009; Taquette and Monteiro, 2019). Therefore, the aim of this article is to provide a narrative review of adolescent intimate partner violence, and to highlight the importance of adopting a public health approach to addressing this hidden problem in which young people are either at risk of or have experienced this type of abuse.
‘Evidence suggests that the some of the highest rates of domestic violence and abuse are experienced by adolescents, with prevalence rates as high as 45% in England.’
Adolescence
Kaplan (2004: 1) defines adolescence as ‘the period of life between childhood and adulthood’, during this transformative stage, young people experience a series of rapid biological, psychological, sociological and environmental changes. However, the specific age range to identify the start and end of adolescence is hard to define, which has been stated as ages 10–19 years (World Health Organization [WHO], 2014) and most recently the expanded inclusive definition of 10–24 years (Sawyer et al, 2018). What is evident is that regardless of what age distinctions are made for this stage of life, this is a unique transition for each individual, which begins with ‘physiological changes (puberty), but unfortunately does not have an equivalent physical definition to the end of adolescence, instead this is often set on the basis of changes to social roles’ (Ledford, 2018: 431). Aligned to this, terminology adds to the confusion on adolescence, as the following terms are used interchangeably to describe individuals in this developmental period; teenagers, youth, young people and adolescents (Sawyer et al, 2018).
Many young people will experience some form of violence of a partner before they reach adulthood
There are three stages of development within the adolescent phase of life (Patton et al, 2016: 2427):
- Early adolescence (10–14 years)
- Late adolescence (15–19 years)
- Young adulthood (20–24 years).
In early adolescence, biologically, young people develop metamorphically through puberty, sexual and brain development. Psychologically, there is an increase in risk-taking behaviours and resistance to peer influences, and sociologically, this is one of the strongest phases of development relating to identity formation and for developing new friendships and romantic relationships (Patton et al, 2016).
Brain development becomes very active within late adolescence, when the prefrontal cortex (responsible for decision making) starts to develop and white matter (responsible for connectivity between brain networks) begins to increase. Young people develop self-regulation skills and want more autonomy, therefore we begin to see a shift from parental influences, to the focus being on peer and romantic relationships (Patton et al, 2016). In young adulthood, from a biological perspective, both puberty and brain development reach maturation point. However, this stage focuses mainly on sociological and environmental development, as young people enter the workforce or further education, which may influence their home environments and the development of new peer and romantic relationships (Patton et al, 2016).
Adolescence is an exciting, critical period of development, where young people develop a sense of self, new friendships and romantic relationships and have an opportunity to explore a range of new experiences. Parallel to this, due to the enormity of biological, psychological, sociological and environmental changes that occur at this time, young people are also vulnerable to a number of risks within the wider social context (Firmin, 2017). This is evident across all stages of this transition, however, particularly during both early and late adolescence, when young people enter a ‘window of neural plasticity in which different regions of the brain start maturing, if this is interrupted, this can create an imbalance and has the potential to impact upon normal development’ (Kanwal et al, 2016: 1).
Intimate partner violence
Intimate partner violence (IPV) refers to (Home Office, 2013): ‘any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are or have been, intimate partners or family members regardless of gender or sexuality’. Types of abuse can include, but are not limited to physical, psychological, sexual, financial and emotional abuse (Her Majesty's Prison and Probation Service [HMPPS], 2019).
Recently, studies have also included an additional type of abuse seen in partner violence, through new technologies (Barter and Stanley, 2016). It incorporates five elements (Wood et al, 2015):
- Emotional online abuse
- Controlling behaviour
- Surveillance
- Social isolation
- Coerced sexting.
IPV can affect both females and males, regardless of class, socio-economic status, religion, sexuality, ethnicity, or culture, and within any setting. IPV has a cycle of three phases (Basu, 2019):
- Tension phase – when stress and emotions build up over a certain period of time, when the abuser will pick fights, show aggression and nitpick
- Acute or crisis phase – when episodes of intimate partner violence occur, the abuser will blame and hurt the victim
- Honeymoon phase – when the abuser will become calmer and try to apologise, ask for forgiveness and promise it will not happen again.
One of the first key national research studies in the UK to be completed on adolescent intimate partner violence was the NSPCC report ‘Partner Exploitation and Violence in Teenage Intimate Relationships’ (Barter et al, 2009). This study involved 1353 young people participants aged between 13 and 17 years, split evenly by gender. Findings from this study showed that nearly three-quarters of girls reported some form of emotional partner violence, that one in three girls reported some form of sexual partner violence and ‘that 25% of females reported a partner had pushed, slapped, hit or held them down on one or more occasions, and 11% of females had been beaten up or hit with an object one or more times’ (Barter et al, 2009: 44). It also found that 50% of boys in a relationship reported experiencing emotional violence, 18% reported physical violence and 16% sexual violence from a partner (Barter et al, 2009: 178).
Following the publication of this research, there was a paradigm shift in relation to adolescent intimate partner violence, which recognised that this type of violence and abuse, needed to have the same acknowledgement as adult experiences of domestic violence (Barter et al, 2009: 178). This led to a series of further research studies being undertaken on adolescent intimate partner violence in the UK (Fox et al, 2013; Barter et al, 2015) which resulted in the UK government expanding its definition of domestic violence and abuse in 2013 to include young people aged 16 and 17 years (Home Office, 2013a).
Although, there have been developments in this field of practice, more still needs to be done, as evidence suggests that the age range must be lowered to account for early adolescence, as this type of abuse can ‘occur at a younger age’ (Barter et al, 2009: 178). However, the Home Office (2020) has stated that there is no intention to lower the age limit of 16 years ‘as it does not want to risk blurring the lines of domestic abuse and child abuse’. This provides further evidence of the need to recognise adolescence as a separate life course, which involves transitioning between childhood and adulthood. Rather than in its current stance, in which young people fail to be recognised within legislation, policy, guidance and safeguarding systems, which are focused on younger children (Littler, 2019).
‘… more still needs to be done, as evidence suggests that the age range must be lowered to account for early adolescence, as this type of abuse can occur at a younger age.’
It is also important to highlight evidence of this type of abuse within late adolescence, as a cross-sectional study with further education students aged 16–19 years in England and Wales, identified ‘55.1% of males and 53.5% of females reported the most common form of abuse they had experienced with a partner as being controlling behaviours’ (Young et al, 2017: 743), as evidence suggests that a number of ‘young people will experience some form of violence from a partner before they reach adulthood’ (Barter et al, 2009: 178).
Transdisciplinary work
School nurses are uniquely placed to assess adolescent intimate partner violence and to respond appropriately if a young person discloses this abuse, within their role in practice (Bradbury-Jones and Clark, 2016). However, a co-ordinated public health approach is paramount to tackle this issue, from a range of different angles, as it is clear that one service or agency cannot tackle this problem in isolation (Brown and White, 2006). Therefore, school nurses need to work with a range of other professional disciplines such as youth work, education, criminal justice, police and social care in order to address IPV in adolescence. Through transdisciplinary working, this places emphasis on ‘translating the research findings into practical solutions to solve social problems’ (Stokols et al, 2013: 5) through ‘integrating natural, social and health sciences in a humanity context’ (Soskolne, 2000: 4). Collectively, all relevant organisations and professionals can provide a range of primary, secondary and tertiary preventative interventions, as well as continuing to build upon the evidence base to inform future professional practice (Catch 22, 2018).
Prevention and intervention
Here are some examples of the primary, secondary and tertiary preventative interventions which can be provided from a health perspective. Primary prevention aims to reduce the number of instances of adolescent intimate partner violence by intervening before the abuse occurs (Harvey et al, 2007: 5). From a population level, the government's commitment to introduce a domestic abuse bill, is currently in the early stages of approval in parliament, which aims to ensure victims have the confidence to come forward and report their experiences, with the assurance that the state will support them and prosecute the abuser (Home Office, 2020). Similarly, public health campaigns, such as ‘This is Abuse’ which ran between 2010 and 2014 and was targeted at young people aged 13–18 years, provide a primary prevention intervention as the aim is to raise awareness and educate young people on violence, abuse, controlling behaviour and consent (Home Office, 2013b). At a community level, school nurses have a key public health role in delivering school-based and community programmes such as peer support and counselling schemes (Barter et al, 2009) and domestic abuse prevention education programmes (Fox et al, 2013). This provides young people with an opportunity to discuss any queries or concerns they may have, through a variety of teaching and learning and peer activities, which both raise awareness and educate them on this key issue (Fox et al, 2013).
Secondary prevention aims to detect any issues early, in order to prevent progression and reoccurrence of the event (Kirk et al, 2017). Therefore, the use of the SafeLives Risk Identification Checklist (RIC) (SafeLives, 2013) has been developed for professionals to work with young people individually ‘to identify risk in cases of domestic abuse, stalking and honour based violence’ in their intimate partner relationships (SafeLives, 2013: 2), this is based upon the original domestic abuse, stalking and honour-based violence (DASH, 2009) for adults. For school nurses completing this risk assessment with young people aged between 13–15 years, this would direct a referral to children's social care for safeguarding, and for young people aged 16–18 years, this will also direct a referral to safeguarding and to a multi-agency risk assessment conference (MARAC) (SafeLives, 2013).
Tertiary prevention focuses on young people who have experienced IPV as the aim is to improve their quality of life through reducing short- or long-term effects of experiencing this abuse. This would involve school nurses referring to child and adolescent mental health services for counselling and psychotherapy and signposting to support services for rehabilitation.
A targeted approach is required for perpetrators of abuse, rather than providing sustained interventions aimed at the general population of young people (Payton and Robinson, 2015). This involves adopting a one-to-one approach, utilising a range of techniques such as counselling, motivational interviewing (cycle of change), cognitive behavioural therapy, and reviewing family dynamics and histories of abuse (Payton and Robinson, 2015: 16). The voluntary organisation ‘Respect’ provides a range of resources and services for perpetrators of partner violence, which includes access to training programmes and toolkits for practitioners delivering interventions to young people who use abuse in their relationships (Barter and Stanley, 2016: 14).
Recommendations for practice
This article has highlighted several areas of practice which require development/improvement, in order to respond to this type of abuse experienced by adolescents. This includes, reviewing legislation such as the age limit of 16 years plus for the proposed domestic abuse bill (Home Office, 2020), which is currently in the approval process in parliament. While a rationale for not reducing the age has been provided due to an overlap with safeguarding systems, maybe it is time for safeguarding policies, guidance and systems to be revised for the adolescent age group so that it reflects current safeguarding issues for young people, instead of their developmental needs being grouped with younger children (Littler, 2019). This links to the need to improve safeguarding education and training (Littler, 2020) so that the adolescent stages of development (early, late and young adulthood) and adolescent intimate partner violence are both clearly represented within training sessions with practitioners, to assist them in this aspect of their role in practice. The re-introduction of public health campaigns such as ‘This is abuse’ (Home Office, 2013) are vital, in order to educate young people on violence, abuse, controlling behaviour, this needs to continue so that they can recognise the signs of abuse, as well as reinforcing the key messages. Finally, it is evident that further research is needed to understand what young people perceive as intimate partner violence, particularly as ‘49% of boys and 33% of girls aged between 13 and 14 years, thought hitting a partner is OK in at least of one of the 12 scenarios' they were presented with in the study (Safe Young Lives, no date). This is even more important given the ‘increase in the use of mobile phones, internet, and social media, which has contributed to the rapidly changing nature of young people's social contexts' (Young et al, 2017: 743). Therefore, we need to understand how new technologies are being used as a form of abuse in young people relationships (Barter et al, 2017). Finally, there is also the need to explore the aetiology and the impact of this violence, both on victims and on perpetrators, so that this can inform and enhance future practice development.
Conclusions
Young people in early and late adolescence experience some of the highest rates of domestic violence in the UK, yet due to the lack of evidence base within this field of practice, this largely remains a hidden abuse, the impact of which has the potential to affect their development across their lifespan. School nurses are in an ideal position to assess and respond to this abuse in their role in practice. However, it is evident that in order to tackle this issue, there needs to be a coordinated public health approach, which involves transdisciplinary working with a range of other disciplines to deliver primary, secondary and tertiary preventative interventions in order to address this issue holistically.