D i Vi l Child dAd l H lh IDENTIFYING AND RESPONDING TO DOMESTIC VIOLENCE CONSENSUS RECOMMENDATIONS FOR CHILD AND ADOLESCENT HEALTH Produced by In partnership with AMERICAN ACADEMY OF FAMILY PHYSICIANS AMERICAN ACADEMY OF PEDIATRICS AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS CHILD WITNESS TO VIOLENCE PROJECT, BOSTON MEDICAL CENTER NATIONAL ASSOCIATION OF PEDIATRIC NURSE PRACTITIONERS Funded by With support from US DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR CHILDREN AND FAMILIES AND THE CONRAD N. HILTON FOUNDATION For more than two decades, the Family Violence Prevention Fund (FVPF) has worked to end violence against women and children around the world. Instrumental in developing the landmark Violence Against Women Act passed by Congress in 1994, the FVPF has continued to break new ground by reaching new audiences including men and youth, promoting leadership within communities to ensure that violence prevention efforts become self-sustaining, and transforming the way health care providers, police, judges, employers and others address violence. The FVPF is a national non-profit organization committed to mobilizing concerned individuals, allied professionals, women’s rights, civil rights, other social justice organizations and children’s groups through public education/prevention campaigns, public policy reform, model training, advocacy programs and organizing. Founded 1947, the American Academy of Family Physicians represents more than 93,500 physicians and medical students nationwide. It is the only medical specialty organization devoted solely to primary care. Family physicians, like other medical specialists, complete an extensive three-year residency program in the specialty after graduating from medical school. As part of their residency, family physicians receive training in six major medical areas: pediatrics, obstetrics and gynecology, internal medicine, psychiatry and neurology, surgery and community medicine. They also receive instruction in many areas including geriatrics, emergency medicine, ophthalmology, radiology, orthopedics, otolaryngology and urology. As a result, family physicians are the only specialists qualified to treat most ailments, and to provide comprehensive health care for people of all ages. The American Academy of Pediatrics (AAP) is an organization of 57,000 primary care pediatricians, pediatric medical sub-specialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. The AAP’s major activities include furthering the professional education of its members through continuing education courses, annual scientific meetings, seminars and publications. Our organization is committed to ensuring that children’s health needs are taken into consideration as legislation and public policy are developed and implemented. With over 43,000 members, the American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of professionals providing health care for women. ACOG is dedicated to the advancement of women’s health through education, advocacy, practice, and research. It is a private, nonprofit organization. ACOG works in four primary areas: 1) serving as a strong advocate for quality health care for women; 2) maintaining high standards of clinical practice and continuing education for its members 3) Promoting patient education and stimulating patient understanding of, and involvement in, medical care; and 4) Increasing awareness among its members and the public of the changing issues facing women’s health care. In fulfilling its purpose, ACOG develops and sponsors continuing medical education programs, creates guidelines to evaluate and improve medical practice, promotes access to the latest research through its publications and clinical gatherings, and supports programs for improved graduate medical education in obstetrics and gynecology. The Child Witness to Violence Project, a program of the Department of Pediatrics at Boston Medical Center was established in 1992 to provide mental health and advocacy services to young children and their families who are affected by violence in the home or community. The project provides clinical services to children and conducts training and technical assistance to a wide range of professionals working with young children and families. The Project has been nationally recognized as an innovative and effective initiative for families affected by domestic violence. National Association of Pediatric Nurse Practitioners (NAPNAP) was founded in 1973 as a non-profit specialty nursing organization devoted to improving the quality of infant and child health care. The pediatric nurse practitioner provides an advanced level of care to children and their families, including: counseling on normal development and behavioral problems, the prevention of illness and preventable injuries, and care of children with acute or chronic conditions. NAPNAP promotes high standards of child health care through education, research, and legislative action involving over 6,650 members in 50 chapters across the country. The Office for Victims of Crime (OVC) is a federal agency located within the Office of Justice Programs of the U.S. Department of Justice (DOJ) that Congress formally established in 1988 through an amendment to the 1984 Victims of Crime Act (VOCA). OVC provides leadership and federal funds to support victim compensation and assistance programs around the country and promotes victim services worldwide. OVC administers formula and discretionary grants designed to benefit victims, provides training for diverse professionals who work with victims, develops projects to enhance victims’ rights and services, and undertakes public education and awareness activities on behalf of crime victims. The Office for Victims of Crime is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance, the Bureau of Justice Statistics, the National Institute of Justice, and the Office of Juvenile Justice and Delinquency Prevention. Preparation of this publication was supported by grant number 2000-VF-GX-K006, awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions expressed in this publication are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice. Produced by First printing: SEPTEMBER, 2002 Updated: AUGUST, 2004 Funded by US DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR CHILDREN AND FAMILIES AND THE CONRAD N. HILTON FOUNDATION IDENTIFYING AND RESPONDING TO DOMESTIC VIOLENCE CONSENSUS RECOMMENDATIONS FOR CHILD AND ADOLESCENT HEALTH Written by BETSY MCALISTER GROVES, MSW, LICSW MARILYN AUGUSTYN, MD, FAAP DEBBIE LEE PETER SAWIRES, MA In partnership with Family Violence Prevention Fund ACKNOWLEDGEMENTS These guidelines were guided by members of the Advisory Committee that met in Boston, MA on December 7, 2001. Their input resulted in further revisions and a final review by the Advisory Committee. The Office of Victims of Crime also reviewed it before finalization. The Family Violence Prevention Fund (FVPF) wishes to thank the following individuals for their time and rigorous attention to the development of these guidelines. Their expertise, experience and guidance were invaluable ADVISORY COMMITTEE Elaine Alpert, MD, MPH Deborah L. Horan, MSW Boston University, School of Public Health American College of Obstetricians Boston, MA and Gynecologists Linda Chamberlain, PhD, MPH Tammy Piazza Hurley Alaska Family Violence Prevention Project American Academy of Pediatrics Anchorage, AK Elk Grove Village, IL Sue Chandler Howard S. King, MD, MPH Center for Community Health Education, Research, Newton-Wellesley Hospital & Services Newton, MA Boston, MA Margaret M. McNamara, MD Cindy Christian, MD, FAAP University of California San Francisco, Department Children’s Hospital of Philadelphia, of Pediatrics Division of General Pediatrics San Francisco, CA Philadelphia, PA Robert M. Pallay, MD M. Denise Dowd, MD, MPH American Academy of Family Physicians Children’s Mercy Hospital Hillsborough, NJ Kansas City, MO Anu Partap, MD, MPH Rev. Dr. Bobbie Groth Maricopa Medical Center, Department Milwaukee Women’s Center, Inc. of Pediatric Milwaukee, WI Phoenix, AZ Joyce Haas Robert M. Reece, MD American Academy of Family Physicians American Academy of Pediatrics Leawood, KS West Falmouth, MA Leah Harrison, MSN, CPNP Molly Resnik, MSW National Association of Pediatric Domestic Violence Project Safe House Nurse Practitioners Ann Arbor, MI Bronx, NY Family Violence Prevention Fund Advisory Committee Jennifer L. Robertson The AWAKE Project, Children’s Hospital Boston, MA Robert D. Sege, MD, PhD The Floating Hospital for Children, New England Medical Center Boston, MA Howard R. Spivak, MD New England Medical Center Boston, MA Jennifer Stallbaumer-Rouyer, LMSW, LCSW The Children’s Mercy Hospital, Department of Emergency Medicine Kansas City, MO Melinda Strauss, ACSW, LICSW Partners HealthCare System, Inc of Newton-Wellesley Hospital Newton, MA Peter Stringham, MD East Boston Neighborhood Health Center East Boston, MA Erin E. Tracy, MD, MPH, FACOG Massachusetts General Hospital Boston, MA Therese Zink, MD, MPH Univeristy of Cincinnati, Department of Family Medicine Cincinnati, OH Barry S. Zuckerman, MD Boston University School of Medicine/Boston Medical Center, Department of Pediatrics Boston, MA SPECIAL THANKS TO: Margaret McNamara, MD, Josephine Yeh, JD, Robin Hassler Thompson, JD, Ariella Hyman, JD, Nanette Falkenberg, and Sarah Stout AND FAMILY VIOLENCE PREVENTION FUND (FVPF) STAFF: Lisa James, MA, Debbie Lee, Anna Marjavi, Vibhuti Mehra, MA, Stephanie Moy, Fran Navarro, MSW, Rebecca Whiteman, MA Additional copies of this publication may be purchased online http://store.yahoo.com/fvpfstore, by phone: (415) 252-8089, or by completing and returning the order form found at the end of this publication. ANY ADAPTATION OR REPRINTING OF THIS PUBLICATION MUST BE ACCOMPANIED BY THE FOLLOWING ACKNOWLEDGEMENT: PRODUCED BY The Family Violence Prevention Fund 383 Rhode Island Street, Suite 304 San Francisco, CA 94103-5133 (415) 252-8900 TTY (800) 595-4889 www.endabuse.org First printing: September 2002 Updated: August 2004 Graphic design by Liz Chalkley Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Family Violence Prevention Fund CONTENTS Part One: Overview 12 DEFINITIONS 3 PREVALENCE OF INTIMATE PARTNER VIOLENCE 4 HEALTH EFFECTS OF INTIMATE PARTNER VIOLENCE ON ADULTS AND TEEN VICTIMS 5 HEALTH EFFECTS OF INTIMATE PARTNER VIOLENCE ON CHILDREN 6 WORKING CROSS CULTURALLY 7 RECENT TRENDS 7 IDENTIFYING AND RESPONDING TO ABUSE CAN MAKE A DIFFERENCE 11 Part Two: Dilemmas Faced by Providers 11 WHEN DOES CHILD EXPOSURE TO DOMESTIC VIOLENCE BECOME CHILD ABUSE? 14 Intimate Partner Violence Victimization Reporting Requirements for Health Care Providers 15 Asking about Intimate Partner Violence with a Child in the Room 16 Documentation 17 Responding to a Child’s Disclosure of Intimate Partner Violence in the Home 21 Part Three: Consensus Recommendations 21 ASSESSING FOR INTIMATE PARTNER VIOLENCE WHEN YOUR PATIENT IS A CHILD OR ADOLESCENT 21 Who and How Often to Assess 22 How to Assess 22 What to Ask 24 Asking about Intimate Partner Violence with a Child in the Room 25 Who Should Assess 25 RESPONDING TO INTIMATE PARTNER VIOLENCE WHEN YOUR PATIENT IS A CHILD OR ADOLESCENT 25 Support the Victim 26 Provide Information on Intimate Partner Violence 26 What to Say to the Child Who has Witnessed Intimate Partner Violence 26 For Adolescents Who are Victims of Violence 27 Assess and Address Safety Issues 28 Referrals for Adults and Adolescents 29 Referrals for Children 29 Reporting Requirements for Child Abuse and Intimate Partner Violence 30 How to Document Intimate Partner Violence 30 What to do if a Patient Says “No” or Will Not Discuss Abuse 33 Part Four: Preparing Your Child Health Practice Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Contents 37 37 Appendices I. Position Statements of Medical and Health Professional Associations 41 44 49 53 II. Bibliography III. Abstracts of Selected Studies on Provider and Patient Attitudes Toward Screening for IPV in the Child Health Setting IV. Dilemmas When Assessing All Patients for Victimization V. Indicators of Abuse 54 56 58 61 VI. Expanded Assessment for Victims of Domestic Violence VII. Safety Plan and Instructions VIII. Intimate Partner Violence Victimization Reporting Requirements: How It Affects Child Health Settings IX. State Codes on Intimate Partner Violence Victimization Reporting Requirements for Health Care Providers 63 67 75 X. Legislation Regarding Child Witnesses to Domestic Violence XI. Child Abuse Reporting Laws XII. Resources for Providers and Patients 81 Endnotes Training and Education Materials Catalog Family Violence Prevention Fund PART I OVERVIEW OVERVIEW Family Violence Prevention Fund OVERVIEW Family Violence Prevention Fund Overview PART I OVERVIEW Over the past 15 years, there has been a growing recognition among health care professionals that domestic violence is a major health problem with devastating effects on individuals, families and communities. Health care professional associations have issued position statements or guidelines for their members that describe the impact of domestic violence on patients and suggest strategies for inquiring about domestic violence (See the Appendix I for position statements from several professional associations). Studies show that regular screening for domestic violence in medical settings has been effective in identifying women who are victims1,2,3 and that victims are not offended when asked about domestic violence.4,5,6,7,8 In 1998, the American Academy of Pediatrics (AAP) issued a position statement declaring, “The abuse of women is a pediatric issue.”9 The statement made a strong case for recognizing domestic violence in child health care settings, but did not offer specific guidelines for inquiry and response or discuss the policy and practice dilemmas that arise when child health providers implement inquiry and response protocols. The guidelines offered here provide specific recommendations for assessing and responding to domestic violence in child health settings, which provide a unique and important opportunity to inquire about for domestic violence and to educate parents about the impact of such violence on children. Virtually every child is seen at some point by a health provider. Thus, it is possible to assess every family that uses the health care system. These guidelines also speak to the need for child health providers to engage in, model, and take leadership in delivering effective primary prevention of domestic violence, as well as other types of family and community violence, by highlighting violence prevention during well child and other routine visits, as a component of routine anticipatory guidance. Part One of the guidelines presents an overview of the impact of domestic violence on children and adolescents, and the rationale for regular and universal assessment for domestic violence in child health settings. Part Two addresses dilemmas that providers may encounter in discussing domestic violence with parents of their patients and adolescents. Part Three contains the specific guidelines for inquiry and response. Part Four recommends elements to create a clinical environment that effectively responds to domestic violence. Several useful resources have been included in the Appendices. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Overview Overview DEFINITIONS The term “family violence” and sometimes “domestic violence” has been used to describe acts of violence between family members, including adult partners, a parent against a child, caretakers or partners against elders and between siblings. While all forms of family violence can be devastating, this monograph focuses only on domestic violence or “intimate partner violence.” In this monograph, “intimate partner violence” will be used to more specifically define a range of behaviors between intimate or dating partners: Intimate partner violence is a pattern of purposeful coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats. These behaviors are perpetrated by someone who is, was or wishes to be involved in an intimate or dating relationship with an adult or 10 adolescent victim and are aimed at establishing control of one partner over the other. Legal definitions of domestic violence or intimate partner violence are generally more restrictive and refer specifically to threats or acts of physical or sexual violence including forced rape, stalking, harassment, certain types of psychological abuse and other crimes where civil or criminal justice remedies apply. Laws vary from state to state. Since evidence exists that non-physical intimate partner violence has many devastating physical, psychological, behavioral and developmental effects, the definition used in these Guidelines is better suited for the identification and treatment of intimate partner violence in the health care setting. “Child exposure to domestic violence or intimate partner violence” is a term encompassing a wide range of experiences for children whose caregivers are being abused physically, sexually, or emotionally by an intimate partner. This term includes the child who actually observes his/her parents being harmed, threatened or murdered, who overhears this behavior from another part of the home or who is exposed to the short- or long-term physical or emotional aftermath of caregiver’s abuse without hearing or seeing a specific aggressive act. Children exposed to intimate partner violence may see their parents’ bruises or other visible injuries, or bear witness to the emotional consequences of violence such as fear or intimidation without 11 having directly witnessed violent acts. Studies consistently show that the vast majority of victims of intimate partner violence are women. In fact, the latest United States Bureau of Justice Statistics report on intimate violence report found that 85 percent of victims are women.12 The language in this monograph reflects this trend. However, it is important to note that some victims of intimate partner violence are men, and that violence exists in same sex relationships as well. All victims should be responded to appropriately. Family Violence Prevention Fund DEFINITIONS Overview Overview Prevalence of Intimate Partner Violence Intimate partner violence is a health problem of enormous proportions. It is estimated that 20 percent to 30 percent of all women and 7.5 percent of men in the United States have been physically and/or sexually abused by an intimate partner at some point in their adult lives.13,14,15 Heterosexual women are five to eight times more likely than heterosexual men 16 to be victimized by an intimate partner.From 1993 to 1998, victimization by an intimate accounted for 22 percent of the violence experienced by females and three percent of the 17 violent crime sustained by males.Females are also approximately ten times more likely to be killed by an intimate partner than males. For adolescents, rates of experiencing some form of dating violence vary from 20 to 60 percent.19,20,21 Women age 16 to 24 experience the highest per capita rate of intimate partner violence with 15.6 victimizations per 1,000 females age 16 to 24, as opposed to 5.8 per 1,000 females in general.22 Teens are also at higher risk for abuse during pregnancy: 21.7 percent of pregnant teens experience abuse as opposed to 15.9 percent of pregnant adults.23 While studies indicate that boys and girls may accept physical and sexual aggression as normal in dating and intimate partner relationships, female teens are more likely to receive more significant physical injuries and to be sexually victimized by their partners.24 Finally, adolescent girls who have been sexually and physically hurt by dating partners are six to nine times more likely to attempt suicide or have suicidal ideation than those who reported no abuse.25 Far less data exist on lesbian, gay, transgender, and bisexual (or LGTB) victimization, however available literature suggests similarly high rates for LGTB adolescents and adults.26,27 Intimate partner violence occurs in every community—urban, suburban or rural; in all social classes; and in all ethnic groups. Consequently, all health care settings and professionals are affected by intimate partner violence. The estimates of numbers of children who are exposed to intimate partner violence vary from 3.3 million to ten million children per year, depending on the specific definitions of witnessing violence, the source of interview and the age of child included in the survey.28 Children who are five and under are disproportionately represented in households in which there is intimate partner violence and a sizable number of these children are involved because they calling for help, are identified as the cause of the dispute that led to violence, are caught in the cross fire, or are directly physically abused by the perpetrator.29 In a study conducted in an urban outpatient pediatric clinic, 40 percent of a sample of 160 mothers had filed a restraining order against a boyfriend or husband.30 In another study conducted in an office-based pediatric practice, 2.5 percent of mothers reported current intimate partner abuse and 14.7 percent reported abuse in past relationships.31 In the Adverse Childhood Experiences (ACE) Study, conducted on a large sample of members Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Overview Overview (30,000 adults) of the Kaiser Health Plan in California, 12.5 percent of respondents indicated childhood exposure to intimate partner violence and 10.8 percent indicated a history of child abuse, including physical, sexual and emotional abuse.32 Together these studies indicate that children who witness intimate partner violence are seen with both frequency and regularity in virtually all health settings and that young children are disproportionately represented in the population of children who live with intimate partner violence. Health Effects of Intimate Partner Violence on Adult and Teen Victims In addition to injuries sustained by women during violent episodes, physical and psychological abuse are linked to a number of adverse physical health effects including arthritis, chronic neck or back pain, migraine and other frequent headaches, stammering, sexually transmitted infections, chronic pelvic pain, peptic ulcers, spastic colon, and frequent indigestion, diarrhea or constipation.33 Additionally, optimal management of other chronic illnesses such as asthma, HIV/AIDS, seizure, diabetes and hypertension may be problematic in women who are being abused. Emerging research shows that women who are abused are less likely to engage in important preventive health care behaviors such as regular mammography.34 Intimate partner violence is also linked with significant short- and long-term mental health consequences for victims.35,36,37,38,39 Female adolescents who reported being sexually or physically abused are more than twice as likely to report smoking, drinking and using illegal drugs as non-abused teens.40 In addition, 32 percent of teen victims report bingeing and purging, compared to 12 percent of non-abused teens. Adolescent women who are battered are also less likely to attend school and less likely to receive good grades if they are in school.41 Adolescents’ experiences with sex are also associated with their history of dating violence. A study of adolescents found that those who experienced dating violence were more likely than their non-abused peers to have sexual intercourse before age 15 and to have had three or more sex partners in the past three months.42 Among young mothers on public assistance, half (51 percent) report birth control sabotage by a dating partner.43 Additionally, high school girls reporting violence from dating partners are approximately four to six times more likely than their non-abused peers to have ever been pregnant.44 The experience of interpersonal violence is correlated with rapid repeat pregnancy and higher incidences of miscarriage among low-income adolescents.45 Finally, abused teens are more likely to enter prenatal care later in their pregnancy: 24 percent of teens identified as abused enter prenatal care in the third trimester compared to only nine percent of non- abused teens.46 Family Violence Prevention Fund Overview Overview Health Effects of Intimate Partner Violence on Children More than 100 studies have explored the effects of intimate partner violence on children. These studies enumerate both short and long term effects of intimate partner violence on children.47 The most obvious and potentially dangerous risk for children who live in homes in which there is intimate partner violence is that they become direct victims of abuse. In 30 to 60 percent of families affected by intimate partner violence, children are also directly abused.48 Young children and adolescents are more vulnerable to the abuse. Very young children cannot get out of harm’s way, and adolescents more frequently intervene to stop the violence, thereby putting themselves at greater risk for injury.49 Children who are exposed to intimate partner violence, particularly chronic episodes of violence, often show symptoms associated with posttraumatic stress disorder. One study found that exposure to intimate partner violence (without being directly victimized) was sufficiently traumatic to precipitate moderate to severe symptoms of posttraumatic stress in 85 percent of the children.50 Children who are exposed to intimate partner violence are more likely to exhibit behavioral and physical health problems including chronic somatic complaints, depression, anxiety and violence towards peers.51 They are also more likely to attempt suicide, abuse drugs and alcohol, run away from home, engage in teenage prostitution and commit sexual assault crimes.52 Children who are exposed to intimate partner violence have increased difficulties with learning and school functioning.53 Symptoms of trauma including sleep difficulties, hyper-vigilance, poor concentration and distractibility which interfere with a child’s ability to focus and to complete academic tasks in a school setting. Intimate partner violence also affects parenting. The emotional consequences of being injured, harassed or terrified may be significant for the parent who is victimized. That parent may be less attuned to children’s needs or less emotionally available to the children. However this does not mean that victims of intimate partner violence are inherently abusive or neglectful of their children. Parents who batter are generally less involved with child rearing, more likely to use physical punishment and less able to distinguish or recognize the child’s needs as separate from the parent’s needs. Children who grow up with violence in the home learn early and powerful lessons about the use of violence in interpersonal relationships. They learn that violence is an acceptable way to assert one’s views, get one’s way or to discharge stress. These children also learn that violence may be an inherent part of loving relationships. Exposure to violence thus provides justification for children to use violence in their own relationships. This may be particularly true for adolescents.54 Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Overview Overview Studies demonstrate that children are not equally affected by exposure to intimate partner violence.55,56,57 Children react in different ways to trauma, and they have a range of strengths and vulnerabilities to cope with this stress. Some children appear to be more resilient; others may be deeply affected. Variables such as age, gender, proximity to the violence and the frequency and severity of the violence affect children’s responses. In addition, the response of the caregiver and other characteristics of the family and community affect children’s responses. Working Cross Culturally Intimate partner violence affects people regardless of race, ethnicity, class, sexual and gender identity, religious affiliation, age, immigration status and ability. The term culture is used in this context to refer to those axes of identification and other shared experiences. Because of the sensitive nature of abuse, providing culturally relevant care is critical when working with victims of abuse. In order to provide care that is accessible and tailored to each patient and their family, providers must consider the multiple issues that victims may deal with simultaneously (including language barriers, limited resources, homophobia, acculturation, accessibility issues and racism) and recognize that each victim of intimate partner violence will experience both the abuse and the health system in culturally specific ways. Disparities in access to and quality of health care also have an impact on ability of providers to help victims of intimate partner violence. For example, women who are members of racial and ethnic minority groups are more likely than white women to experience difficulty communicating with their doctors, and often feel they are treated disrespectfully in the health care setting.58 English-speaking Latinos, Asians and Blacks report not fully understanding their doctors and feeling like their doctors were not listening to them.59 People with disabilities that affect cognitive or communication may be dependent on an abusive intimate partner and thus at especially high risk. In addition, some patients may experience abuse from the health care system itself and this may affect their approach to and utilization of the health care system.60 Providers also enter health care encounters with their own cultural experiences and perspectives that may differ from those of the victim. In a successful health care interaction within a diverse client population, the provider communicates effectively with the patient, is aware of personal assumptions, asks questions in a culturally sensitive way and provides relevant interventions. Eliciting specific information about the patient’s beliefs and experience with abuse, sharing general information about intimate partner violence relevant to that experience and providing culturally accessible resources in the community, improves the quality of care for victims of violence. In addition, having skilled interpreters who are trained to understand intimate partner violence (and not family members, caregivers or children) is crucial when helping non-English speaking patients 61 and their families. Culturally sensitive inquiry questions for all caretakers and adolescent patients can facilitate discussion and help providers offer appropriate and effective interventions. Family Violence Prevention Fund Overview Overview Recent Trends These guidelines reflect an important shift in terminology. “Assessment” or “inquiry” has replaced the work “screening” throughout this document. The concept of screening in the medical model usually involved the use of a standardized clinical test to detect disease in asymptomatic patients. Psychosocial health issues like IPV do not fit well into a disease- based approach, particularly when identification of the health concern relies primarily on the patient’s response to a question. The U.S. Preventive Services Task Force (USPSTF) uses the term “assessment” in their recommendations for many psychosocial issues such as tobacco use and alcohol consumption. The USPSTF and other prominent medical organizations have identified the problems with fitting IPV into a traditional screening paradigm. The FVPF believes that using the term “assessment” will lead to a more appropriate evaluation of the importance of routine inquiry for IPV in the health care setting. With growing recognition of the connection between IPV and other risk factors, there is a trend to integrate routine inquiry for IPV into assessment tools addressing a wide range of psychosocial issues associated with current or past victimization such as tobacco use, weight control, and access to preventive health care. This has led to innovative strategies for more comprehensive assessment and integrated service delivery. The Maternal and Child Health Bureau has funded several perinatal demonstration projects to develop as assessment tool for IPV, depression, and substance abuse. Another exciting initiative through the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes coordinated services for women who experience violence, mental health problems, and have substance abuse issues. Identifying and Responding to Abuse Can Make a Difference The health care system plays an important role in identifying and preventing public health problems. Models developed to identify other chronic health problems may effectively be applied to intimate partner violence. A primary starting point to improve the medical practice approach to intimate partner violence is routine assessment, with a focus on early identification of all families and victims of intimate partner violence whether or not symptoms are immediately apparent. Since nearly all young children and teens are seen at some point in a health care setting, these settings present a compelling opportunity to identify teens, mothers and children who may be living with intimate partner violence. A 2001 study in North Carolina found that only 23 percent of women injured by a partner shortly after pregnancy received treatment for their injuries. However, almost all of these women used health care services for their infants, indicating that child health settings are potentially important for identifying intimate partner violence.62 Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Overview Overview Universal and regular face-to-face screening of women in adult health settings by skilled health care providers markedly increases the identification of victims of intimate partner violence, as well as those who are at risk for verbal, physical and sexual partner abuse.63,64 Expert opinion suggests that such interventions in adult health settings may lead to reduced morbidity and mortality.65 Inquiry for IPV can assist clinicians in their diagnosis and assure more appropriate care for a victim’s health symptoms by treating the underlying problems. Inquiry also gives victims a valuable opportunity to tell their providers about their experiences with abuse.66 Battered women report that one of the most important parts of their interactions with their physicians is being listened to about the abuse. (See Appendix III: Abstracts of selected studies on Provider and Patient Attitudes: Forward Screening for IPV in the Child Health Setting.) Although there is no research as yet that proves the efficacy of assessment in child health settings, it is reasonable to assume that such inquiry would increase opportunities for identification and intervention within families, thereby enabling pediatric, family practice and primary care providers to assist both victims and their children. When child witnesses of intimate partner violence, victims or those at risk for intimate partner violence are identified early, providers may be able to intervene to help patients understand their options, live more safely within the relationship or safely leave the relationship. The child health care provider’s direct discussion about safety at home tells the family that this is an important topic and one that belongs in the realm of pediatric and family practice care. Even if a woman denies that she is being abused, the provider can often lay the groundwork for the possibility of future disclosure or discussion of the issue. Family Violence Prevention Fund PART II DILEMMAS FACED BY PROVIDERS DILEMMAS Family Violence Prevention Fund DILEMMAS Family Violence Prevention Fund PART II DILEMMAS FACED BY PROVIDERS Dilemmas A policy of universal and regular inquiry for intimate partner violence in child health settings presents dilemmas to the providers who assess that may not exist when assessing patients in an adult health setting. Perhaps the fundamental difference lies in the fact that adults are not the primary patients during pediatric visits. This section reviews several major dilemmas and provides specific recommendations for responding. Because these dilemmas present challenging practice and ethical questions for the provider, this panel strongly recommends that child health practices have access to legal consultation, as well as consultation from battered women’s service providers, child protection and child mental health. These resources can be helpful in making decisions about how to intervene in ways that do not increase risk for the family or unnecessarily alienate the non-offending parent. When Does Child Exposure to Intimate Partner Violence Become Child Maltreatment? Because of the high rate of co-occurrence of intimate partner violence and child abuse, child health providers need to be concerned about the possibility of child abuse whenever intimate partner violence is disclosed. Whenever a child is abused, either intentionally or unintentionally, as a result of intimate partner violence, state law requires health care providers to report this abuse to child protection services. Mandated reporters would also report any high-risk situation of intimate partner violence in which children are at risk. However, state laws are less clear about whether exposure to domestic violence in the absence of injury or serious risk of injury to the child would require a report to children’s protective services. • In some states, stringent rules/laws require mandated reporters to notify child protection services whenever a child is in the home and has been exposed to a parent’s abuse, whether or not the child has been directly abused. Proponents of this definition point to the ample documentation of the overlap between adult intimate partner violence and child abuse and the adverse psychological effects on children who witness intimate partner violence. Opponents of this policy believe it penalizes women for abuse that they have no control over and may discourage women from seeking help. • In other states, a child’s exposure to intimate partner violence does not automatically require a mandatory child protection report. The provider has wider discretion to assess whether a child has been directly involved and what other factors may exist to put the child at risk. In these states, a provider would take into account the existence of direct injury to a child, the potential danger of the situation, and the capacity of the mother to keep her children safe in deciding whether to notify Child Protective Services (CPS). Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Dilemmas Many victim advocates recommend having the victim place a phone call themselves to CPS from the practitioner’s office, thus protecting her from charges of “failure to protect” while simultaneously protecting the child and meeting statutory child abuse reporting laws. Unless a child health care provider is legally required to report all incidences of intimate partner violence to CPS, it is preferable to make this decision based on the specifics of the case and the provider’s clinical judgment. In some instances, the children are not in danger; the victim has planned for their safety and is responding adequately to the child’s needs or emotional reactions. In these cases, a provider should offer voluntary services and support instead of simply submitting a report to CPS, especially if not mandated. A policy that automatically defines child exposure to intimate partner violence as neglect or maltreatment assumes that victims are neglectful parents solely because their children witnessed the abuse, implying that somehow the victim could have stopped the abuse. This approach implies that not only are these parents victims of abuse, but that they also bear the responsibility for child neglect. This may be inaccurate and unfair. This policy also makes the assumption that all children are adversely affected by exposure to violence, no matter the circumstances. It ignores the fact that some children are more adversely affected than others and that some families and communities are more able to support children than others. Finally, opponents of this policy allege that mandatory reports also would increase the demands on protective services—a system that is already overburdened and under funded in most states.67 In addition, the practice of routinely reporting intimate partner violence incidents that involve children to protective services discourages victims from seeking help with intimate partner violence. If a victim believes that children may be removed from her care, she will be less likely to seek help from medical professionals. A mandatory reporting policy also may discourage child health care providers from assessing for intimate partner violence because they do not want to involve protective services in their patient’s life. RECOMMENDATIONS: Know your state’s child abuse reporting laws (see Appendix XI) and its specific policies on defining child exposure to intimate partner violence as child maltreatment (see Appendix X). In a state that requires mandated reporting in all cases of intimate partner violence, the provider should inform the non-offending parent of the obligation to file a report to CPS, assess the safety needs of the victim, and inform CPS about the specifics of the perpetrator, his anticipated response and the potential for danger. In states where more discretion is left to the provider, the provider should assess the specifics of each situation as a means of making a decision about whether it is necessary to make a report. The assessment should include inquiries about injury or abuse to children, the current safety of the home, and whether the perpetrator has made threats to the children. Depending on the answers to these questions, the provider can make a decision about the imminent risk of harm to Family Violence Prevention Fund Dilemmas DILEMMAS Dilemmas Dilemmas the child and victim. If the situation is not currently dangerous, the provider can refer the victim to voluntary services: battered women’s services, counseling (preferably with a provider who has worked with victims of intimate partner violence), or child-focused services. If the situation is currently dangerous to the child, a report needs to be filed. Consider involving the mother in filing the report and follow the recommendations above to maximize the protection afforded to the mother during the CPS investigation. BOX 1 In States with Mandatory Reporting Requirements for Child Exposure to Intimate Partner Violence PROVIDERS SHOULD: • Inform the non-offending parent of obligation to report to CPS • Assess the safety needs of the victim • Give CPS specific information about the perpetrator, the intimate partner violence, and the potential for danger • Have resources available for the non-offending parent In States with Less Specific Reporting Requirements for Child Exposure to Intimate Partner Violence PROVIDERS SHOULD DECIDE WHETHER TO FILE A REPORT WITH CPS BASED ON: • An inquiry about direct injury to child • An assessment of potential for danger (threats, weapons, substance abuse) • An assessment of mother’s ability to plan for children’s safety • An assessment of support and connections to community If provider decides not to report to CPS, he/she should offer referrals to voluntary services and provide follow-up care. IF PROVIDER DOES DECIDE TO REPORT: • Consider asking the mother to file a report herself to avoid charges of “failure to protect” • Follow all the steps outlined above for reports in mandated states Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Dilemmas Intimate Partner Violence Victimization Reporting Requirements for Health Care Providers While all states mandate reporting of child abuse or neglect, most states have also enacted general mandatory reporting laws which require the reporting of specified injuries and wounds, suspected abuse or intimate partner violence for individuals being treated by a health care professional. These mandatory reporting laws are distinct from child abuse, elder abuse or vulnerable adult abuse reporting laws, in that the individuals to be protected are not limited to a specific class. These laws pertain to all individuals to whom the health care professional provides treatment or medical care, or who come before the health care facility. The laws vary from state to state, but generally fall into four categories: 1) states that require reporting of injuries caused by weapons; 2) states that mandate reporting for injuries caused in violation of criminal laws, as a result of violence, or through non- accidental means; 3) states that specifically address reporting in intimate partner violence cases; and 4) states that have no general mandatory reporting laws. (See Appendix IX for state codes on Intimate Partner Violence Victimization Reporting Requirements for Health Care Providers). In the majority of states, neither statutory nor case law specifies if a health care provider must report a parent’s injuries if they are observed or discovered during a health care visit with that parent’s child. Therefore, under a strict reading of most laws, if a child’s health care provider is not providing treatment or medical care to the abused parent during the child’s visit, the health care provider would not be required to make a report. In family practice situations where the child and parent are the provider’s patients, and the current visit appointment is for the child, the same reasoning could be applied, although it is less clear-cut. That is, the health care provider would not be required to report since he or she is not treating the parent for the specified injuries during the appointment. This issue merits further discussion among health care providers, advocates, licensing authorities, Dilemmas and other professionals, as it is uncharted territory. There has been much debate about the benefit of mandatory reporting of intimate partner violence by health care providers. A more extensive discussion of these laws, their risks and benefits, and their application to pediatric and family practice providers can be found in Appendix VIII. RECOMMENDATIONS: Providers should know their state’s intimate partner violence reporting law, including who is required to report and under what conditions. (Appendix IX contains a chart listing state codes). In order to maximize patient input regarding law enforcement action, providers should also familiarize themselves with how their local law enforcement agency responds to such reports. Becoming familiar with such procedures will allow the Family Violence Prevention Fund Dilemmas Dilemmas provider to better assist the patient in safety planning, and in knowing what to expect. Intimate partner violence reporting responsibilities should be carefully discussed with teens prior to assessing for dating violence or intimate partner violence in their homes. Additionally, recent federal privacy regulations require providers to inform patients of health information use and disclosure practices in general, and whenever a specific report has been made. Health care facilities should ensure that their intimate partner violence protocols and training materials address their state reporting laws and federal regulations. Asking about Intimate Partner Violence with a Child in the Room Providers differ in their practice of asking sensitive questions to the mother when the child is present. Generally, if the child is under age three, most providers assume that asking a mother about safety or other sensitive issues is appropriate. However, there is not consensus about whether to require that an older child not be present in the room when screening the mother for intimate partner violence. Some providers are concerned about asking questions when older children are present. They assert that having the child in the room will be a barrier to disclosure because parents will avoid discussing it in front of their children. Some say that it would be upsetting for children to hear such conversation or that children may reveal the conversation to the batterer which may endanger the mother and child. Other providers believe that the assessment questions about intimate partner violence should be asked regardless of the age of the child. They assert that children generally are aware of the intimate partner violence and that mothers will indicate if they are uncomfortable with the subject, thus giving the provider the opportunity to schedule a more private conversation with the parent. RECOMMENDATIONS: It is best to conduct assessment without children in the room and should occur regardless of the age of the child. In some practices it is possible to have the child wait in a supervised waiting area or under the supervision of another staff member. In other practice settings, it is not possible to have children leave the exam room. In these situations, providers can ask general questions and should always be sensitive to the comfort level of the parent. If the parent seems uncomfortable, the provider can offer other options for talking more privately, either by telephone or in a follow-up visit. Providers should be aware of the impact of a disclosure on a child, and should ask follow-up questions about the child and family’s safety. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Dilemmas BOX 2 Asking about Intimate Partner Violence with a Child in the Room Child in the Room Child not in the Room PRACTICAL POINTS: PRACTICAL POINTS: 1. Ask general questions first. 1. Ask during routine parts of visit 2. Be sensitive to comfort level of parent. when child is not in the room: 3. If parent is uncomfortable, schedule a vision screening, immunizations, time to talk without the child present. laboratory work. 2. Have the child wait briefly in a supervised waiting area if possible. Documentation There is no consensus over the procedure for documenting the presence of intimate partner violence in a family in a child’s chart. If the batterer is the biological or custodial parent, he may have access to the chart and the information about the victim would thus not be confidential. Therefore, putting information about intimate partner violence disclosures in the child’s chart may not be advisable. On the other hand, the information is important and other providers who work with the family should know about this risk factor if they read the child’s chart. Charting can also be helpful to the victim should custody disputes arise. RECOMMENDATIONS: A review of the literature and current practice reveals that recommendations for documentation are contradictory and inconsistent. One recommendation is for the provider to document all screenings for intimate partner violence in the child’s chart. The suggested notation, perhaps in the section on anticipatory guidance, is: “The parent was routinely asked about verbal abuse, threats, physical violence in the home and community. If so, the parent was offered information about community resources for safety planning and counseling.” This type of routine documentation is recommended for tracking and quality assurance. If possible, the documentation for the outcome of the inquiry (if positive for abuse) should be placed in the woman’s health chart or in social work notes where there is more protection of confidentiality. Some practices use non-specific terms or a code word to indicate the presence of intimate partner violence in a child’s chart: for example, “family problems,” “difficult home situation” or “+ wtv.” Some practices maintain a section of the child’s chart that is confidential and is not released when there is a request for medical records. A brief notation of intimate partner violence in this section is appropriate. Intimate partner violence should not be listed as a discharge diagnosis or billing information that is sent home or can be viewed by the perpetrator. Family Violence Prevention Fund Dilemmas Dilemmas Dilemmas If the provider is unsure about documentation and its confidentiality from the battering parent, he/she should consult with medical records experts, billing personnel, risk management professionals or attorneys. BOX 3 Options for Documentation • Document that inquiry has occurred. • Document results of inquiry by using non-specific terms or code works: “family problems,” “difficult home situation,” or “wtv.” • Maintain a section of the child’s chart that is confidential (not released with a request for medical records). Document finding of intimate partner violence in this section. • If possible, document the existence of intimate partner violence in the woman’s health chart or in social work notes where there is more confidentiality. Responding to a Child’s Disclosure of Intimate Partner Violence in the Home Direct disclosures of intimate partner violence occur more frequently with older children or teenagers who see child health providers without their parents. If the parents are unaware of the disclosure, the provider must decide how to inform the parents in a way that protects the child and does not create an unsafe situation in the home. The provider may feel uncomfortable about how to handle this disclosure. Should the provider notify child protective services? What are the consequences for the child of telling someone outside the family about the violence? What are the issues and laws related to confidentiality? RECOMMENDATIONS: Find out as much specific information as possible about the abuse and the extent of risk for the child and the adult victim. If the situation is dangerous, notify protective services. Inform the child of your concern about his/her safety and tell the child that you would like to speak to the non-offending parent about the situation. Inform the non-offending parent of the child’s concerns, taking care to stress that you are concerned and that you want to be helpful and supportive. Ask if the parent is safe and what types of supports would be helpful. If possible, make a referral to an intimate partner violence support agency or to counseling/ social services/mental health. Schedule a follow-up appointment for the next week. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Dilemmas BOX 4 Responding to Child Disclosure of Intimate Partner Violence PRACTICAL POINTS: • Inform the child of your concern about her/his safety and that you intend to speak to the non-offending parent about the situation. • Inform the non-offending parent of the child’s concerns. • Ask if the parent is safe and what types of supports would be helpful. • If possible make a referral to an intimate partner violence support agency or to counseling/social services/mental health for the adult or adolescent victim and their children. • Schedule a follow-up appointment for the next week. • Notify protective services if there are safety concerns about the child. Dilemmas Family Violence Prevention Fund PART III CONSENSUS RECOMMENDATIONS CONSENSUSRECOMMENDATIONS Family Violence Prevention Fund RECOMMENDATIONS CONSENSUS Family Violence Prevention Fund PART III CONSENSUS RECOMMENDATIONS ASSESSING FOR INTIMATE PARTNER VIOLENCE WHEN YOUR PATIENT IS A CHILD OR ADOLESCENT All health care providers seeing children and adolescents should provide intimate partner violence assessment as part of routine patient care in public health, private practice and managed care settings. Who and How Often to Assess: • Assess female caregivers/parents who accompany their children during new patient visits; at least once per year at well child visits; and, thereafter, whenever they disclose a new intimate relationship. • Assess female and male caregivers/parents known to be in same-sex relationships who accompany their children during new patient visits; at least once per year at well-child visits; and, thereafter; whenever they disclose a new intimate relationship. • Assess adolescents during new patient visits; at health maintenance visits once per year; or whenever they disclose a new intimate relationship. • Ask pregnant teens at first pre-natal visit; at least once per trimester; and at the postpartum visit.i • Also ask whenever signs and symptoms raise concerns:ii • Specifically, assess when the child or adolescent has: • Obvious physical signs of physical or sexual abuse; • Behavioral or emotional problems, such as increased aggression, increased fear or anxiety, difficulty sleeping or eating, or other signs of emotional distress; or • Chronic somatic complaints. • When adults present with obvious physical injuries or a history of intimate partner violence. (See Appendix IV: Dilemmas When Assessing All Patients for Victimization.) i Recommended by the American College of Obstetricians and Gynecologists ii See Appendix V: Indicators of Abuse. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health 21Consensus Recommendations Consensus Recommendations Who and How Often to Assess: BOX 5 TYPE OF VISIT WHO TO ASSESS WHEN TO ASSESS New Born Caregiver At postpartum visit New Patient Caregiver & Adolescent At first visit Well Child: Child Caregiver At 2, 6 and 12 months, then yearly Adolescent Adolescent Yearly Prenatal Adolescent Mother Once per trimester Mental Health Caregiver & Adolescent At initial visit Emergency Caregiver & Adolescent At every visit Other Visits Caregiver or Adolescent Whenever there are physical or behavioral indicators or chronic somatic complaints How to Assess: • Direct questions should be asked, whether or not signs or symptoms are present and whether or not the provider suspects abuse has occurred. • Inform patient about the limits of practitioner/patient confidentiality related to intimate partner violence prior to assessing. • Use language that is direct, specific and easy to understand. • Conduct assessment in a private room. • For a parent, it should take place without the intimate partner or other adult family members present. • For adolescents, it should take place without the parent (or partner) in the room. • Can be included as part of a written health questionnaire or health history, but this should not replace face-to-face assessment. • Should be conducted in a patient’s primary language. Consensus Recommendations • If an interpreter is used, it should not be an acquaintance or relative of the family. Children should never be used as interpreters. What to Ask:iii Intimate partner violence questions can be framed within discussion of other safety issues such as car and bicycle helmet safety, and assessing for guns at home or community violence. iii There are no controlled studies of the efficacy of screening questions in pediatric or family practice settings. The questions we propose are drawn from three sources: Family Violence Prevention Fund, Preventing Domestic Violence: Clinical Guidelines on Routine Screening. San Francisco, October, 1999. Groves, B. (1994). Children who Witness Violence, in Developmental and Behavioral Pediatrics: A Handbook for Primary Care. Parker, S. and Zuckerman, B., eds. Boston, Little Brown & Co. 334-336. McNamara M. (2001). “Clinical guidelines for screening and responding to child and youth exposure to domestic violence for healthcare providers”. LINC (Living in a Nonviolent Community), UCSF Department of Pediatrics, November 2001. Family Violence Prevention Fund Consensus Recommendations Consensus Recommendations For adults who accompany their children: INTRODUCTORY STATEMENTS OR QUESTIONS: • “I have begun to ask all of the women/parents/caregivers in my practice about their family life as it affects their health and safety, and that of their children. May I ask you a few questions?” • “Violence is an issue that unfortunately effects everyone today and thus I have begun to ask all families in my practice about exposure to violence. May I ask you a few questions?” INDIRECT QUESTIONS: • “What happens when there is a disagreement with your partner/husband/boyfriend or other adults in your home?” • “Do you feel safe in your home and in your relationship?” DIRECT QUESTIONS: • “Have you ever been hurt or threatened by your partner/husband or boyfriend?” • “Do you ever feel afraid of (or controlled or isolated by) your partner/husband/ boyfriend?”iv • “Has your child witnessed a violent or frightening event in your neighborhood or home?” For adolescents: INTRODUCTORY STATEMENTS OR QUESTIONS: • “Many teens your age experience threats, name calling, uninvited touching, sex or violence, so I ask all my teen patients about it. May I ask you a few questions?” • “ I don’t know if this is a concern for you, but many teens I see are dealing with violence or bullying issues, so I’ve started asking questions about violence routinely.” • “Sometimes when I see an injury like yours, it’s because somebody got hit. How did you get this injury/bruise?” • “ Now I am going to ask you confidential questions. The answers are confidential, unless your health is in immediate danger.” • “How are disagreements handled in your family?” INDIRECT QUESTIONS: • “Are you in a relationship or seeing anyone?” or “Do you have a boyfriend or girlfriend? What happens when you disagree with them?” • “How are your parents getting along?” iv In case of same sex relationships we recommend using “partner” or mirroring the language of the adult being screened. For example, if a parent refers to her same sex partner as “roommate,” use “roommate.” If the sexual orientation is unknown, we recommend “partner.” Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Consensus Recommendations • “How often do you have yelling or screaming fights? Do any of them involve pushing or slapping?” DIRECT QUESTIONS: • “Sometimes if someone is being hurt in her/his own relationship, they may have seen it happen in their own family. Have you seen anyone get hurt in your home?” • “Teens see a lot of violence these days. Seeing parents or other adults fight can feel as bad as being hit yourself. Has this happened to you?” • “We all have disagreements sometimes with family members or friends. Have you ever been hurt or threatened by anyone?” • “Have you ever been hurt – hit, kicked, slapped, shoved, pushed by a friend or person you know?” • “Have you ever been forced to do something sexual that you didn’t want to do?” —as part of sexual history. • “Do you ever feel afraid of or controlled by someone you’re dating or a friend?” • “Has anyone hit you at home in the last year?” QUESTIONS BASED ON INDICATORS: • “I noticed that you have an injury. Sometimes injuries like that come from someone hurting you. What happened to you?” Asking about Intimate Partner Violence with a Child in the Room There are different opinions about whether inquiry about sensitive issues such as intimate partner violence should take place with the child in the room or whether the questions should be asked without the child’s presence. For further discussion of this issue, see page 10. • If it is possible to see the parent without the child, (e.g. the child is old enough to wait alone; the child is in a supervised waiting area; the child is having laboratory work or vision /hearing screening done), questions can be asked in the manner mentioned in the Consensus Recommendations section “What to Ask” above. • For children under age three, asking the mother questions about safety and relationships in the presence of the child is generally not an issue. IF THE CHILD IS IN THE ROOM: • Begin inquiry with an indirect question (see section “What to Ask” above). • If parent appears uncomfortable or upset and it is not possible to see the parent alone in this visit, ask if there is another time to speak by telephone or to follow-up. • If parent appears comfortable with the questions, proceed to ask more specific questions about intimate partner violence. Family Violence Prevention Fund Consensus Recommendations Consensus Recommendations Who Should Assess: QUESTIONS CAN BE ASKED BY ANY HEALTH CARE PROVIDER WHO IS: • Educated about the dynamics of intimate partner violence, how children are affected and how to assess safety of children and/or know what resources are available for further assessment and counseling services; • Trained on how to ask about abuse, how to assess the safety needs of an abuse victim, and how to assist the victim, and who recognizes her autonomy and right to make her own decision or is trained to refer the patient to someone who can assess safety needs and further assist her; • Sensitive to issues of culture and class in interactions with patients; and • Knowledgeable about community resources. RESPONDING TO INTIMATE PARTNER VIOLENCE WHEN YOUR PATIENT IS A CHILD OR ADOLESCENT If the patient or his/her mother tells you that s/he has been abused, you become an important part of her/his support system. Living with intimate partner violence or making the decision to leave a relationship are ongoing issues for both patient and family that affect their health care. Providers need to respect the integrity and authority of victims of intimate partner violence to make decisions about their own relationships, even if the provider does not agree with those decisions. The health care provider can play an important role in the victim’s decision making process by asking the right questions, providing information about the nature of intimate partner violence, giving messages of support, and letting her know about resources available to her. At times it will be appropriate for the health care provider to make recommendations about what to do, but only after understanding the reality of the victim’s situation and only with the understanding that, ultimately, the victim must and will make her own choices, not withstanding child abuse laws. Support the Victim: • Express concern for the patient’s or parent’s safety. • If the victim is comfortable, encourage her/him to talk about what has happened. • Listen without making judgments. • Tell victims that they are not alone and that you and other people can help them. • Tell her/him that the violence is not their fault, s/he does not deserve to be abused and that only her/his abuser can stop the abuse, and that there is no excuse for intimate partner violence. • Make sure s/he knows that there is help available and that there are people s/he can turn to for support. • Remind the victim that you are a resource, should s/he need further assistance. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Consensus Recommendations • Inform the attending parent or adolescent of any reporting laws and requirements. Provide Information on Intimate Partner Violence: • Intimate partner violence is common (among all social strata, educational levels and ethnic groups). • Most violence continues for a long time and often gets more frequent and more severe. • Violence happens in all kinds of relationships – including teen relationships and lesbian and gay relationships. • Violence in the home can harm all family members including children, both physically and emotionally • There are resources for families, and this clinic/practice/provider can help find them. • Intimate partner violence affects victim health and the health of the family. What to Say to the Child Who has Witnessed Intimate Partner Violence: If a parent discloses intimate partner violence, the provider with the parent’s permission can specifically acknowledge the disclosure with the child by saying: • “What are your worries about the fighting at home?” • “I am concerned about the safety of people in your home and I am glad your mother told me about this.” • “What is going on in your house is not your fault.” • “You are not responsible for solving these problems. I am going to work with your mother (father, caretaker, etc.) to try to make things better.” The way in which the provider discusses these issues with children will vary by their age and level of cognitive development. For a four-year-old, it is probably sufficient to provide simple acknowledgment and reassurance about safety. For an eight-year-old, it may be appropriate to add more specific reassurances about what steps the parent is taking to handle the situation. For an older child or an adolescent, it may be important to offer the opportunity to talk about their perspectives of the situation at home. Consensus Recommendations For Adolescents Who are Victims of Violence: • Address the health issues by obtaining a complete history. • If possible, conduct a complete, unclothed, physical exam. Look for – and document – evidence of current or previous injuries and of sexual abuse. • Ask about medical and psychological effects resulting from abuse, such as chronic pain, worsening of existing medical conditions, psychological distress, anxiety, sleeping and eating disorders, miscarriages or substance abuse. • Schedule a follow-up appointment, encourage your patient to return and make other Family Violence Prevention Fund Consensus Recommendations Consensus Recommendations appropriate referrals. • Encourage the patient to talk to his/her parents or trusted adult about dating violence. • For severe violence, inform adolescents that you must inform their parents or guardian to keep them safe. In this case, you may need to inform state protective service if the caretaker will not protect the child. Assess and Address Safety Issues: Before your adolescent patient or a parent leaves, talk with her/him about immediate and future safety. These questions can also be asked over time and during subsequent visits. • Ask her/him about her/his immediate plans. Is s/he going home to the person who hurt her/him? Does s/he have a friend or relative s/he can talk to? If s/he is going to leave, where is s/he going to go? • Depending on the amount of time the clinician has, the following issues can be pursued to assess current danger: • What happened during the latest incident? Is the abuse increasing in frequency or severity? • Were weapons involved? • Have there been prior incidents? • Have you sought any kind of assistance for previous battering? Have you ever left before? • Has the abuser ever threatened or physically injured the children? • Assess for suicidal ideation and risk of homicide: • Have you ever considered, threatened or attempted suicide? • What injuries did you sustain during the worst incident of violence? • Has the violence increased in frequency and/or severity? • Has the abuser ever threatened to kill you? Do you believe s/he is capable of killing you? Has the abuser used a weapon or threatened you with a weapon before? • Are you planning to leave/divorce him in the near future? • Are there firearms or other weapons in the house? • Help parents think about safety issues for their children. For example: • Do the kids usually get involved when a violent incident occurs? • What do they do when violence erupts? • Do you talk with them about it? What do you say? • Children should be taught that their job in a violent situation is to stay safe, not to protect their parents or stop the fighting. They should be taught now to call 911(where age appropriate). • Help the victim think about options and their implications. • Inquire about the possibility of referring a victim to appropriate services from a battered women’s shelter or support network and/or other culturally relevant agency such as a Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Consensus Recommendations community center, church or other organization serving the victim’s community. (See Appendix VII for a Safety Plan and Instructions). Referrals for Adult Parents and Adolescents: Help your patient find culturally appropriate support from a hospital or community-based social worker or advocate who can help the victim with: • Emergency shelter or permanent housing • Emergency financial assistance or transportation • Counseling and/or support groups for victims and their children • Child care, visitation centers • Legal assistance • Mental health and substance abuse treatment • Social services • Batterer intervention programs • Independent living centers Note: Couples treatment and mediation are not usually recommendedv When possible, refer patients to organizations that reflect their cultural background or address their special needs such as organizations with multiple language capacity and those who specialize in working with teen, disabled or LGBT (lesbian, gay, bisexual, or transgender) clients. Allow her/him to use your phone to make calls. If you don’t have information about intimate partner violence programs in your area, call the National Domestic Violence Hotline at 800-799-SAFE (800-799-7233 or TDD: 800-787-3224). Consensus Recommendations v Mediation and couples counseling imply that both parties are responsible for the perpetrator’s violent behavior, a message that blames victims and fails to hold offenders accountable for their crimes. Mediation also presumes that both parties have equal power and can negotiate a mutually agreeable settlement. Where there is domestic violence, sexual assault, or stalking behavior, however, one party has controlled the other through sexual, physical, emotional and/or economic abuse. Even the most skilled mediator or therapist cannot shift the balance of power when one party has abused or assaulted the other, making mediation and joint counseling dangerous and ineffective in such cases. Family Violence Prevention Fund Consensus Recommendations Consensus Recommendations Referrals For Children: Children react to witnessing intimate partner violence in many different ways. The family’s capacity to support these children also varies, as do their beliefs or ways of seeking help. If the parent is concerned about her child, options for help should be discussed, including a counseling referral, mental health assessment or other support services (such as Big Brother/Big Sister). A referral would be strongly recommended in the following circumstances: • If the child has witnessed severe violence resulting in injury or hospitalization of either the child, sibling or the parent. • If the child’s symptoms have persisted for more than three months. • If there has been a change in behavior or an increase in aggression or depression. • If the caretaker is unable to be emotionally attuned to the child’s needs. • If the violence has resulted in the death of a parent. Reporting Requirements for Child Abuse and Intimate Partner Violence: Know your state’s child abuse and intimate partner violence reporting laws. (Discussion of the complexity of these issues can be found in Appendices VIII, IX & X). Contact your local prosecutor or state attorney general, and local law enforcement to interpret the law. • Before asking about intimate partner violence, you may want to disclose any limits of confidentiality. Since many adolescents who are victimized by an intimate partner do not want their family to know about an intimate relationship, it is important that you understand and explain the limits of confidentiality of both their medical record and reporting before screening.vi • If the child has been injured, or if your state requires mandated reporting in all cases of a child’s exposure to intimate partner violence, you must: • Follow the state guidelines for completing a report. • Encourage the victim to place a call to CPS themselves from the practitioners office, thus protecting her from charges of “failure to protect” while simultaneously protecting the child and meeting statutory child abuse reporting laws. • If possible, when making the report yourself, tell the attending parent what you will say in the report and/or allow her to read/hear what you will say. • When making the report to CPS, inform the screener or intake worker about the specifics of the domestic abuse and give as much information as possible about the risks for safety of the mother and child, the perpetrator, his current location, the anticipated response and the potential for subsequent violence. vi Federal health privacy regulations allow parents of teens to access health information unless the teen is emancipated or legally seeking care without parental consent such as services offered in Title XX, family planning clinics or STD clinics. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Consensus Recommendations How to Document Intimate Partner Violence: Documentation provides information on the effects of intimate partner violence over time and improves continuity of care. Make sure you are following your institution, state and federal privacy policies. • Documentation is recommended. However, use caution in documenting intimate partner violence in a child’s chart if the abuser is the biological or custodial parent. It may be advantageous to document on a separate form. • For adolescents, documentation should be handled consistently with documentation of other sensitive issues, such as sexual activity, alcohol or drug use.vi • When documenting, use direct quotes like “ Mother/Patient states…”. Avoid judgmental terms such as “patient alleges” or “patient claims.” • With permission, photograph or draw picture of any injuries. What to Do if a Patient Says “No” or Will Not Discuss Abuse: Many victims of intimate partner violence will talk about their experiences if asked to do so in a sensitive and empathetic way. However, some victims may be reluctant to talk about their experiences regardless, because they are embarrassed or ashamed, or afraid that if they tell anyone they may face more severe abuse. There may be financial issues and or immigration concerns. Patients need to decide for themselves about whether they wish to disclose. If you suspect intimate partner violence and the victim remains reluctant to discuss or disclose, let her/him know that should s/he need your assistance in the future, you are available. The goal is not to get the victim to admit to the problem, but to let her/him know that you are a resource should intimate partner violence ever be an issue for them. Consensus Recommendations Family Violence Prevention Fund PART IV PREPARING YOUR CHILD HEALTH PRACTICE PREPARINGYOUR PRACTICE Family Violence Prevention Fund PREPARING YOUR PRACTICE Family Violence Prevention Fund PART IV PREPARING YOUR CHILD HEALTH PRACTICE Preparing Your Practice It is important that the practice or clinic setting be set up to support the staff in responding effectively and efficiently to disclosures of intimate partner violence. In preparing your practice to begin routine inquiry for and response to intimate partner violence, it is advisable to obtain support from the leadership and administration, as well as to solicit staff input. Physical environment should: • Allow for confidential interviewing • Have posters on intimate partner violence that are multicultural and multilingual; that present available resources; and that include information about victims, perpetrators, and/or other family and community members affected by family violence • Have brochures/pocket cards for victims and perpetrators and resources that describe the impact of intimate partners violence on children. • Have brochures placed in exam rooms and private places such as bathrooms • Patient materials should include: brochures, discharge instructions, safety planning handouts and referral information on services for on-site or off-site advocacy, counseling, and legal and other community-based services for child witnesses, victims, perpetrators and others affected by intimate partner violence (See Appendix XII for resources or www@endabuse.org/health for materials.) Training for staff should include: • Short- and long-term developmental and behavioral effects of childhood exposure to domestic violence and child abuse • Survivors’ perspectives • Cultural competency • Dynamics of victimization and perpetration • Skills building—how to assess, intervene supportively and document appropriately • Interactive role playing and modeling of inquiry and response techniques • Information on where employees in abusive relationships can access help Training should be part of staff orientation; ongoing, repeated and institutionalized; and mandatory for all employees. Providers who will be assessing and documenting in the medical record should receive training on dynamics and clinical response. Other staff —including allied health professionals, receptionists and security, who can play an essential role in identifying and protecting victims and their children — should receive general awareness training on intimate partner violence. Interpreters in particular should be trained in advance about the dynamics of intimate partner violence, childhood exposure to violence, the importance of confidentiality and non-judgmental interpretation, and appropriate word choices for translation of routine assessment. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Preparing Your Practice Protocols should include: • Definitions, guiding principles, routine assessment, intervention and documentation strategies, reporting policies and confidentiality rules • Roles and responsibilities of staff All staff should receive an orientation on the protocol. It should also be updated regularly and informed by new knowledge, laws and policies regarding intimate partner violence. It should be accessible to all staff. Continuous Quality Improvement (CQI) Program: • Scheduled audits of medical records to review compliance with the protocol • Patient satisfaction surveys • Regular discussions during staff meetings regarding functioning of intimate partner violence program • Links to other quality improvement efforts • Links to medical information system developments • CQI goals publicized Provider resources should include: • Chart prompts in the medical record • Documentation and assessment forms • Posters and practitioner pocket cards • Materials that are easily accessible to providers and regularly updated • Consultation with on-site or off-site domestic violence advocates, legal and forensic experts, counselors with expertise in trauma treatment, and community experts from diverse communities (LGBT, disability, elder, teen, and ethnic-specific, immigrant, and others) • Feedback mechanisms for providers Preparing Your Practice Employee assistance or human resources programs (for large facilities) should: • Address intimate partner violence victimization and perpetration • Be confidential (within legal limits), easily accessible and well publicized • Be incorporated into managerial training • Include intimate partners violence information in employee publications and alerts Family Violence Prevention Fund APPENDICES APPENDICES Family Violence Prevention Fund APPENDICES 37 I. POSITION STATEMENTS OF MEDICAL AND HEALTH PROFESSIONAL ASSOCIATIONS 41 II. BIBLIOGRAPHY 44 III. ABSTRACTS OF SELECTED STUDIES ON PROVIDER AND PATIENT ATTITUDES 49 IV. DILEMMAS WHEN ASSESSING ALL PATIENTS FOR VICTIMIZATION 53 V. INDICATORS OF ABUSE 54 VI. EXPANDED ASSSESSMENT FOR VICTIMS OF DOMESTIC VIOLENCE 56 VII. SAFETY PLAN AND INSTRUCTIONS 58 VIII. INTIMATE PARTNER VIOLENCE VICTIMIZATION REPORTING REQUIREMENTS: HOW IT AFFECTS CHILD HEALTH SETTINGS 61 IX. STATE CODES ON INTIMATE PARTNER VIOLENCE VICTIMIZATION REPORTING REQUIREMENTS FOR HEALTH CARE PROVIDERS 63 X. LEGISLATION REGARDING CHILD WITNESSES TO DOMESTIC VIOLENCE 67 XI. CHILD ABUSE REPORTING LAWS 75XII. RESOURCES FOR PROVIDERS AND PATIENTS 81 ENDNOTES TRAINING AND EDUCATION MATERIALS CATALOG Family Violence Prevention Fund APPENDIX I POSITION STATEMENTS FROM HEALTH PROFESSIONAL ASSOCIATIONS —EXCERPTS— Appendix I AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON CHILD ABUSE AND NEGLECT The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women (RE9748) ABSTRACT. Pediatricians are in a position to recognize abused women in pediatric settings. Intervening on behalf of battered women is an active form of child abuse prevention. Knowledge of local resources and state laws for reporting abuse are emphasized. The abuse of women is a pediatric issue. The American Academy of Pediatrics (AAP) and its membership recognize the importance of improving the physician’s ability to recognize partner violence as well as child abuse and other forms of family violence.1 Intervention is crucial because children whose mothers are being assaulted are also likely to be victims. Identifying and intervening on behalf of battered women may be one of the most effective means of preventing child abuse. 7 Abuse of spouses and intimate partners is a pediatric issue even when children are not being physically assaulted. Pediatricians should be aware of the profound effects family violence has on children who witness it or even overhear it. Witnessing violence in the home can be as traumatic for children as being the victim of physical or sexual abuse. Children whose mothers are abused may experience serious emotional distress and manifest severe behavioral problems as a result.6,8 Adolescents who observe abusive relationships at home may repeat that dynamic in dating or other relationships. (Men and older persons of both genders also can be victims of partner and intimate violence, but they are less likely to be seen in pediatric settings.) Abused women are unlikely to seek care for their injuries from pediatricians. However, mothers of children seen by pediatricians may show signs of injury such as facial bruising. They may have other less obvious signs of abuse such as depression, anxiety, failure to keep medical appointments, reluctance to answer questions about discipline in the home, or frequent office visits for complaints not borne out by the medical evaluation of their child. Women may reveal the abuse to the pediatrician if they are questioned in a sympathetic and sensitive manner, in a confidential setting, away from the abuser, and provided some assurance of safety. Questions about family violence should become part of anticipatory guidance. Pediatricians must understand the dynamics of abusive relationships. Excellent guidelines for managing situations of abuse have been published,9-13 and pediatricians need to become familiar with them. There also are increasing numbers of continuing education opportunities available to learn intervention techniques. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Appendix I Pediatricians should have a protocol or action plan that has been reviewed with local authorities on domestic violence. Because of time constraints in a busy office practice or emergency room setting, an interdisciplinary approach to family violence may be most appropriate. Pediatricians can call on nurses, social workers or advocacy groups with expertise in assisting and counseling victims. The AMA’s 1996 Diagnostic and Treatment Guidelines on Domestic Violence state that optimal care for the woman in an abusive relationship depends on the physician’s working knowledge of community resources that can provide safety, advocacy, and support. The AMA and many state medical associations provide directories of agencies that provide services or information about all forms of family violence. Pediatricians can provide education to agencies that deal with battered women about the risk of primary and secondary abuse to children whose mothers are abused. Every effort should be made to secure counseling for children who have been exposed to family violence. Such treatment may be provided in groups or individually, but the focus should be on understanding violence and how to avoid it. There is increasing evidence that children who grow up with violence are prone to violent behavior themselves, and pediatricians are in a position to break the cycle. THE AAP RECOGNIZES THAT FAMILY AND INTIMATE PARTNER VIOLENCE IS HARMFUL TO CHILDREN. THE AAP RECOMMENDS THAT: 1. Residency training programs and continuing medical education (CME) program leaders incorporate education on family and intimate partner violence and its implications for child health into the curricula of pediatricians and pediatric emergency department physicians; 2. Pediatricians should attempt to recognize evidence of family or intimate partner violence in the office setting; 3. Pediatricians should intervene in a sensitive and skillful manner that maximizes the safety of women and children victims; and 4. Pediatricians should support local and national multidisciplinary efforts to recognize, Appendix I treat and prevent family and intimate partner violence. American Academy of Child and Adolescent Psychiatry This statement has been approved by the Council on Child and Adolescent Health. The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright © 1998 by the American Academy of Pediatrics. AMERICAN ACADEMY OF FAMILY PHYSICIANS-Violence (Position Paper) Family violence permeates our society. It affects us as individuals, family physicians, parents, spouses, educators and citizens. The breadth of the problem is staggering. Public health officials identify family violence as a public health issue of epidemic proportions. Family Violence Prevention Fund Appendix I Appendix I THE FAMILY PHYSICIAN’S ROLE Family violence will affect at least one third of the patients cared for by family physicians, and the impact of family violence may become evident in the one-on-one relationship of the family physician and the patient. It is imperative that physicians be aware of the prevalence of violence in all sectors of society and be alert for its effects in their encounters with virtually every patient. Violence against women will be the form of family violence most frequently seen in family practice. Physicians need to recognize that women who are victims of domestic violence will be patients in every family practice in this country because one in every four women has been a victim of domestic violence at some point in her life, and one in seven women has been victimized in the past year. Pregnancy confers no protection. In fact, abuse often begins or escalates during pregnancy. One in six pregnant women is abused during pregnancy and 17 percent of physical or sexual abuse of women occurs during pregnancy. One study reported abuse in 37 percent of obstetric patients and showed that class, race and educational level made no difference. THE ROLE OF THE FAMILY PHYSICIAN IN THE IDENTIFICATION AND TREATMENT OF FAMILY VIOLENCE Despite barriers to the diagnosis and treatment of victims of family violence, family physicians are in an ideal position to take on this challenge and are compelled to do so by the sheer magnitude of the problem. Family physicians are better able to identify those at risk because they are trained to care for the whole family and for the individual as a part of the larger community. Because of the continuity of care family physicians provide, they can gain patient confidence over time and can serve as sympathetic listeners and patient advocates. Family physicians can provide early intervention to break the cycle of violence through routine screening and the identification of abuse. They can help by teaching parenting skills and counseling patients on the stress of caring for children or elderly parents. Physicians can talk with women and men about their experiences of previous abuse and can be a central referral source for other resources in the community. AAFP INITIATIVES TO DECREASE FAMILY VIOLENCE Among activities for the American Academy of Family Physicians (AAFP) to consider are the following: 1. Developing or adapting teaching modules for members to present to medical students, residents, hospital staff and community groups; 2. Creating an ongoing education program for members on screening, recognition and treatment of violence, including distribution of the American Medical Association’s guidelines for history-taking around issues of violence and abuse; 3. Supporting or developing university-, hospital- or office-based protocols and policies about family violence; 4. Publicizing to members the hot-line numbers for organizations that help physicians and Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Appendix I patients deal with abuse; 5. Offering continuing medical education for members to increase their skills in screening for, identifying and treating cases of domestic violence; 6. Participating in public policy initiatives and legislative reform to protect victims and rehabilitate batterers and partnering with other organizations committed to decreasing family violence; 7. Promoting reasonable and responsible control of firearms and other weapons. AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Division of Women’s Health Issues, ACOG Educational Bulletin, No. 257, December 1999 Domestic Violence – SCREENING AND IDENTIFICATION Specific measures can be taken to improve identification and facilitate disclosure of domestic violence. A prefacing statement followed by a few simple, direct questions will identify most women with a history of abuse or assault. The introduction or preface should establish that screening is universal. The screening assessment should follow with direct questioning. Children in violent homes should be evaluated by a professional who can assess the child’s behavioral patterns and help the child address the emotional impact of the violence. Referrals to such resources are essential, because the victim may not be willing or able to do so on her own, especially if she fears removal of the child more than the violence. Physicians or other health care workers who provide acute or chronic medical care to the older adult may see the older adult on a regular basis and have unique opportunities for screening and assessment. Additionally, an opportunity for screening and recognition exists during all health-related encounters of older individuals, such as routine gynecologic examinations. SUMMARY Many physicians, especially in the current managed care environment, are concerned that abuse screening and disclosure will require inordinate amounts of time, but with an established protocol and referral system this important problem can be managed. Screening all patients is the key to identifying abuse. With disclosure of ongoing domestic violence, the physician’s responsibility should incude acknowledgement of abuse, making a safety assessment, assisting with a safety plan, providing appropriate referrals, documentation, and continued support. For disclosure of past violence, the responsibilities are similar but generally do not require immediate intervention. Women with a history of past victimization need to have that history identified and acknowledged and may need referral to other professionals to assist with the resolution of their trauma-related issues. Regardless of the types of victimization a woman has experienced, providing a safe setting in which she can discuss the problem and receive support is an important part of her recovery. Through these measures, the health care team can help abused women take the first steps toward ending the violence and achieving a healthy recovery. Appendix I Family Violence Prevention Fund Appendix II APPENDIX II BIBLIOGRAPHY Identifying and Responding to Domestic Violence in Child Health Settings Augustyn M, Parker S, Groves B, Zuckerman B. Silent victims: Children who witness violence. Contemporary Pediatrics. 1997;12 (8), 35-57. Carter L, Stevenson C. The Future of Children: Domestic Violence and Children. Los Altos, CA: The David and Lucille Packard Foundation;1999;9(3). Christian CW, Scribiano P, Seidl T, Pinto-Martin JA. Pediatric injury resulting from family violence. Pediatrics. 1997;99(2). Cohall A, Cohall R, Bannister H, Northridge M. Love shouldn’t hurt: strategies for health care providers to address adolescent dating violence. J Am Med Women’s Association. 1999;54(3):144 148. Committee on Child Abuse and Neglect, American Academy of Pediatrics. The role of the pediatrician in recognizing and intervening on behalf of abused women. Pediatrics. 1998;101(6):1091-1092. Dubowitz H, King H. Family violence: a child-centered, family-focused approach. Pediatic Clinics of North America. Philadelphia, PA: W.B. Saunders Company; 1995;42(1):153-163. Duffy SJ, McGrath ME, Becker BM, Linakis JG. Mothers with histories of domestic violence in a pediatric emergency department. Pediatrics. 1999;103(5):1007-1013. Edelson JL. Children’s witnessing of adult domestic violence. J Interpersonal Violence. 1999;14(8): 839-870. Edelson JL. The overlap between child maltreatment and women battering. Violence Against Women. 1999;5(2):134-154. Erickson MJ, Hill TD, Siegel RM. Barriers to domestic violence screening in the pediatric setting. Pediatrics. 2001;108(1): 98-102. Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. San Francisco, CA: Family Violence Prevention Fund; 2002 Fantuzzo J, Boruch R, Beriama, et al. Domestic violence and children: prevalence and risk in five major U.S. cities. J Am Academy Child Adolesc Psychiatry. 1997;36(1):116-122. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Kiss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med. 1998;14(4):245-258. Groves BM. Children Who See Too Much: Lessons from the Child Witness to Violence Project. Boston: Beacon Press; 2002. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Appendix II BIBLIOGRAPHY Groves BM, Zuckerman B, Marans S, Cohen D. Silent Victims: Children who witness violence. JAMA. 1993; 269(2):262-264. Jacoby M, et al. Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents. Am J Prev Med. 1999;16(4):318-321. Jaffe P, Suderman M. Child witness of women abuse: research and community responses. In Stith S, Straus M. Understanding partner violence: prevalence, causes, consequences, and solutions. Families in Focus Services, 2. Minneapolis, MN: National Council on Family Relations; 1995. Jaffe P, Wolfe,Wilson. Children of Domestic Violence. Newbury Park, CA: Sage Publications; 1990. Kerker BD, Horowitz SM, Leventhal JM, Plichta S, Leaf PJ. Identification of violence in the home. Arch Pediatr Adolesc Med. 2000;154:457-462. Kilpatrick KI, Litt M, Williams L. Post-traumatic stress disorder in child witness to domestic violence. American Journal of Orthopsychiatry. 1997; 67(4):639-644. King H, Strauss M. Routine Screen for Domestic Violence in Pediatric Practice. Newton, MA: Newton- Wellesley Hospital or online at www.drkingsoffice.com; 2000. King HS, Strauss M. Routine Screening for Domestic Violence in Pediatric Practice. Wellesley, MA: Newton-Wellesley Domestic Violence Prevention Council, 2000. Knapp JF, Dowd MD. Family violence: implications for the pediatrician. Pediatrics in Review. 1998;19(9):316-319. Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA. 1999;285(12):1581-1584. McKibben L, Roberts L. The Pediatric Family Violence Awareness Project: Partner Violence Training for Pediatric Health Care Providers. Working Draft. 1996 Plichta SB, Duncan MM, Plichta L. Spouse abuse, patient-physician communication, and patient satisfaction. Am J Prev Med. 1996;12(5):297-303. Appendix II National Institute of Justice and Centers for Disease Control and Prevention. Prevalence, Incidence and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice and Centers for Disease Control and Prevention; 1998. Parkinson GW, Adams RC, Emerling FG. Maternal domestic violence screening in an office based pediatric practice. Pediatrics. 2001;108:1-9. Renzetti C. Violent betrayal: partner abuse in lesbian relationships. Newbury Park, CA: Sage Publications; 1998:18. Richards J. Battering in a population of adolescent females. J Am Academy Nurse Practitioners. 1991;3(4). Family Violence Prevention Fund Appendix II BIBLIOGRAPHY Appendix II Siegel RM, Hill TD, Henderson VA, Ernst, HM, Boat BW. Screening for domestic violence in the community pediatric setting. Pediatrics. 1999;104(4):874-877. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual behavior, pregnancy, and suicidality. JAMA. 2001; 286(5):572-578. Spaccarelli S, Coatsworth JD, Bowden BS. Exposure to serios family violence among incarcerated boys: its association with violent offending and potential mediating variables. Violence and Victims. 1995;10:163-182. Thompson RS, Krugman R. Screening mothers for intimate partner abuse at well-baby visits. JAMA. 2001;285(12) U.S. Department of Justice. Intimate partner violence. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2000. U.S. Department of Justice. Violence by intimates: analysis of data on crimes by current or former spouses, boyfriends, and girlfriends. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 1998. U.S. Department of Justice. Violence by intimates: analysis of data on crimes committed by current & former spouses, boyfriends & girlfriends. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics;1997.* Whitney P, Davis L. Child abuse and domestic violence in Massachusetts: Can practice be integrated in a public child welfare setting? Child Maltreatment. 1999;4(2):159-166. Wolfe DA, Wekerle C, Reizel D, Gough R. Strategies to address violence in the lives of high risk youth. In Peled E, Jaffe PG, Edleson JL (eds). Ending the Cycle of Violence: Community Responses to Children of Battered Women. Newbury Park, CA: Sage Publications; 1995. Wright RJ, Wright RO, Isaac NE. Response to battered mothers in the pediatric emergency department: a call for an interdisciplinary approach to family violence. Pediatrics. 1997;99(2):186-192. Zink T. Should children be in the room when the mother is screened for partner violence? Journal of Family Practice. 2000; 49(2):130-136. Zuckerman B, Augustyn M, Groves BM, Parker, S. Silent victims revisited: the special case of domestic violence. Pediatrics. 1995;96:511. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health APPENDIX III ABSTRACTS OF SELECTED STUDIES ON PROVIDER AND PATIENT ATTITUDES Knocking Down Walls: Barrier Myths to Screening for Violence in Primary Care Marilyn Augustyn, Tracy Magee, Mary Duffy Pediatrics, Boston University School of Medicine, Boston, MA; Nursing, Boston College, Boston, MA BACKGROUND: In 1998 the AAP in a policy statement recommended that “questions about domestic violence(DV) should become part of anticipatory guidance”. Since that time, studies have shown that providers are hesitant to follow the recommendation. Barriers have been sited from child presence in the room to fear of offending parents. OBJECTIVE: This study explored how frequently providers in an urban practice screened for DV, whether children’s age and/presence in the room, length of time providers knew the family and how providers perceived parents response influenced screening. DESIGN/METHODS: At baseline, 24 providers in an urban pediatric practice completed an interview about their current practices of screening for a child’s exposure to violence. Over the following 4 weeks, they completed a form at the conclusion of well child care visits(children birth to 12 years) which covered several areas including whether they screened for DV and a Likert scale rating provider perceptions of parents’ response to being asked these questions. RESULTS: The providers were 16 residents, 6 attending pediatricians, 1 Nurse practicioner and 1 fellow. 84% reported they asked screening questions with the child in the room. During the 4 week period of the study, 60% of the providers reported that they screened for DV with 60% also reporting screening for community violence (CV). 93% of the time, providers asked these questions with the child in the room. Of these encounters, 78% were first visits with the family. Of the 22% that were repeat visits, 80% had known the family more than 6 months. 70% of the providers rated parent response as an 8 or higher on a 10 point scale (10 being most receptive). Controlling for child age and how long the provider knew the family, providers were more likely to screen when the child was older whether or not they had known the family previously. CONCLUSIONS: Over 3 years after the statement was issued recommending universal screening for DV, providers continue to struggle with several barriers. In this pilot data of an urban practice, only 60% of visits were screened and these primarily were visits among older children. Interestingly, child presence in the room did not appear to be a barrier nor did parent response to the questions. Since the greatest risk for DV is often when children are less than 5 years of age, providers perhaps need to consider alternative methods to screen more effectively. Family Violence Prevention Fund Appendix III Appendix III ABSTRACTS OF SELECTED STUDIES ON PROVIDER AND PATIENT ATTITUDES Appendix III Maternal Screening for Domestic Violence during Pediatric Visits: Physicians’ Practices and Perspectives Linda Chamberlain, Ph.D. MPH OBJECTIVES: Very little is known about how physicians respond to domestic violence in the pediatric setting. Our objectives were to examine physicians’ maternal screening and intervention practices for domestic violence and to investigate perceived barriers to screening during child health care visits. METHODS/DESIGN: A 17-question survey about current screening and intervention practices, training and perspectives on perceived screening barriers was conducted by mail. SAMPLE STUDIED: All physicians practicing in Alaska who provided health care to children, age 18 or younger. PRELIMINARY RESULTS: Surveys were completed by 393 (73%) of the 540 eligible physicians, including 208 family practitioners and general practitioners; 70 pediatricians and 48 emergency medicine physicians. Forty-nine percent of physicians had specific training on the effects of domestic violence on children. More than one-quarter (29%) estimated that 1 in 10 children in their practices had lived in a household with domestic violence. The majority of physicians screened often or always for domestic violence when the mother had signs of injury (88%) or when they suspected child abuse (95%). Routine screening was less common at initial pediatric visits (16%), well-child visits (11%), urgent care visits (31%), and when providing counseling/anticipatory guidance to mothers of newborn infants (16%). Commonly reported intervention strategies included providing information on victim services (87%), talking to the mother about safety concerns (81%), and talking to the child alone when appropriate (51%). The majority of physicians did not consider commonly perceived barriers such as inadequate training and concerns about child witness reporting requirements as major barriers to screening. Nearly all (98%) respondents agreed that witnessing domestic violence in an important health issue for children. Eighty-five percent of physicians agreed that they have a responsibility as part of their practice to screen mothers for domestic violence when providing health care to children. There was nearly total agreement (99.5%) among respondents that helping a mother who is being battered can make a difference in the lives of her children. CONCLUSION: While physicians frequently screen mothers for domestic violence when there is evidence of maternal injury or suspected child abuse, opportunities to screen at other child health care visits are being missed. Most physicians agreed that domestic violence is an important children’s health care issue that should be addressed in the pediatric setting. Many commonly perceived barriers to screening may not be predictive of physicians’maternal screening practices Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Appendix III ABSTRACTS OF SELECTED STUDIES ON PROVIDER AND PATIENT ATTITUDES Mothers’ and health care providers’ perspectives on screening for intimate partner violence in a pediatric emergency department M. Denise Dowd, MD, MPH; Christopher Kennedy, MD; Jane F. Knapp, MD From the Division of Emergency Medicine, Children’s Mercy Hospital, Kansas City, MO NOTE: This abstract with full article will be published in Archives of Pediatric and Adolescent Medicine, August, 2002. For full citation with pages send email to apam@u.washington.edu OBJECTIVE: To determine the attitudes, feelings and beliefs of mothers and pediatric emergency department health care providers toward routine intimate partner violence screening. METHODS: This qualitative project employed focus groups of mothers who brought their children to a children’s hospital emergency department for care and physicians and nurses who staffed the same department. We held six ethnically homogeneous mother groups: two Caucasian, two African-American, two Latina and four provider groups: two predominately female nurse groups and two physician groups: one male and one female. Professional moderators conducted the sessions using a semi-structured discussion guide. All groups were audio- and videotaped and tapes were reviewed for reoccurring themes. RESULTS: A total of 59 mothers, 21 nurses and 17 physicians participated. Mothers identified intimate partner violence as a common problem in their communities and most remarked that routine screening for adult intimate partner violence is an appropriate activity for a pediatric emergency department. However, many expressed concern that willingness to disclose might be affected by a fear of being reported to child protective services. They stressed the importance of addressing the child’s health problem first, that screening be done in an empathetic way and that immediate assistance be available if needed. Themes identified in the provider groups included concerns about time constraints, fear of offending and concerns that unless immediate intervention was available the victim could be placed in jeopardy. Many said they would feel obligated to notify child protective services upon disclosure of intimate partner violence. Appendix III CONCLUSIONS: Intimate partner violence screening protocols in the pediatric emergency department should take into consideration the beliefs and attitudes of both those doing the screening and those being screened. Those developing screening protocols for a pediatric emergency department should consider:1) Those assigned to screen must demonstrate empathy, warmth and a helping attitude. 2) The importance of addressing the child’s medical needs first and a screening process that is minimally disruptive to the emergency department. 3) A defined, organized approach to assessing danger to the child and how and when it is appropriate to notify CPS when a caregiver screens positive. 4) Resources must be available immediately to a victim who requests them. Family Violence Prevention Fund Appendix III ABSTRACTS OF SELECTED STUDIES ON PROVIDER AND PATIENT ATTITUDES Appendix III Pediatrician’s views on the treatment and preventions of violent injuries to children LM Olson, KG O’Connor, H Spivak & MZ Esquivel, American Academy of Pediatrics, Elk Grove Village, IL. (PERIODIC SURVEY OF FELLOWS, American Academy of Pediatrics, Division of Health Policy Research from PEDIATRIC ACADEMIC SOCIETIES , May 2001) OBJECTIVE: To assess the portion of pediatricians treating violent injuries and their perceived capacity to address violence in the office setting. DESIGN: National random sample, mailed survey. PARTICIPANTS: 574 U.S. members of the American Academy of Pediatrics who provide direct patient care. RESULTS: Many pediatricians report they treated (in the past 12 months) injuries due to child abuse (61%), domestic violence (43%) or community violence (45%). Substantial numbers of respondents believe that pediatricians should address, in the community and in practice, violence against children. However, while pediatricians generally feel confident about their skills in treating child abuse, they are less likely to feel adequately prepared to treat children at risk for domestic violence. Proportion of Pediatricians Indicating Agreement (%) CHILD ABUSE DOMESTIC VIOL. COMMUNITY VIOL. Are confident in ability to identify children at risk for….............. 63.7 35.1 32.6 Are confident in ability to manage cases of…............................. 62.6 43.1 46.4 Have received adequate training in the area of…......................... 48.5 19.7 15.8 CONCLUSION: Injury from violence is a problem confronting large numbers of pediatric practices. The identified gaps can help shape new training programs and interventions to help practitioners address this critical risk to children. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Appendix III Appendix III ABSTRACTS OF SELECTED STUDIES ON PROVIDER AND PATIENT ATTITUDES Should Children Be in the Room When the Mother Is Screened for Partner Violence? Zink, Therese MD, MPH The Journal of Family Practice, © 2000 by Appleton & Lange. All rights reserved. Volume 49(2) February 2000 pp 130-136 BACKGROUND: The goal of our study was to understand the important issues to consider when screening women for intimate partner violence in front of their children. METHODS: Interviews and focus groups were conducted with experienced family physicians and pediatricians and family violence experts (child psychologists, social workers, and domestic violence agency directors). Session transcripts were coded and categorized. RESULTS: Experts disagreed on the appropriateness of general screening for intimate partner violence in front of children older than 2 to 3 years. The majority thought that general questions were appropriate, if the in-depth questioning of the abused parent was done in private. Screening for child abuse when domestic violence is identified (and for domestic violence when child abuse is discovered) was recommended. Documentation about intimate partner violence in the child’s medical chart raises questions about confidentiality, since the person committing the abuse may have access, if he or she is a legal guardian. Physicians need more education on the symptoms of children who are exposed to violence between adults. CONCLUSIONS: More research is needed to understand appropriate questions and methods of screening for intimate partner violence in front of children. The tension is between practical recommendations for routine screening and preserving the safety of the parent and the children. Intimate partner violence screening by physicians is important. Interrupting the cycle of violence may give a child a better chance at maturing into a healthy adult. Family Violence Prevention Fund Appendix IV APPENDIX IV DILEMMAS WHEN ASSESSING ALL PATIENTS FOR VICTIMIZATION Routinely assessing all parents and caretakers (both female and male) for IPV victimization raises additional policy and practice issues for providers and there is debate in the field about appropriate responses. Those opposed to these policies assert that the risks of alerting perpetrators to protocols identifying and assessing IPV outweigh the benefits. The concerns are that perpetrators may limit their partners’ access to health care, may threaten victims who disclose, or may learn about safety planning materials which could ultimately undermine victim safety. Proponents of policies to assess men and women assert that, because men in same sex relationships experience DV at equal rates as women in heterosexual relationships, and some men in heterosexual couples experience abuse, it is critical to identify and assist as many victims as possible. Proponents also argue that determined perpetrators can already access safety planning materials and that assessing all patients offers unparalleled opportunities for abuse prevention. Still others maintain that because the majority of IPV victims are women, providers should begin by assessing all female patients and integrate inquiries for men as a second step, after gaining more experience in screening for victimization and developing policies to address some of the difficult practical concerns that are raised when assessing all parents and caretakers. Providers and health facilities should consider the dilemmas and recommendations listed below as they develop their unique protocols. DILEMMAS: It may be difficult to assess who the victim is. The accounts of one or both parties may lead to significant confusion about the incident. • Male perpetrators often claim victimization to avoid consequences or as a tactic to further control victims.69 Because of the majority of IPV perpetrators are male, assessing men increases the likelihood of assessing perpetrators who may claim they are victims. There is not sufficient experience with female perpetrators of violence to know if this is also true in with female batterers. • Victims may take the blame for the abuse because they have been told repeatedly by their partners that the problems in the relationship are their fault or because they used violence or other tactics in self-defense. • Both parties may use physical force in an incident. Whether the patient is viewed as a victim or perpetrator will influence the health care providers’ response and may lead to inappropriate treatment. • A victim who takes the blame for the abuse might prevent providers from offering them support and information about IPV • Perpetrators who falsely claim they are victims might lead providers to sharing safety-planning strategies with perpetrators, inadvertently colluding with them and Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health Appendix IV DILEMMAS WHEN SCREENING ALL PATIENTS FOR VICTIMIZATION undermining victims’ safety planning efforts. • What is recorded in the medical record by the health care provider can have legal ramifications for the victim particularly in divorce, custody or other legal cases. While it is not the role of the health care provider to determine if the patient is telling the truth, the provider should take care in evaluating the patient’s information and in identifying whether or not she/he is a victim of IPV, just as they take care in evaluating other patient’s reports of health concerns. Understanding the definition of IPV and being skilled in behavioral inquiry assists providers in making accurate identification of victimization. RECOMMENDATIONS FOR POLICY IMPLEMENTATION: The Family Violence Prevention Fund recommends that providers implement policies to assess all male and female parents for victimization only after taking precautions to protect victims whose perpetrators claim to be abused. Training providers on perpetrator dynamics and responses to gay, lesbian and straight victims is critical for all IPV programs, including those that target women only. When implementing a policy to assess all patients, first: • Contact local DV programs (and batterer’s intervention programs that they recommend) and explain that you are considering a plan to assess all patients for victimization. This will prepare them for referrals and will give them an opportunity to inform the development of your protocol. • Inform all patients that you assess men and women for victimization and make safety planning materials available to both, so that victims who are concerned about perpetrators sabotaging their safety plan efforts can plan accordingly. Make information available about advocates on-site or in the community that can help the victim with these plans, regardless of whether the victim discloses abuse. • Understand and conduct training on the IPV prevalence studies. Emerging research demonstrates that IPV occurs at similar rates in LGTB adolescent and adult populations70 with higher rates in male same sex relationships than female.71 Most studies indicate Appendix IV that about 5-10%72 of all victims are men (an unknown percentage of whom are gay). Because of this, you should expect to see a fairly small percentage of heterosexual male victims in your practice – but should be prepared to respond to all victims. • Understand and conduct training on the dynamics of IPV: IPV serves the purpose of establishing power and control through various tactics. This establishment of an abusive imbalance of power and control is fundamentally what distinguishes IPV perpetrators from victims. There are multiple indicators of abusive behavior (denying access to friends/family, intimidation, etc) not just physical abuse, and victims’ lives generally become more limited and controlled. Family Violence Prevention Fund Appendix IV DILEMMAS WHEN SCREENING ALL PATIENTS FOR VICTIMIZATION Appendix IV Recommendations for Clinical Practice: • Do not blame patients or force them to prove their “victimhood.” • Assessments should be handled sensitively and without bias. • Even if you are unsure if your patient is a victim, document that you inquired, the patients’ response, and note the details of the abuse and health consequences. Offer the patient educational materials about IPV and referrals. HEALTH CARE PROVIDER RESPONSE TO GAY, LESBIAN AND HETEROSEXUAL MALE VICTIMS Lesbian, Gay Bisexual and Transgendered victims of abuse: Emerging research demonstrates that IPV occurs at similar rates in LGTB adolescent and adult populations as in heterosexual populationsvii with higher rates in male same sex relationships than femaleviii. However, it is important to realize that the statistics may be low because those in a same sex relationships may not be comfortable stating their sexual preference. A policy to assess all patients should include specific recommendations for responding to lesbian, gay bisexual, and transgendered (LGBT) victims. Specialized services may be limited in your area so, when unavailable, refer patients to national organizations or the National Domestic Violence Hotline. PRIOR TO IMPLEMENTING A PROGRAM TO ASSESS ALL PATIENTS, IT IS IMPORTANT TO: • Beware of your own bias and/or homophobia • Call your local IPV program and determine what resources are available for lesbian, gay, bisexual and transgendered clients • Call any local programs for LGBT communities and determine what resources they offer for victims of IPV • In addition (or if no programs exist in your area), provide LGBT victims with the national DV hotline number for more information or materials. • Have educational and safety materials available that are appropriate for LGBT victims (for materials, go to the FVPF website www.endabuse.org/health) • Refer gay male victims of IPV to Community United Against Violence (San Francisco), Gay Men’s Domestic Violence Project (Boston) or other organizations for information and support (See Appendix XII). vii Bureau of Justice Statistics Special Report, Intimate Partner Violence and Age of Victim, 1993-99, United States Department of Justice, October 2001. viii Morrow, Jeanie (April 1994). Identifying and treating battered lesbians. San Francisco MedicineLetellier, Patrick (April 1994). Identifying and treating battered gay men in a medical setting. San Francisco Me