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By

Carmen DavisReviewed by

Jennifer Robertson and the Harvard Medical School Violence

Education Steering Committee

Family Violence

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Slides Created for Pediatric Family Violence Awareness

Project: Improving the Health Care Response to Battered Women and Children

in Massachusettsby

Linda McKibben and Liz Roberts

• Funded by a federal Healthy Tomorrows Partnership for Children Program Grant (MCHB and the AAP)

• Co-Sponsored by: MHRI, DPH, Carney Hosp., and the Medical Foundation

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Session Groundrules

• Assume there are survivors, abusers in room• Pay attention to your

reactions• Take care of yourself• Respect confidentiality

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“Identifying and Treating Battered Adult and Adolescent Women and Their Children...”

• Special Populations, children and adolescents

• Risk Assessment and Safety Planning

• Using the Courts: Restraining Orders

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Project Goals• Teach pediatricians/maternal and

child health care providers to identify women at risk for violence

• Through routine screening of mothers of patients and women as patients

• During primary care preventive visits• Recognition of patterns at all visits

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Improving Family Violence Detection Skills• Become knowledgeable about

community resources• Acknowledge effects of maternal

abuse on children• Identify routinely by asking all adult

and adolescent women privately• Be familiar with characteristics of

batterers

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Battering is Common• 3-4 million women are battered each

year in the US• Battering is the most common cause

of injuries in women• >50% are battered at some time in

their lives; >1/3 repeatedly• 17-25% of pregnant women are

battered

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Battering Harms Children

• 80% of children in violent homes are aware of the problem

• 3-10 million children per year witness abuse of their mothers

• Partner violence and child abuse overlap 40-60%

• Boys who witness violence are 1000% more likely to abuse their adult partners

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The Myth of Mutual Abuse

• 95% of cases are male violence against women

• A global pattern supported by cultural traditions and history

• Same-sex violence has coercive pattern, one partner controlling another

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Resulting Barriers to Accurate Identification

• Higher rates of reported abuse in families of color or poor families• Less likely that middle class,

white families are screened appropriately

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What is Adult Partner Abuse?

• Pattern of behavior resulting in coercive control

• 4 major forms of abuse, usually concurrent:–Emotional –Economic –Physical –Sexual

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Another Common Misconception about

Partner Violence

• Partner violence is primarily a problem of poor communities and communities of color

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Partner Abuse Occurs in All Groups

• Cultural Differences include:–Patterns of abuse–Community responses–Individual responses–Resources available–Appropriate interventions

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Victims Do Not Cause Their Abuse

• Certain characteristics of victims (esp. women) are thought to lead to their abuse–codependency- victims need it–masochism- victims like it

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Supportive Message for Survivors

• “I’m afraid for your safety”• “I’m concerned about your

children’s safety and well-being”• “I’m here for you if you need

help in the future. Here are some other numbers too”

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Misconceptions about Causes

• Substance abuse• Lack of self control• Poor self esteem• Child abuse

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Unhelpful/ Blaming Messages for Survivors• “What did you do...to make

him/her do that?”• “Why do you keep going

back?”• “Don’t let him hit you in the

stomach.” (Spoken to a pregnant woman.)

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Anyone Can Be Battered

• No consistent factors distinguish battered from non-battered women

• Surgeon General Koop recommended that all women be screened for risk for partner abuse (1985)

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Providers’ Barriers

• Lack of training

• Loss of control

• Fear of offending

• Time and situational constraints

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Confusion is part of the pattern!

• Partner may appear disorganized; the batterer appears “in control”

• Partner appears fearful• At other times, she appears to

protect him• Clinic/Hospital staff can be split

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Identification Barriers (Clients/Patients)

• Tendency to deny and minimize abuse• Fear of losing children• Disclosure may take time• Role of shame, guilt and fear

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Recognizing Batterers’ Patterns

• Batterers may be charming or aggressive• Batterers may present as

victims or accusers• Batterers often come with

their victims

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Providers’ Roles

• Routine screening of women• Danger assessment• Safety Planning• Referrals• Documentation• Follow-up

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Interviewing Guidelines

• PRIVACY• Project concern and confidence• Sit down• Eye contact if culturally appropriate• Address patient, not interpreter• Avoid blaming advice or questions• Avoid stigmatizing terms• Use gender neutral language

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Screening Schedule• Upon intake and annually thereafter• Each trimester of pregnancy• Pediatrics:–Prenatal– Intake–Annual physicals–At least every six months in the

first two years of her child’s life

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Safety Recommendations

• Avoid interventions with batterers–Do not share woman’s concerns–Do not warn the batterer that you

know–Do not do “couples counseling”

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Routine Screening• Approach as a routine health

concern• Screen for partner violence through

women, not their children• Use two to three direct questions• Give information about resources to

everyone asked

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“I ask all my patients, do you feel safe in your home?”

• “Is anyone hurting you, harassing you, or making you feel afraid?”

• “At any time, has your partner ever pushed, hit or kicked you?”

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Should I Ask All My Patients?

• Screening men for battering may endanger their partners and children• No protocols or guidelines for

effective, safe screening of men exist

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Clinical Presentations in Women

• Any injury, esp. To face, central body, breasts and genitals; bilateral or multiple injuries

• Delay between occurrence of injury and seeking of care

• Explanation inconsistent with injuries

• Chronic pain with no clear etiology

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Pediatric Indicators

• Problems with child support and visitation• Conflicts around child rearing• Divorce and separations• Remember to ask directly

about partner violence

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Assessment of Survivors

• Emotional, economic control• Suicidality, homocidality–Distinguish fantasies vs. plans

• Sexual coercion, rape• Depression, PTSD, Substance

abuse

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More Clinical Presentations

• Sexual assault, recurrent STDs• Unwanted or any adolescent

pregnancy• Substance abuse, depression• Abuse of her child (most

commonly by her batterer)

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Following Disclosure

• Get permission to consult• Follow-up visits more frequently• Assess safe ways of making

contact• Remain non-judgmental• Articulate your concern and

continuing support

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Danger Assessment

• Weapons and criminal history• Threats and stalking• Batterer’s resources• Substance abuse, mental illness• Child abuse• Batterer’s suicidality

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Escalation

• Severity of injuries• Frequency of attacks• Isolation of victim(s)• Nature of threats• Use of weapons

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Other Possible Effects• Behavior - aggressive, withdrawn• Developmental delays - school failure• Emotional - suicidality• Health Effects - chronic diseases, dental

neglect, immunization delay• Risk-taking - substance abuse, sexuality

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Filing More Safely• Report your concern for her safety• File against the violent partner if

situationally appropriate• Gather information about how DSS

may safely contact her• For example, what kind of car does

the batterer drive, license plate #, etc.?

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Assess Safety to Child

• Child abuse–Discuss mandated reporter status

first–Assess evidence of physical,

sexual child abuse and child neglect

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Child Abuse Reporting• Legally mandated when child

physical,sexual, emotional abuse or neglect

• Reporting is NOT mandatory for all cases of domestic violence

• Use clinical judgment otherwise - Escalation, danger assessment

• Tell the woman and help safety plan

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Suspected Child Abuse and Domestic Violence

• Ask mother privately• “Whenever I am concerned about the

safety of children, I am also worried about the safety of others in the home....

• Has your partner/ the child’s father ever hurt or threatened you?”

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Safety Planning• Extra clothes• Car keys• Important papers• Cash• Create signal with neighbors/

children to get help• Children’s special toys or objects

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Framing Your Documentation

• “Patient declines restraining order because of partner’s threat to kill her.” (She’s afraid. She’s protecting her kids. Her plan is rational.)

Versus • “Patient refuses restraining order.”

(She’s non-compliant. She’s not protecting her kids.)

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Documentation for Pediatrics

• Document that screening of mother occurred in child’s chart (DV screened)

• Preferably document outcome of screening in woman’s chart or in social work notes

• Document referrals and concerns nonspecifically if batterer has access to child’s records

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Referrals

• Clinic/ Hospital Resources–Social Work Services–Advocates

• Community Resources...

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• Battered women’s shelters and hotlines• Support groups for women and children• Victim/ witness advocates from courts• Certified batterers’ intervention programs• Child visitation center• DSS Domestic Violence Specialists

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Messages for Children

• Mothers are not to blame• It’s not the child’s fault• Each of us are responsible for

our own behaviors• Feelings need not lead to

violence• Love is not ownership

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Primary Prevention

• Dating Violence Intervention Project• School-based curriculum for

adolescents