Intimate Partner Violence : A Pediatric Problem

1. Intimate Partner Violence:A Pediatric Problem

2. Disclaimer This material was developed by the American Academy of Pediatrics under award #2012-VF-GX-K011, awarded by the Office for Victims of Crime, Office of Justice Programs, US Department of Justice. The opinions, findings, and conclusions or recommendations expressed herein are those of the contributors and do not necessarily represent the official position or policies of the US Department of Justice.

3. What is Intimate Partner Violence? • A pattern of behaviors in partner relationships that incorporates a range of abusive tactics-emotional, physical, and sexual- which serve to establish coercive control of one partner over the other. • An intimate partner relationship is defined, regardless of marital relationship, cohabitation, sexual relationship or gender of the partners

4. What is Intimate Partner Violence? • The majority of the victims are women or mothers • IPV is not just Physical violence; it can also be: • Emotional (threatening, or harming one’s self-worth) • Sexual (forcing a sex act without consent) • Stalking (harassing or threatening tactics that are both unwanted and cause fear) • Virtual (repeated texting or posting sexual pictures online

5. Children are affectedPrevalence • Intimate Partner Violence (IPV) exists in approximately 25% of all homes. It is estimated that 3 million US children per year witness IPV.

6. IPV Affects Children • IPV may be the single major precursor to child abuse and neglect fatalities in this country. (US Advisory Board on Child Abuse and Neglect, 1995) • Children from homes with IPV have up to 15 times the risk of physical abuse (Wright, RJ et. al. Pediatrics.1997:99:186-192) • Short- and long-term effects of IPV on children are well documented. -Sleep difficulties, hyper-vigilance, poor concentration, school problems, aggression, somatic complaints, increased rates of anxiety and depression

7. Most common presentation of IPV: • A healthy child without obvious signs of maltreatment or stress. • A parent without obvious evidence of injury or unusual stress • Therefore, UNIVERSAL assessment for IPV is the best way to help families

8. The importance of IPV screening in pediatric settings • In a large study of pregnant women: • 7% experienced IPV before pregnancy • 6% experienced IPV during pregnancy • Of those with IPV: 77% were injured but only 23% sought medical care • Nearly 100% of women brought their child for well child care. • Victims of IPV will seek care for their children but not for themselves Martin SL, et al JAMA 2001;285:1581-1584

9. Effects on Children: Common Misconceptions • It won’t hurt the children • They are young, they’ll forget • They don’t really understand • They’re unaware of what’s happening

10. How To Assess In Child Health Settings • Use introductory, framing statement. Eg: “Violence is an issue that unfortunately effects nearly everyone today and so I have begun asking families in my practice about exposure to violence.” • No consensus about best way to ask • Indirect assessment. Eg: “Do you feel safe in your home and in your relationship?” OR • Direct assessment. Eg: “Do you ever feel afraid of (or controlled by) your partner/spouse/boyfriend?” Groves, B. M. A., & Family Violence Prevention Fund (U.S.). (2004). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco, Calif: Family Violence Prevention Fund.

11. Should I ask about IPV with the child in the Room? • Best to ask with the child is not in the room • When that is not possible: • Child under three years: probably ok to ask in front of child • For older children: best to use a written screen or have child leave room. Groves, B. M. A., & Family Violence Prevention Fund (U.S.). (2004). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco, Calif: Family Violence Prevention Fund.

12. If the IPV Assessment is Positive • Express concern for victim • Ask about child’s safety • Tell her about resources available • Offer to link her to resources. (be ready with ability to place phone call and link to local IPV advocacy services) • Schedule a follow-up appointment to check in with victim Groves, B. M. A., & Family Violence Prevention Fund (U.S.). (2004). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco, Calif: Family Violence Prevention Fund.

13. If the IPV Assessment Is Positive:Child safety assessment • Do a brief child safety assessment: • Does the child have evidence of injury from abuse? • Has the child been threatened? • Is the victim parent able to protect the child? • If the child safety assessment is positive further inquiry by child protection services or a social worker is necessary Groves, B. M. A., & Family Violence Prevention Fund (U.S.). (2004). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco, Calif: Family Violence Prevention Fund.

14. Documentation in the child’s chart • No consensus on best way to document • If abusing partner has access to child’s chart this could increase risk for victim parent • Suggestions: • Document with nonspecific terms, eg: +WTV (witness to violence) • Maintain section of child’s chart which is confidential and not released with request for medical record Groves, B. M. A., & Family Violence Prevention Fund (U.S.). (2004). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco, Calif: Family Violence Prevention Fund.

15. Should A CPS Report Be Filed Whenever IPV Is Identified? • A report to CPS is NOT always required. Know your state laws! • Consult with a social worker should be obtained, if possible. • Report necessary if: • Explicitly mandated by law OR • Injuries secondary to abuse are present • There is immediate concern for the child’s safety. • Inform the mother that report will be made Groves, B. M. A., & Family Violence Prevention Fund (U.S.). (2004). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco, Calif: Family Violence Prevention Fund.

16. Role of the Pediatrician in the Medical Home (IPV Basic Competency) • Basic competency means • Identifying cases • Assessing needs and services • Expressing concern • Offering support and referral • Basic competency does not require you to solve or treat IPV Cohn F, Salmon ME, Stobo JD (Eds) Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence,. Washington, DC: National Academy Press, Institute of Medicine, 2002.

17. What else can I do? • Remember, your concern and your offer of resources are the essential first step toward helping a victim of IPV. • Information for the family: • DV hotline: www.thehotline.org • 1-800-799-SAFE • DOJ Safe Start Center: www.safestartcenter.org/ • NCTSN: fact sheets for parents of children affected by domestic violence: http://nctsn.org/sites/default/files/assets/pdfs/QA_Groves_final.pdf

18. Thank you! Thank you for utilizing this component of the online training toolkit, produced by the American Academy of Pediatrics Medical Home for Children Exposed to Violence project. Additional resources on intimate partner violence and other similar issues can be found on the project Web site: www.aap.org/medhomecev Many thanks to M. Denise Dowd, MD, MPH, FAAP and Betsy McAlister Groves, MSW, LICSW for developing the content for this presentation.