Screening for domestic violence in a general pediatric clinic: be prepared!

Intimate partner violence and children's health outcomes

A growing body of literature has established that childhood health is a crucial determinant of human capital formation. Shocks experienced in utero and during early life may have far-reaching consequences that extend well into adulthood. Nevertheless, there is relatively little evidence regarding the effects of parental behaviour on child health. This paper contributes to the literature by examining the impact of intimate partner violence (IPV) on the child's health production function. Using data from the UK's Millennium Cohort Study and leveraging information on both child health and IPV, our analysis reveals that exposure to IPV is negatively associated to child's health. Children witnessing IPV in their household see their probability of being in excellent health reduced by 7 percentage points. Our results also suggest that children exposed to IPV are subject to increased morbidity, manifested in elevated risks of hearing and respiratory problems, as well as long-term health conditions and are less likely to get fully immunised.

Feasibility of Screening Programs for Domestic Violence in Pediatric and Child and Adolescent Mental Health Services: A Literature Review

Each year, 275 million children worldwide are exposed to domestic violence (DV) and suffer negative mental and physical health consequences; however, only a small proportion receive assistance. Pediatricians and child psychiatrists can play a central role in identifying threatened children. We reviewed experiences of DV screening in pediatric and child and adolescent mental health services (CAMHS) to understand its feasibility and provide clues for its implementation. We performed bibliographic research using the Sapienza Library System, PubMed, and the following databases: MEDLINE, American Psychological Association PsycArticles, American Psychological Association PsycInfo, ScienceDirect, and Scopus. We considered a 20-year interval when selecting the articles and we included studies published in English between January 2000 and March 2021. A total of 23 out of 2335 studies satisfied the inclusion criteria. We found that the prevalence of disclosed DV ranged from 4.2% to 48%, with most prevalence estimates between 10% and 20%. Disclosure increases with a detection plan, which is mostly welcomed by mothers (70–80% acceptance rates). Written tools were used in 55% of studies, oral interviews in 40%, and computer instruments in 20%. Mixed forms were used in three studies (15%). The most used and effective tool appeared to be the Conflict Tactics Scale (CTS) (30% of studies). For young children, parental reports are advisable and written instruments are the first preference; interviews can be conducted with older children. Our research pointed out that the current literature does not provide practical clinical clues on facilitating the disclosure in pediatric clinics and CAMHS. Further studies are needed on the inpatient population and in the field of children psychiatry.

Australian hospital staff perceptions of barriers and enablers of domestic and family violence screening and response

Background

Hospital presentations provide unique opportunities to detect DFV. However, up to 70% of women experiencing Domestic and Family Violence (DFV) go undetected by hospital staff. While routine DFV screening is internationally encouraged, there is still much debate surrounding its implementation. The aim of the study was to determine staff perceptions of barriers and enablers of DFV screening and response.

Methods

A cross-sectional survey was conducted at a tertiary level public hospital and health service. Health care staff in allied health, maternity and mental health divisions (n = 615) were invited to participate by email and through team meetings. 172 responses were analysed.

Results

Less than a third of respondents reported routinely asking patients about DFV, with 34.9% reporting they did not have sufficient training to assist with DFV. Increased levels of training were positively correlated with screening practices, preparedness and knowledge. Major barriers were presence of partner and language barriers, while written protocols and supportive work environment were the principal enablers of screening.

Conclusion

Staff generally believed that routine screening was important and should encompass all forms of abuse. Many felt ill-equipped to ask about or manage disclosure of DFV. More training improves staff capacity for DFV detection and response, and written guidelines should be made available to all staff.

Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review

Background

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. Screening for IPV within healthcare settings can identify women who experience IPV and inform counseling, referrals, and interventions to improve their health outcomes. Unfortunately, many screening programs used to detect IPV have only been tested in research contexts featuring externally funded study staff and resources. This systematic review therefore investigated the utility of IPV screening administered by frontline clinical personnel.

Methods

We conducted a systematic literature review focusing on studies of IPV screening programs for women delivered by frontline healthcare staff. We based our data synthesis on two widely used implementation models (Reach, Effectiveness, Adoption, Implementation and Maintenance [RE-AIM] and Proctor's dimensions of implementation effectiveness).

Results

We extracted data from 59 qualifying studies. Based on data extraction guided by the RE-AIM framework, the median reach of the IPV screening programs was high (80%), but Emergency Department (ED) settings were found to have a much lower reach (47%). The median screen positive rate was 11%, which is comparable to the screen-positive rate found in studies using externally funded research staff. Among those screening positive, a median of 32% received a referral to follow-up services. Based on data extraction guided by Proctor's dimension of appropriateness, a lack of available referral services frustrated some efforts to implement IPV screening. Among studies reporting data on maintenance or sustainability of IPV screening programs, only half concluded that IPV screening rates held steady during the maintenance phase. Other domains of the RE-AIM and Proctor frameworks (e.g., implementation fidelity and costs) were reported less frequently.

Conclusions

IPV is a population health issue, and successfully implementing IPV screening programs may be part of the solution. Our review emphasizes the importance of ongoing provider trainings, readily available referral sources, and consistent institutional support in maintaining appropriate IPV screening programs.

Plain language abstract

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. IPV screening and response can identify women who experience IPV and can inform interventions to improve their health outcomes. Unfortunately, many of the screening programs used to detect IPV have only been tested in research contexts featuring administration by externally funded study staff. This systematic review of IPV screening programs for women is particularly novel, as previous reviews have not focused on clinical implementation. It provides a better understanding of successful ways of implementing IPV screening and response practices with frontline clinical personnel in the context of routine care. Successfully implementing IPV screening programs may help mitigate the harms resulting from IPV against women. Findings from this review can inform future efforts to improve implementation of IPV screening programs in clinical settings to ensure that the victims of IPV have access to appropriate counseling, resources, and referrals.

Postpartum Domestic Violence in Homes With Young Children: The Role of Maternal and Paternal Drinking

There has been limited investigation of mothers' drinking patterns and their experience of domestic abuse while parenting young children, especially in the context of co-resident fathers' drinking. Using data representative of the 2001 U.S. birth cohort, the authors conducted longitudinal latent class analyses of maternal drinking over four perinatal time points as predictors of maternal victimization at 2 years postpartum due to intimate partner violence. Women classified as higher risk drinkers over the study period faced significantly increased risk of physical abuse while parenting a 2-year-old child. Among non-drinking mothers, paternal binge drinking signaled additional risk, with clinical and programmatic implications.

Coordinated public health initiatives to address violence against women and adolescents

Intimate partner violence (IPV) is a well-recognized public health problem. IPV affects women's physical and mental health through direct pathways, such as injury, and indirect pathways, such as a prolonged stress response that leads to chronic health problems. The influence of abuse can persist long after the violence has stopped and women of color are disproportionately impacted. Successfully addressing the complex issue of IPV requires multiple prevention efforts that target specific risk and protective factors across individual, interpersonal, institutional, community, and societal levels. This paper includes examples of community-based, state led and federally funded public health programs focused on IPV along this continuum. Two community-based efforts to increase access to mental health care for low income, women of color who had experienced IPV, Mindfulness-Based Stress Reduction, and a telehealth intervention are discussed. Core tenets of a patient-centered comprehensive approach to assessment and responses and strategies for supporting a statewide comprehensive response are described in Project Connect: A Coordinated Public Health Initiative to Prevent Violence Against Women. Project Connect provides technical assistance to grantees funded through the Violence Against Women Act's health title and involves developing, implementing, and evaluating new ways to identify, respond to, and prevent domestic and sexual violence and promote an improved public health response to abuse in states and Native health programs. Health care partnerships with domestic violence experts are critical in order to provide training, develop referral protocols, and to link IPV victims to advocacy services. Survivors need a comprehensive response that addresses their safety concerns and may require advocacy around housing or shelter, legal assistance, and safety planning. Gaps in research knowledge identified are health system readiness to respond to IPV victims in health care settings and partner with domestic violence programs, effects of early IPV intervention, and models for taking interventions to scale.

Child exposure to parental violence and psychological distress associated with delayed milestones

OBJECTIVE

To examine the association between parental report of intimate partner violence (IPV) and parental psychological distress (PPD) with child attainment of developmental milestones.

METHODS

By using data collected from a large cohort of primary care patients, this cross-sectional study examined the relationship between parental report of IPV and/or PPD and the attainment of developmental milestones within the first 72 months of a child's life. Multivariate logistic regression analyses were used to adjust for parental report of child abuse concern and sociodemographic characteristics.

RESULTS

Our study population included 16 595 subjects. Children of parents reporting both IPV and PPD (n = 88; 0.5%) were more likely to fail at least 1 milestone across the following developmental domains: language (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI] 1.3-3.3), personal-social (aOR 1.9; 95% CI 1.2-2.9), and gross motor (aOR 3.0; 95% CI 1.8-5.0). Significant associations for those reporting IPV-only (n = 331; 2.0%) were found for language (aOR 1.4; 95% CI 1.1-1.9), personal-social (aOR 1.7; 95% CI 1.4-2.2), and fine motor-adaptive (aOR 1.7; 95% CI 1.0-2.7). Significant associations for those reporting PPD-only (n = 1920; 11.6%) were found for: language (aOR 1.5; 95% CI 1.3-1.7), personal-social (aOR 1.6; 95% CI 1.5-1.8), gross motor (aOR 1.6; 95% CI 1.4-1.8), and fine-motor adaptive (aOR 1.6; 95% CI 1.3-2.0).

CONCLUSIONS

Screening children for IPV and PPD helps identify those at risk for poor developmental outcomes who may benefit from early intervention.

Associations of early exposure to intimate partner violence and parental depression with subsequent mental health outcomes

IMPORTANCE

Children with known exposure to intimate partner violence (IPV) or maternal depression are at risk for negative mental health outcomes as early as preschool age. Active ongoing surveillance for these risk factors can lead to earlier mental health intervention for children.

OBJECTIVE

To examine the association between parent reports of IPV and depressive symptoms within the first 3 years of a child's life with subsequent mental health conditions and psychotropic drug treatment.

DESIGN

Prospective cohort study linking parental IPV and depression with subsequent billing and pharmacy data between November 1, 2004, and June 7, 2012.

SETTING

Four pediatric clinics.

PARTICIPANTS

A total of 2422 children receiving care from clinics that implemented the Child Health Improvement Through Computer Automation (CHICA) system.

MAIN OUTCOME MEASURES

Any report of IPV and/or parental depressive symptoms from birth to age 3 years, mental health diagnoses made with International Classification of Diseases, Ninth Revision criteria, and any psychotropic drug treatment between ages 3 and 6 years.

RESULTS

Fifty-eight caregivers (2.4%) reported both IPV and depressive symptoms before their children were aged 3 years, 69 (2.8%) reported IPV only, 704 (29.1%) reported depressive symptoms only, and 1591 (65.7%) reported neither exposure. Children of parents reporting both IPV and depressive symptoms were more likely to have a diagnosis of attention-deficit/hyperactivity disorder (adjusted odds ratio = 4.0; 95% CI, 1.5-10.9), even after adjusting for the child's sex, race/ethnicity, and insurance type. Children whose parents reported depressive symptoms were more likely to have been prescribed psychotropic medication (adjusted odds ratio = 1.9; 95%, CI 1.0-3.4).

CONCLUSIONS AND RELEVANCE

Exposure to both IPV and depression before age 3 years is associated with preschool-aged onset of attention-deficit/hyperactivity disorder; early exposure to parental depression is associated with being prescribed psychotropic medication. Pediatricians play a critical role in performing active, ongoing surveillance of families with these known social risk factors and providing early intervention to negate long-term sequelae.

Universal screening for intimate partner violence: a systematic review

Intimate partner violence (IPV) is known to be prevalent among therapy-seeking populations. Yet, despite a growing understanding of the dynamics of IPV and of the acceptability of screening, universal screening practices have not been systematically adopted in family therapy settings. A rapidly growing body of research data-almost entirely conducted in medical settings-has investigated attitudes and practices regarding universal screening for IPV. This article is a systematic review of the IPV universal screening research literature. The review summarizes literature related to IPV screening rates and practices, factors associated with provider screening practice, the role of training and institutional support on screening practice, impact of screening on disclosure rates, client beliefs and preferences for screening, and key safety considerations and screening competencies. Implications for family therapy and recommendations for further inquiry and screening model development are provided.

Applying surveillance and screening to family psychosocial issues: implications for the medical home

Within the medical home, understanding the family and community context in which children live is critical to optimally promoting children's health and development. How to best identify psychosocial issues likely to have an impact on children's development is uncertain. Professional guidelines encourage pediatricians to incorporate family psychosocial screening within the context of primary care, yet few providers routinely screen for these issues. The authors propose applying the core principles of surveillance and screening, as applied to children's development and behavior, to also address family psychosocial issues during health supervision services. Integrating psychosocial surveillance and screening into the medical home requires changes in professional training, provider practice, and public policy. The potential of family psychosocial surveillance and screening to promote children's optimal development justifies such changes.

Intimate partner violence victimization and perpetration by Puerto Rican women with severe mental illnesses

Previous research indicates a higher prevalence of victimization among severely mentally ill women. Few studies have either compared these levels across diagnostic categories or evaluated perpetration by the women. We report qualitative and quantitative findings regarding intimate partner violence perpetrated both against and by a sample of 53 Puerto Rican women diagnosed with major depression, bipolar disorder, or schizophrenia. Interviewers shadowed participants for a period of 2 years. Two-thirds of the women with serious mental illness had histories of victimization. However, 23% of the women also reported histories of violence towards their significant others. This was attributed to various reasons, such as anger, revenge, control, and self-defense. Participants described their personal conceptualization of the violence they received and perpetrated. This has implications for programs designed to prevent family violence, for health care professionals in general, and for psychiatrists, who may be called upon to address future risk of victimization or commission of violence.

Posttraumatic stress among young urban children exposed to family violence and other potentially traumatic events

This study examines the relationship between the number of types of traumatic events experienced by children 3 to 6 years old, parenting stress, and children's posttraumatic stress (PTS). Parents and caregivers provided data for 154 urban children admitted into community-based mental health or developmental services. By parent and caregiver report, children experienced an average of 4.9 different types of potentially traumatic events. Nearly one quarter of the children evidenced clinically significant PTS. Posttraumatic stress was positively and significantly related to family violence and other family-related trauma exposure, nonfamily violence and trauma exposure, and parenting stress. Additionally, parenting stress partially mediated the relationship between family violence and trauma exposure and PTS. This study highlights the need for early violence and trauma exposure screening in help-seeking populations so that appropriate interventions are initiated.

Intimate partner violence screening in the emergency department: U.S. medical residents' perspectives

Intimate Partner Violence (IPV) is physical, psychological, or sexual harm committed by a current or former partner, spouse, boy/girlfriend. In the United States, the National Center for Injury Prevention and Control (2003) estimates that 1.5 million women experience physical assault each year while the lifetime prevalence rate of IPV for women reaches almost 30%. Given the frequency and range of injuries and other health-related problems that result from IPV, the medical system shows promise as a central source of service provision for large numbers of abused women and their children. However, identification rates of IPV in many medical settings are low. This article describes a study that examined focus group data from 25 physicians in residency training at an urban hospital in the United States. Physicians discussed their knowledge and attitudes about IPV screening in the emergency department (ED) setting and suggestions to address perceived barriers to such screening. These data depict multiple barriers to physician screening of IPV in the ED. Findings substantiate previous research and provide new direction for enhancing IPV identification, referral, and treatment mechanisms in the ED setting including alternatives to physician mandated universal screening.

Potentially violent disagreements and parenting stress among American Indian/Alaska Native families: analysis across seven states

OBJECTIVES

We examined the prevalence and correlates of potentially violent disagreements among AI/AN families with children.

METHODS

We conducted a cross-sectional examination of data from the 2003 National Survey of Children's Health, limited to seven states for which AI/AN race/ethnicity was available in public use files (Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota). Disagreements were classified based on how the family deals with conflict. If disagreements involved actual (hitting) or symbolic (throwing) violence, even rarely, the household was categorized as having "potentially violent disagreements," with heated argument and shouting being classified as "heated disagreement." Parenting stress and demographic characteristics were included as potential correlates.

RESULTS

Potentially violent disagreements were reported by 8.4% of AI/AN and 8.4% of white families. The odds for potentially violent disagreements were markedly higher among parents reporting high parenting stress, in both AI/AN (OR 7.20; CI 3.45-15.00) and white (3.59, CI 2.71-4.75) families. High parenting stress had similar effects on the odds for heated discussion. Having a child with special health care needs was associated with parenting stress.

CONCLUSIONS

Questions about disagreement style may be useful as potential screens for domestic violence.

Screening for intimate partner violence in medical settings

Intimate partner violence (IPV) is associated with negative health consequences. Universal screening for IPV offers many opportunities for successful intervention, yet this practice in medical settings is controversial. This article examines the potential impact of the U.S. Preventive Services Task Force (USPSTF) recommendations for IPV screening and the emerging literature supporting measurable health benefits resulting from screening interventions in medical settings. Several screening tools and methods of administration that have been evaluated in various clinical settings, with goals to increase their sensitivity and to determine a best method of administration, are reviewed in this article. Mandatory reporting is closely linked to screening practices and may influence healthcare worker practice and patient disclosure. Mandatory reporting studies are lacking and show variable physician compliance, victim acceptance, and scant outcome data. Informed consent prior to screening, explaining the process of mandatory reporting statutes and victim options should be evaluated to increase sensitivity of screening tools.

The prevalence of violent disagreements in US families: effects of residence, race/ethnicity, and parental stress

CONTEXT

Witnessing domestic violence increases a child's chance of emotional or behavioral problems during childhood and entering abusive relationships in adulthood, even without co-occurring child maltreatment.

OBJECTIVE

Our goals were to estimate the prevalence of reported violent disagreements in the homes of US children and to assess prevalence differences by race/ethnicity, residence, and reported parenting stress.

PATIENTS AND METHODS

Data were drawn from the 2003 National Survey of Children's Health. Case subjects with unknown gender, race/ethnicity, or residence were excluded, yielding 99660 observations. Disagreements were classified on the basis of how the family deals with serious disagreement. If disagreements involved hitting or throwing, even rarely, the household was categorized as having violent disagreements. Households reporting heated argument and shouting were classified as having heated disagreement.

RESULTS

Nationally, 10.3% of children lived in homes with reported violent disagreements. Violent disagreements were most prevalent among black households (15.1%), followed by "other" (12.1%), Hispanic (11.3%), and white (8.6%) households. Urban areas had higher prevalence (10.7%) than did small through large rural counties (8.3%-9.9%). In multinomial logistic analysis, parents living in rural counties were less likely to report violent disagreements compared with those in urban. Black children were more likely to be exposed to both violent and heated disagreements than were white children. Parents reporting high parenting stress had higher odds of violent and heated disagreement than parents reporting less stress.

CONCLUSIONS

A substantial number of children are exposed to violent disagreement. Although demographic and cultural factors may also influence disagreement style, parental stress seems instrumental in the development of violent disagreements. Parents who experience difficulty with parenting constitute a high-risk population. Helping parents understand and address child behavior may reduce such stress.

Violence against women and the Millennium Development Goals: Facilitating women's access to support

Violence against women is a serious health and development concern, as well as a violation of women's human rights. Violence against women has a devastating effect on women's sexual and reproductive health, as well as the health of their children, and is rooted in gender inequality. Reducing violence against women is therefore a key strategy for the achievement of the Millennium Development Goals. Key lessons have emerged from more than two decades of experiences dealing with violence against women within the health sector. Interventions must go beyond training and curricula reform and utilize a system-wide approach, including changes in policies, procedures and attention to privacy and confidentiality. Providers must work together with other sectors, particularly at a community level, to strengthen local networks for support of survivors of violence. Prevention activities are critical, particularly those that seek to change cultural norms and laws that encourage violence and discriminate against women and girls.

Evaluation of a curriculum for intimate partner violence screening in a pediatric emergency department

OBJECTIVE

We sought to describe the assessment of course participant changes in attitudes, self-efficacy, and behaviors after completion of the Its Time to Ask training curriculum for screening for intimate partner violence (IPV) in a pediatric emergency department (PED).

METHODS

A 22-item Likert scale questionnaire was administered at baseline (before training), after training, and at 6-month follow-up to PED employee participants in a 2-hour IPV education program. Mean participant responses were compared between baseline/posttraining and baseline/6-month follow-up. Participants also completed a course-satisfaction survey.

RESULTS

A total of 79 PED staff completed the baseline questionnaire before the training. Eighty-seven participants completed the posttraining questionnaire, and 48 completed the 6-month follow-up questionnaire. Participants had consistent, positive changes in attitudes after training that persisted at the 6-month follow-up for 5 items on the questionnaire. Attitudes that did not change showed baseline means already in disagreement with questionnaire statements. Participants reported significant, positive changes for all 7 self-efficacy statements at 1 or both of the posttraining evaluations. The only changes in behavior were observed at 6 months. The majority of participants were satisfied with the training and would recommend it to colleagues.

CONCLUSIONS

Significant, self-reported changes in attitudes, self-efficacy, and behaviors/clinical practice regarding screening for IPV in a PED can be achieved through participation in a brief training curriculum.

Female caregivers' experiences with intimate partner violence and behavior problems in children investigated as victims of maltreatment

OBJECTIVE

We examined the relationship between women's experiences with intimate partner violence and their reports of child behavior problems.

METHODS

Data were from the National Survey of Child and Adolescent Well-Being, a national probability study of children who were the subjects of child abuse and neglect investigations. The sample consisted of 2020 female caregivers of children between the ages of 4 and 14 years who were interviewed about demographic characteristics, child behavior problems, female caregiver mental health, parenting behaviors, experiences with intimate partner violence, and community characteristics. Information on child abuse and neglect was obtained in interviews with child protective services workers. Multiple-regression analyses were used to investigate the association between caregiver victimization and child behavior problems while controlling for the effects of child, family, and environmental characteristics. The potential moderating effects of caregiver depression and parenting practices on the relation between intimate partner violence and child behavior problems were examined also.

RESULTS

Severe intimate partner violence was associated with both externalizing and internalizing behavior problems when other risk factors were controlled. Use of corporal punishment and psychological aggression were significant moderators, but maternal depression did not moderate the relation between intimate partner violence and behavior problems.

CONCLUSIONS

This study adds to the evidence that maternal caregivers' experiences with intimate partner violence are related to child functioning. The findings suggest that systematic efforts are needed to ensure that mental health needs are identified and addressed appropriately in children exposed to this violence.