Screening For Domestic Violence In The Pediatric Emergency Department

Table of Contents

 

1. Abstract
2. Abbreviations Used In This Article
3. Critical Appraisal Of The Literature
4. Epidemiology, Etiology, Pathophysiology
5. Differential Diagnosis
6. Prehospital Care
7. ED Evaluation
   1. What if she says "YES?"
8. Diagnostic Studies
9. Treatment
10. Special Circumstances
    1. Teens And Dating Violence
11. Controversies And Cutting Edge
    1. Effect Of DV/IPV Mandatory Reporting Laws
    2. Screening With Children In The Room
12. Disposition
13. Summary
14. Key Points
15. Risk Management
16. Cost Effective Strategies
17. Clinical Pathway: DV Screening In The ED
18. Clinical Pathway: Management of Responses To Screening
19. Tables and Figures
    1. Table 1: Sample Questions For Domestic Violence Screening
    2. Table 2: Sample Responses For Domestic Violence Screening
    3. Table 3: Stages Of Change In Domestic Violence And Stage Matched Interventions
    4. Table 4: National Resources For Domestic Violence Victims
    5. Table 5: Resources On Domestic Violence For Health Care Providers
20. References
21. Appendix A: RADAR

Abstract

Similar scenarios are commonly encountered by all emergency medicine (EM) physicians. However, physicians are often hesitant to ask about Domestic Violence (DV). In a study by Sugg, physicians reported that exploring domestic violence in the clinical setting was analogous to "opening Pandora's box," citing lack of comfort, fear of offending, powerlessness, loss of control, and time constraints as concerns.¹

DV, or intimate partner violence (IPV), is commonly defined as a pattern of coercive behaviors including repeated battering and injury, psychological abuse, sexual assault, progressive isolation, deprivation and intimidation.^2-4 Women who are injured as a result of DV/IPV often present to the emergency department. However, the majority of these women are not identified as victims. In one study, 37% of female patients with injuries presenting to the emergency department were injured by their partner, but only 5 to 7% of these battered women were identified by emergency department (ED) staff.⁵ In another study, 44% of women murdered by their partner had visited an emergency department within two years of the homicide; over 90% of these women presented to the ED for evaluation of injuries incurred as a result of DV/IPV. Another ED study found the incidence of acute DV/IPV with a current male partner to be 11.7%. The cumulative lifetime prevalence of DV/IPV exposure was 54.2%.⁶ The American College of Emergency Physicians encourages emergency personnel to screen patients for domestic violence and appropriately refer those patients who indicate that domestic violence may be a problem in their lives.⁷

There has been heightened awareness of DV/IPV as a pediatric problem as well. In a recent position paper, the American Academy of Pediatrics stated that "recognizing and intervening in domestic violence may be the single best way to prevent child abuse."⁸ Approximately 3.3 to 10 million children witness the abuse of a parent or adult caregiver each year.^9-11 Children living in families with domestic violence are more likely than their peers to be victims of abuse; the incidence of child abuse in families experiencing domestic violence ranges between 30 to 60%.^{9, 12,13} One study found that children of abused mothers were 57 times more likely to have been harmed because of DV/IPV between their parents, compared with children of non-abused mothers.¹⁴

Children who live with domestic violence face increased risks of exposure to traumatic events, neglect, direct abuse, and losing one or both of their parents. Several studies have shown that exposure in one's home environment to domestic violence as a child leads to the increased likelihood of adult health issues and risk taking behaviors, such as behavioral and emotional problems, cognitive problems, depression, and risks of violence in adult relationships.^9,12,15 Children who are raised in homes with domestic violence are at an increased risk of perpetrating or experiencing violence in adulthood, and are more likely to be victims of child abuse. In addition, a child's exposure to DV/IPV can lead to moderate to severe post traumatic stress disorder (PTSD).¹⁶

While a physician may be the first non-family member that a victim of domestic violence may turn to for help,² current rates of screening for domestic violence are low (8 to 21%). This is particularly true in the pediatric setting, in part because pediatricians may feel they lack training in family violence screening and intervention skills.¹⁷ ED staff and EM and pediatric emergency medicine (PEM) physicians are in a unique position to recognize DV/IPV and intervene on behalf of the victim and children. However, while physicians may observe patterns of injury, repeated injuries, and the adverse mental outcomes of domestic abuse, they may fail to recognize them as DV/IPV.

Without institutional policies and procedures for detecting and treating victims of DV/IPV, many abused women will remain unidentified and without intervention. Only recently has the health care system become an important site for DV/IPV programs.¹⁸ In 1992, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required that all accredited hospitals implement policies and procedures in their facilities to identify, treat, and refer victims of DV.² However, most of these programs focus on screening and identification, and few focus on treatment of victims of DV/IPV.¹⁸ In one study, pediatric ED providers supported both DV/IPV resource information and routine screening. ¹⁹

Abbreviations Used In This Article

ACEP - American College of Emergency Physicians

DV - Domestic Violence

IPV - Intimate Partner Violence

ED - Emergency Department

EM - Emergency Medicine

EMS - Emergency Medical Service

ISF - Institute For Safe Families

JCAHO - Joint Commission on Accreditation of Healthcare Organizations

PEM - Pediatric Emergency Medicine

PTSD - Post Traumatic Stress Disorder

USPSTF - The US Preventative Services Task Force

Critical Appraisal Of The Literature

Moving beyond the general ED that serves adult patients, pediatric EDs have explored their role in DV/IPV screening.^27-29 In 1997, a survey of 125 pediatric emergency medicine fellows demonstrated a significant disparity between prior child abuse training (97.6%) when compared to DV training (29.6%).²⁸ Fellows reported much more first hand experience with handling child abuse cases than with DV/IPV cases and only 4.2% of fellows reported having protocols in place for responding to battered women in the pediatric ED. Multiple barriers were identified to screening women for DV, including lack of protocol, lack of formal training, lack of DV/IPV experience, belief that DV/IPV was outside the purview of pediatrics, and a variety of potential attitudinal barriers including frustration with what could be done in response to a positive screen and inadequate time to respond. Seven years later, a survey of 130 pediatric chief residents again demonstrated a continuing disparity between child abuse and DV/IPV training with 60% receiving 11 hours or more of child abuse training in residency and 80% receiving less than four hours of DV/IPV training. The disparity extends to experience with child abuse versus DV cases with 78% of respondants working in programs without a formal evaluation protocol, while nearly all had some experience with child abuse cases.³⁰ On a positive note, 93% of pediatric chief residents who responded to the survey thought pediatricians should screen for DV/IPV in patients' families, although only 20% universally screened. Eighty percent voiced an interest in receiving training in how to effectively screen and intervene for DV/IPV. A qualitative study explored the perspectives of 59 mothers, 21 nurses, and 17 physicians in a pediatric ED on IPV screening and found that mothers viewed DV/IPV as a common problem that warranted routine screening in the pediatric ED.²⁹ The study concluded with the following recommendations about DV/IPV practices in pediatric EDs: 1) Those assigned to screen must demonstrate empathy, warmth, and a helping attitude; 2) The child's medical needs must be addressed first and screening for DV/IPV should be performed in a minimally disruptive manner; 3) A clear and organized process around determining risk to the child from the IPV environment must be maintained, especially when child protective services needs to be involved; and 4) Resources and referrals for women who request them must be available.²⁹

Risk Management

1. Don't assume your patient is not a victim of domestic violence because "They are from a nice suburban family." Domestic violence crosses all socioeconomic, racial, and geographic boundaries.
2. Don't assume your patient is not a victim of domestic violence because they are male. Up to fifteen percent of victims are male.
3. Don't forget to screen all patients at high risk: Pregnant, peripartum, and postpartum women, teens, and patients with difficult to explain or repeated injuries.
4. When a victim says "yes" to screening, avoid condescending comments such as, "Why don't you just leave?" These comments further decrease the victim's self-confidence. Be empathetic; say something like, "Many women are victims of abuse, but that doesn't make it right."
5. Don't coerce a victim into immediately leaving the relationship. This may not be safe. It must be the victim's decision. Leaving is a process and most homicides occur at this stage. Steps must be taken to ensure safety for the victim and the victim's children.
6. Don't forget to screen for concurrent child abuse. Children in homes with domestic violence are at a 6 to 15 times increased risk of being abused.
7. Don't forget to report child abuse. While domestic violence is not reportable in most states, practitioners are mandated to report child abuse in all 50 states.
8. Don't forget to give resources if it is safe to take them home. Even if the victim is not ready to leave, make sure he or she at least has a hotline number to call for help.
9. Don't forget to document. Document that you screened even if the answer was no. Document the details of the violence if it is safe to document in the child's chart. Thoroughly document the extent of the injuries.
10. Last but not least, don't be afraid to ask. Studies have shown that even though the victim may not report to a physician the first time asked, they do appreciate that the question was asked.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the

reference, where available.

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