Our Role in Addressing Adolescent Relationship Abuse

1. Our Role in Addressing Adolescent Relationship Abuse Tonya Chaffee, MD, MPH Associate Clinical Professor UCSF/SFGH October 6, 2011

2. OBJECTIVES • Understand Intimate Partner Violence in Adolescents (or Adolescent Relationship Abuse-ARA) • Understand the difference of IPV in youth vs. adults • Identify 3 ways adolescent development may impact how ARA can develop • Become familiar w/ risk associates w/, and the behaviors resulting from ARA in adolescents. • Learn how to screen for ARA, and identify the provider’s role addressing those who are at risk or victims of ARA • Develop skills for promoting healthy relationships.

3. Video

4. Definitions: IPV/ARA vs Date Rape IPV Physical and/or sexual violence or threats of physical and sexual violence, psychological/ emotional abuse including coercive tactics that adults or adolescents use against current or former intimate partners. Centers for Disease Control

5. IPV/ARA vs. Date Rape “Date Rape” is defined as a specific sexual abuse event (vs. physical abuse) that most often occurs as a single event, but may occur in the context of IPV. Date rape often overlaps with “dating violence”, a term often used to define IPV in adolescents. Adolescent Relationship Abuse (ARA) incorporates both of these terms

6. Research on the Effects of Adolescent Relationship Abuse

7. ARA is common • 1 in 5 female high school students report physically and/or sexually abuse by a dating partner • Silverman et al., JAMA 2001 • 20-30% of youth report verbal or psychological abuse by a dating partner • National Longitudinal Study of Adolescent Health • Youth in same-sex dating are just as likely to experience dating violence as youths involved in opposite sex dating • Halpern et al, J of Adol Health, 2004 • In youth, perpetrators are equally likely to be female or male • Girls more likely to be victims of physical abuse • Boys more likely to be victims of psychological abuse • Mutual aggression is common • Mulford and Giordano, NIJ Journal 2009

8. Adolescent Relationship Abuse is a Public Health Problem Sexual and reproductive health Mental health Overall health status

9. ARA and Reproductive Health • Teens in abuse relationships 3x more likely to become pregnant. This is associated with greater: • Depression • Substance Use • Late entry into PNC • School drop-out • Contraceptive “sabotage” • School/work “sabotage” • Kennedy, Am J Orthopsych. 2006

10. ARA and Pregnancy • 20% of pregnant adolescents <20 years old report IPV • IPV in pregnancy is associated with: • 3rd trimester bleeding • Pre-eclampsia • Preterm labor • Pregnant adolescents are 2-3X more likely to experienced violence during and after pregnancy vs adult pregnant women

11. Felt Depressed (past year) Depression and IPV: ORAdj= 2.35 (95% CI 1.56-3.53)

12. Attempted Suicide (past year) Suicide Attempt and IPV: ORAdj= 3.51 (95% CI 1.57-7.83)

13. Victim’s Behaviors in ARA IPV and Risk Behaviors for Girls

14. Adult Response to ARA is Inadequate • 80% of parents endorse that they did not believe or were not aware that Adolescent Relationship Abuse is an issue • Liz Claiborn Inc. & The Empower Program, 2000 • Less than 10% of pediatricians report screening for dating violence • Forcier et al., Ambulatory Pediatrics, 2002

15. Who is “At Risk”

16. Risks for Becoming a Victim • Poor self esteem. • Younger age w/ older aged partners • H/O Family Violence (DV) • History of prior IPV • Substance abuse • For girls • Early sexual debut (< 15 y.o.) • multiple partners • pregnancy

17. Risks for Becoming a Perpetrator Aggressive behavior, jealous, blaming Poor interpersonal skills/problem solving Substance abuse Personal history of physical abuse H/O DV

18. Youth are more at risk because youth typically: Are inexperienced with dating relationships Want independence from parents Have romanticized views of love Are pressured by peers to have dating relationships Are more likely to turn to a friend than a parent or other adult when they experience dating violence

19. Issues with Young Women • Beliefs of: • responsibility for solving problems in their relationships • boyfriend's jealousy, possessiveness and even physical abuse as "romantic" • abuse is "normal" because their friends are also being abused • “curing" the abusive boyfriend • lack of anyone to ask for help

20. Issues with Young Men • Beliefs of • the right to "control" their female partners in any way necessary • “masculinity” is physical aggressiveness • "possession" of their partner • the “right” to demand intimacy • loss of respect if they are attentive and supportive toward their girlfriends

21. Importance of Adolescent Developmental Framework in addressing ARA

22. From “Teen Dating Violence” to “Adolescent Relationship Abuse” Adolescence spans a LONG time (ages 10 – 24) – i.e., not just teenagers Interventions need to be developmentally appropriate Inclusive of range of abusive behaviors (not only violence) How can we take the opportunity for youth and young adults to define diverse and developing “relationships”?

23. Adolescent Developmental Framework Developmental trajectories and transitions Biological Psychological Social Cognitive How do we address? Currently provider’s focus on outcomes of sex (e.g. on pregnancy and STD’s), not “sexual health” and healthy relationships Must recognize the processes of relationship exploration and development

24. Review of Adolescent Developmental Stages Preadolescence: gender identity is established, puberty has not. low physical and mental investment in sexuality. start to establish information about relationships from family, friends, and school. h/o family violence may result in poor modeling of healthy relationships  a risk for unhealthy relationship development

25. Relationship Development Early Adolescence (10-13yo): Physical maturation begins, curiosity about one’s body and that of others, sexual fantasies Crushes begin, casual relationships may start. Relationships are more peer driven and often lack intimacy. Concrete thinking and unable to anticipate consequences including in relationships

26. Relationship Development Middle Adolescence (14-16): Full physical maturation and puberty ends. Increased exploration of relationships, including sexual relationships with dating and break ups. Socially begin to learn concepts of trust/mistrust, respect/disrespect in these relationships and begin to feel “intimacy” Transition from concrete to abstract.

27. Relationship Development Late Adolescence(17-21): Socio-legal maturation. Sexual behaviors more expressive, less exploitative, with development of more close and intimate relationships. Development of abstract thought--> able to anticipate and appreciate consequences of their actions. Can describe concepts of “love”, respect, and a readiness for sexual relationships.

28. Unhealthy Relationship Development Problems arise from: Lack of information to help negotiate healthy behaviors in relationships. Lack of healthy relationship models. Providers not recognizing where young people are developmentally, and that they are overall inexperience in relationships (e.g. the early maturing adolescent)

29. AGE=DEVELOPMENT

30. Counseling Developmentally Important to recognize these developmental milestones when counseling. There are variations (e.g. very mature 14 y.o. and immature 17 y.o. should be approached differently). Effective counseling will reflect more about where a person is “at” developmentally, rather than just lecturing about their behaviors.

31. Developmental Risks for Adolescent Relationship Abuse Sexual drive, bodies maturing faster than brains Intensity of need for social acceptance Constant connections through social media = greater vulnerability to abuse New independence, more reticent to disclose to adults Expectation for violence as norm in the context of trying out new relationships

32. Pearls for Counseling The question “Why” requires abstracted thinking. Can they problem solve? (e.g. a depressed person often can’t, so must counsel concretely) Have they demonstrated positive changes in their relationships, reflecting consequences they have learned? (e.g. leaving a partner or friend who disrespected them)

33. Pearls for Counseling Have the patient identify what is a healthy relationship. Can they describe qualities of “trust, respect” their partner as a milestone for intimacy Do they enjoy sex or is it a part of social status or control. Can they talk to their partner about birth control. How do they communicate if there is conflict

34. Additional considerations with Adolescent Relationship Abuse Electronic media and social networking Minor consent laws – balancing safety, mandated reporting, and confidentiality Clustering of vulnerabilities

35. APPROACHES TO SCREENING

36. Step # 1: ASK Direct questions

37. Steps for Assessing Teen IPV • Patient should be alone • Limits of confidentiality! • Introductory statements to normalize: “So I ask all my patients about the people they are going out with or dating…..” or “I ask all my patients about their relationships, because how we feel in our relationships is such an important part of our lives”

38. One Approach to Screening • Begin with open-ended question about relationships • “What happens when you and your partner disagree? Does it ever get physical?” • Follow with direct questions about specific behaviors such as: • pushing, hitting • being afraid • being hurt • engaging in unwanted sex , being forced to have sex • Control use of cell phone, make threats through texting or on social networks sites. • Hamberger, L.K. & Ambuel, B. (1998). Dating Violence. Pediatric Clinics of North American, 45, 381-390

39. If +…Additional Questions for Suspected Abusive/Coercive Relationships Are you unable to disagree with your partner/boyfriend/girlfriend? Does your partner get jealous when you go out or talk with others? Does your partner put you down, but then tell you he/she loves you? Does your partner constantly check up on you (INCLUDING USING CELL/INTERNET)

40. How to Identify Symptoms and Signs • Screening begins w/ direct questions, but not all youth may disclose or know they are at risk • Many youth may be at risk, and presents w/ both symptoms and signs of ARA

41. “Symptoms” of Possible ARA • Chronic physical complaints: • abdominal pain, HA, vaginitis, fatigue, pelvic pain • Sleep problems • Lack of appetite • Anxiety symptoms: • SOB, chest pain, palpatations, hyperventilation, syncope • Mental Health problems: • Depression, PTSD, anxiety disorders, suicidal ideation/attempts and substance abuse • Acute physical complaints: • vaginal bleeding, STI’s, UTI, vaginitis, amenorrhea

42. “Signs” of Possible ARA Victims behaviors: School problems Suddenly hostile and secretive Youth seems afraid of boyfriend/girlfriend and fears breaking up with him/her Moody, withdrawn or depressed Has stopped seeing friends or has given up favorite activities

43. “Signs” of Possible ARA • Partner behaviors • Partner is possessive, jealous of others, friends and family • Partner uses alcohol or drugs • Partner refuses to leave the room • Frequent cancelled appointments • Injuries not consistent with history, and at different stages of healing • Delay in seeking care for injuries

44. Red flags for ARA in Reproductive Health

45. Victim Barriers Not ready to disclose Living in violent home Low self-esteem/sense of self-efficacy (feel they are unable to change) Fear of parent(s), partner, police, systems Same-sex relationship victims often don’t disclose due to fear of disclosing sexual orientation/identity)

46. Provider Barriers • Not comfortable asking questions • Lack of resources for victims • Lack of knowledge of resources • Time • Not routinely asked • Assumptions that same-sex relationships aren’t at risk for IPV

47. INTERVENTION STRATEGIES

48. OUR MAIN ROLE: Safety • Assess the situation: Questions to ask • “Are you currently safe where you are now?” • “What has been the worst fight? Were weapons used?” • Suicidality, risk of homicide. • “Do you have an adult you can confide in?” • “Have you tried to leave your relationship before? If so, what happened?” • “If a crisis/unsafe situation, where would you go/who could you turn to for help?”

49. Provider’s Role: Intervention • Convey Key Messages • No excuse • Not the victim’s fault • Changing relationships is difficult • Not alone • Can be difficult • There is support • Inform on resources/safety plan

50. Making a Safety Plan • Help plan for safety and to get needed support • Offer information about legal resources • restraining orders, mandatory arrest, the police, and calling 911 • Provide information about community services • youth services, support groups, and legal advocacy • Encourage the patient to develop a specific safety plan. • "What steps can you take in the future to keep yourself safe? " • "Some young people choose to date with a group of friends they trust. Would that be an option?" • "If someone hurt you again, where could you go in an emergency? How would you get there? • Schedule a follow-up appointment and assess any barriers • "Will you be able to get transportation?" • "Will anyone try to prevent you from returning?" Hamberger, L.K. & Ambuel, B. (1998). Dating Violence. Pediatric Clinics of North American, 45, 381-390