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Fifteen million children are exposed to intimate partner violence in their homes each year, and all pediatricians, whether they are aware of it or not, have cared for families in which there is overt or hidden physical or sexual abuse.
Fifteen million children are exposed to intimate partner violence in their homes each year, and all pediatricians, whether they are aware of it or not, have cared for families in which there is overt or hidden physical or sexual abuse. Well-child visits are the best times for pediatricians to screen for this preventable public health issue.
Screening and intervention for intimate partner violence (IPV) may provide pediatricians with the opportunity to protect their patients from years of exposure to violence. Many pediatricians avoid this topic because of a lack of knowledge or comfort in addressing the issue. This article summarizes research and guidelines that have emerged over the past 10 years with the goal of providing pediatricians with the knowledge and tools necessary to comfortably address IPV with the families for whom they provide care.
Whether they recognize it or not, all pediatricians have cared for families affected by IPV. In a recent study from the Centers for Disease Control and Prevention, 36% of adult women reported being physically or sexually assaulted by an intimate partner at 1 point in their lives.1 Six percent had been victimized within the past year. The prevalence of IPV in these population-based surveys differs from what has been described in specific clinical settings.
For example, in a survey of 133 Baltimore women accompanying their children to an ambulatory pediatric visit, Bair-Merritt found that 23% of the women disclosed having experienced IPV during the past year.2 Another survey of 553 women in a private pediatric practice in Falmouth, Massachusetts, found the current prevalence of IPV to be 2.5%.3
It is important to recognize that IPV is not isolated to inner-city environments; rather, IPV occurs in all communities. In fact, when controlling for employment status and poverty, the prevalence rates of IPV among black, Hispanic, and white women are nearly identical.4 Social stigma and reporting bias, however, can make it more difficult to identify IPV in more affluent communities and in men.
Rates of IPV are disproportionately high in families with a child aged younger than 5 years.5 This finding is particularly salient for pediatric providers because women of childbearing age rarely see their own providers, but they frequently bring their infants and toddlers to pediatric visits.6
Women between the ages of 18 and 24 years are at the greatest risk for IPV victimization.7 Low socioeconomic status, unmarried status,3 multiple children in the family (especially if they are younger than 5 years),5 maternal depression,8 and economic instability9 also place women at higher risk for abuse.
All told, up to 15 million children witness IPV in their homes every year.10 To put this number into perspective, childhood IPV exposure in the United States is twice as common as the prevalence of childhood asthma. Thus, what was once considered a “women’s issue” has been increasingly recognized as a preventable pediatric public health issue.
Intimate partner violence has been defined as “a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation and intimidation. These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim.”11 IPV can affect males or females and can take place within same- or opposite-sex relationships. Abusive behaviors can take many forms (Table 1),12,13 including physical abuse (eg, smacking, pushing, kicking, punching, or choking), sexual abuse (eg, forced intercourse), emotional abuse (eg, isolation from family and friends, yelling, and belittling), and financial abuse (eg, controlling financial resources).
More recently, pregnancy coercion14 and technology abuse (also known as cyber-stalking or electronic monitoring)13 have emerged in the medical literature. In pregnancy coercion, the abusive partner sabotages contraceptive techniques with the goal of forcing an unintentional pregnancy upon the woman. In technology abuse, the perpetrator uses cell phone technology, the Internet, and social networking sites such as Facebook to harass, stalk, intimidate, and humiliate. Some of the more recently defined types of violence (eg, pregnancy coercion and technology abuse) may not affect children in the same way as witnessing physical or sexual abuse; however, they can produce secondary impacts on children that result from having an anxious, fearful, or depressed parent.
Children can be directly and indirectly exposed to IPV. The most common indirect IPV exposure comes from overhearing abuse that takes place behind closed doors (eg, shouting, hitting, and the sound of objects breaking). Children are also exposed to the aftermath of an abusive episode (eg, a tearful parent with visible bruising, broken objects or walls, a parent who suddenly leaves the house and slams the door on the way out).
Direct exposure to IPV occurs when physical, sexual, emotional, or other forms of violence take place in the presence of the child. On occasion, children can be caught ”in the crossfire” during an abusive episode.15 For example, infants being held by a parent may be struck by an abusive partner during an argument. In addition, many older children and adolescents will attempt to defend a parent from the abuser and become threatened or injured in the process.
Not all children who witness IPV are equally affected. Factors such as the duration and severity of the abuse, maternal mental health, and parenting skills can all influence a child’s resiliency.16
It is important to recognize that child abuse and IPV are not synonymous. Unlike child abuse, IPV involves the child’s caregiver as the primary victim. Not surprisingly, the relationship between child abuse, in which the child is the direct victim of maltreatment, and IPV is quite strong. In fact, IPV is one of the most preventable and identifiable correlates of child abuse. Studies have demonstrated that the coexistence of IPV and child abuse is 29% to 60%.17 As a result, many child advocacy organizations, including the American Academy of Pediatrics (AAP),6 have advocated IPV screening and intervention as a method for the primary prevention of child abuse.
Health care use
In all age groups, children who have witnessed IPV use health care services (especially the emergency department and mental health settings) more often than their peers and subsequently incur greater health care costs. This increase in health care costs persists even after the abuse has ended.18
Emotional and physical health
Although IPV is most prevalent in homes with children aged younger than 5 years, many parents and providers erroneously believe that IPV does not affect young children because “they are too little to understand what is going on.” On the contrary, infants and toddlers are perhaps at greatest risk for adverse health effects related to IPV exposure. Children in this age group are experiencing a period of rapid brain growth (this is what allows them to learn to talk and walk within a short span of time). Although the traumatic experience of observing IPV is not stored in conscious memory, children’s developing brains are exquisitely sensitive to traumatic experiences in the social environment. A growing body of literature suggests that this type of early trauma can lead to changes in brain structure that may affect learning and emotional regulation.19,20
Young children living in violent homes may experience disruption of eating and sleeping cycles. They often have nightmares, night terrors, excessive clinginess, and separation anxiety.21 In addition, children living with IPV have a higher likelihood of internalizing and externalizing behavior problems (including temper tantrums and aggressive behavior) and are at risk for developmental delays and impaired school readiness.22
Although the mechanism is not completely understood, pregnant women who experience IPV are more likely to lack prenatal care and are at greater risk for delivering premature infants.23 Young children exposed to IPV are more likely to be delayed with immunization and are less likely to receive on-time well-child care.24 Obesity rates25 and asthma incidence26 are also higher in IPV-exposed children.
IPV-exposed school-aged children often exhibit aggressive behaviors both at home and at school and have higher rates of involvement with bullying, both as bullies and as victims.27 Academic underperformance is common,28 as are distractibility and hyperactivity (which can be misdiagnosed as attention-deficit/hyperactivity disorder), posttraumatic stress disorder, depression, and anxiety.21 Nightmares and sleep difficulties may persist into the school-aged years, and somatic complaints such as headache, backache, and abdominal pain are frequently reported by IPV-exposed children.29
Approximately 20% of adolescent girls have been victimized by dating violence (IPV that occurs within the context of an adolescent relationship).30 Adolescents experiencing dating violence have higher rates of risk-taking behaviors such as drug use, smoking, unsafe sexual behaviors, suicide attempts, and fighting.30,31
The Adverse Childhood Experiences (ACE) studies, conducted by Felitti and colleagues, highlight how ACEs such as childhood IPV exposure, parental substance abuse, and parental mental health problems can negatively affect health across the life course.32 In a sample of more than 17,000 adults enrolled in a Kaiser Permanente health plan in California, two-thirds had experienced some form of ACE. In this landmark study, the authors documented that ACEs were related in a dose-dependent manner to a variety of poor adult health outcomes, including smoking, anxiety, obesity, sexual promiscuity, chronic obstructive pulmonary disease, and cancer. Even when controlling for other ACEs, the frequency of childhood IPV exposure was independently and positively correlated with alcoholism, substance abuse, and depression as an adult.33 The impact of these studies cannot be overstated because they solidify the notion that childhood IPV exposure, especially when combined with other ACEs, is a public health issue that can affect physical and mental health throughout life.
Stress is a common experience for children and adults, and tolerable stress helps to build one’s ability to cope with challenging situations. However, IPV-exposed children live with a phenomenon termed toxic stress.19,20 Toxic stress is defined as the chronic, unpredictable, and uncontrollable exposure to adverse experiences without access to the buffering effects of a stable and responsive caregiver relationship.19 Childhood IPV exposure meets all the criteria for being a toxic stressor. For most families, the violence is chronic and unpredictable, and children are not able to stop or prevent the violence. Furthermore, IPV often makes effective, positive parenting more difficult. For example, parents with IPV histories are more likely to use corporal punishment and are less likely to use positive disciplinary strategies than are parents who have not experienced IPV.34 These parents may be anxious, preoccupied, and depressed, and therefore may be less likely to engage their children in activities that require uninterrupted attention, such as reading.35
Toxic stress causes frequent and prolonged activation and dysregulation of the autonomic nervous system and the hypothalamic-pituitary-adrenocortical axis. When children are exposed to IPV, they chronically mount their fight-or-flight response. Although this response is adaptive in the short term, repetitive activation alters neuroendocrine systems, with an adverse impact on the developing brain and organ systems.20
In a 2012 policy report, the AAP stated that it was “committed to leveraging science to inform the development of innovative strategies to reduce the precipitants of toxic stress in young children and to mitigate their negative effects on the course of development and health across the life span.”36 The AAP also recommended that pediatricians routinely screen caregivers for toxic stressors.
Several professional organizations endorse routine IPV screening of women of childbearing age, including the AAP,6 the Institute of Medicine,37 the American College of Obstetricians and Gynecologists,38 and the American Academy of Family Physicians.39 The US Preventive Services Task Force stated that IPV screening and intervention may improve some of the aforementioned health outcomes while having a minimal risk of harm and therefore gave IPV screening a “B” rating.40
Despite the recommendations of professional organizations, many health care providers find IPV screening to be challenging or impractical. The barriers most commonly identified in the medical literature include not recognizing that IPV is a pediatric issue, forgetting to screen, feeling uncomfortable screening, having insufficient time, lacking a relevant protocol, and lacking resources for IPV victims.35,41 Preparing your office to screen for IPV requires the use of “champions” who can dedicate their energy toward developing effective strategies to overcome these barriers (Table 2).41
RADAR (Routinely screen, Ask, Document, Assess, Refer/Resources) has been proposed as a mnemonic to facilitate screening for IPV.42
IPV screening should take place as routinely as possible because this de-stigmatizes the issue for providers and for patients and helps identify those individuals who do not have obvious red flags for abuse. For example, although many physicians recognize that a woman with a black eye should be screened for IPV, it is rare for someone to present to the office with visible bruising. Routine screening also provides practice for providers who are looking to improve their screening approach. Pediatric offices may consider providing parents with a handout that describes their practice philosophy on the issues of psychosocial screening (eg, depression, substance use, IPV) and confidentiality.
Even if some practices are unable to offer routine IPV screening, it is imperative that they screen the following high-risk populations of women: those involved in a new relationship, those with visible signs of abuse, those who have children with aggressive behaviors or previous victimization by abuse, or those who have been noted in your practice to have had public arguments with their partners. Pediatricians should also screen for IPV in adolescent girls, especially during pregnancy and postpartum.
Screening does not guarantee disclosure
One possible explanation for lack of disclosure of IPV involves the transtheoretical model of behavior change (ie, the “stages of change” model). This model proposes that individuals experiencing IPV progress through stages of behavior change (eg, precontemplation, contemplation, preparation, action, maintenance, and relapse) and that asking about IPV during a precontemplative stage might result in a negative response.43,44 In addition, women often must be asked multiple times before they disclose; they must trust the person to whom they disclose; and they must believe that that person will be able to provide them with a menu of options from which to find a solution. A negative IPV screen should never been seen as a low-yield exercise, but instead as a statement to the mother that if she ever finds herself in an abusive relationship, you and your colleagues are available as resources.
The manner of screening for IPV also may affect a victim’s likelihood of disclosing abuse to you. Rhodes and colleagues determined that patients experiencing IPV were less likely to disclose abuse to physicians who screened in an awkward or perfunctory manner and were more likely to disclose abuse to physicians who allowed for open-ended answers and who asked probing follow-up questions.45
Why victims remain
Although each person experiencing IPV has unique circumstances, it is fair to say that most have made a calculated decision that the benefits of remaining in an abusive relationship (eg, financial stability, father figure for their children) outweigh the risks and losses associated with leaving (eg, life in a shelter, humiliation, fear of losing custody of their children). They may not choose to leave until this balance changes. Other reasons for remaining in an abusive relationship include fear of the unknown, lack of family or social support, cultural norms that prohibit divorce, concerns about losing legal immigration status, love for the abuser, depression, and fear that leaving might result in injury or death.44,46
Ask direct questions
Experts disagree about whether IPV screening should be self-administered (written or computer assisted; (Table 3)47 or verbally administered by a health care professional (Table 4). Many patients have reported that self-administered screening is less awkward and more private, and research shows that it has better psychometric properties than verbal screening.48 On the other hand, verbal screening can be tailored to the parent’s unique situation and allows immediate response from a provider.
All experts agree, however, that IPV screening questions must be direct and have strong psychometric properties. Psychometric properties refer to the ability of a screening tool to accurately and reliably perform its intended function. In the case of IPV screening, one is most interested in the sensitivity and positive predictive value of the screening tool. Unfortunately, one of the most commonly used IPV screening questions, “Do you feel safe at home?” is remarkably vague and has a sensitivity of just 8.8%.
Direct verbal screening for IPV in the presence of children aged 3 years or older is not recommended because the child may report your conversation to the perpetrator.35 In these situations, you may choose to be more subtle in your approach (Table 4), or you may use self-administered screening modalities.
Documentation of IPV screening in the medical record has several benefits.35 Most importantly, it can assist the IPV victim in taking legal action against the perpetrator. It is necessary to ask permission from the person experiencing IPV before documenting it in the chart because the perpetrator, if he is the father of the child, has access to the medical record and may inadvertently discover the content of your conversation. Direct quotes should be used whenever possible in the documentation. Many institutions have used cryptic acronyms (“MIPV + / - / ?” for maternal IPV positive/negative/unknown) to document IPV status. “Unknown” status can indicate that IPV screening was not performed or that the provider suspected abuse but was unable to screen for confidentiality reasons. Other institutions have created “shadow charts” to document IPV and other social problems when confidentiality is of great importance. These charts are separate from the official medical record.
Assess safety and willingness to leave
After obtaining a positive IPV screen, the best response is to pause and allow the parent an opportunity to speak in more detail (Table 4). A statement such as “Tell me more about this . . .” is appropriate. In addition, let the parent know that she does not deserve to be treated that way and that help is available. The next best step is to assess the parent’s willingness to change her situation by asking, “Have you thought about what you might want to do about this situation?” or “Would you like to speak to a counselor about this?” Alternatively, tell the parent that “there is a menu of options for you to consider in terms of next steps,” thereby allowing her to make empowered decisions.
An assessment of safety is also critically important and may include the following questions:
· “Is it safe for you to go home today?”
· “What have you been doing to keep yourself and your children safe?”
· “Do you think the abuse is getting worse?”
· “Are drugs or alcohol influencing the abuse?”
· “Does your partner have access to weapons?”
IPV counselors are especially skilled in assessing safety and developing safety plans.35 Given that the risk of mortality from IPV increases when a person attempts to leave, collaboration with an IPV counselor can be extremely valuable. Physicians should never advise a caregiver experiencing IPV to “just leave” without ensuring that a well-designed safety plan is in place.
An assessment for child abuse must take place if a parent discloses IPV. Ask the parent how she believes that the IPV has affected her child and whether the child has been physically or emotionally abused by the perpetrator. If child abuse is present, it must be reported to Child Protective Services. In a few states, clinicians are mandated to report childhood IPV exposure or IPV; thus, it is imperative to know your state’s reporting law and to make caregivers aware of these requirements before you screen.35 Your local IPV agency should be able to provide this information for you.
Refer and provide resources
If a parent discloses IPV to you, offer to contact your local IPV hotline from an office telephone. IPV counselors have a unique set of skills and resources that may not be available to health care professionals or traditional social workers. First and foremost, they have the time to devote exclusively to this issue. They can develop individualized plans for physical, sexual, emotional, financial, and technological safety. Furthermore, IPV counselors are familiar with IPV-related legal issues, such as child custody, restraining orders, and divorce.
IPV programs provide far more than shelter; most of them also offer personal IPV advocates, counselors, and legal aid. If you do not have a local IPV counselor, you may find one locally through the national IPV hotline (1-800-799-SAFE) or online at www.thehotline.org. Children exposed to IPV should also be referred to mental health services, preferably those that use a trauma-informed approach.35
IPV is a toxic stressor that is associated with a wide range of adverse physical and mental health outcomes. Physicians who routinely screen for IPV can connect patients and their parents to services that have been shown to improve the safety and well-being of IPV-affected families. Screening for IPV requires effective training and a clear office protocol, both of which can be developed through collaboration with a local IPV agency.
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46. Davies J. Advocacy beyond leaving: helping battered women in contact with current or former partners. www.futureswithoutviolence.org/userfiles/file/Children_and_Families/Advocates%20Guide(1).pdf. Published 2009. Accessed April 9, 2013.
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48. Chang JC, Dado D, Schussler S, et al. In person versus computer screening for intimate partner violence among pregnant patients. Patient Educ Couns. 2012;88(3):443-448.
Dr Cruz is an assistant professor of pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania, and Associate Pediatric Residency Program Director, St. Christopher’s Hospital for Children, Philadelphia. Dr Bair-Merritt is an associate professor of pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.