It’s not Pandora’s Box: Intimate Partner Violence Assessment in Pediatric Medical Settings Terri L. Weaver, Ph.D. Department of Psychology Saint Louis University Saint Louis, Missouri

Goals of the Presentation Attendees will Learn the national prevalence rates of IPV and the prevalence rates of reported IPV in pediatric medical settings. Learn three behaviorally specific questions that can be used to assess for IPV in pediatric medical settings. Learn the range of psychological and physical sequelae of IPV for adult women and child witnesses. Learn five specific safety planning interventions that can be conducted to enhance safety for mothers and their children.

AMA Recommendations In 1992, the American Medical Association (AMA) and other professional organizations, including the American Academy of Family Practice (AFT) advocated for the screening of intimate partner violence (IPV) adult female patients.

Opening Pandora’s Box Sugg & Inui (1992) Primary Care Physicians’ Response to Domestic Violence: Opening Pandora’s Box Explored family care physicians’ thoughts about assessing for IPV (n = 38) Assessing for IPV in clinical settings is like opening Pandora’s Box. It evokes concerns about offending clients, powerlessness, loss of control, concern about time constraints.

Intimate Partner Violence: Statement of the Problem Identified as one of the Nation’s Most Pressing Public Health Problem. Women are more likely to be repeatedly attacked, raped, injured or killed by male partner than by any other type of perpetrator. Severe, serial nature enhanced by easy access, high levels of exposure, privacy.

Definitions Physical Violence ranges from minor to lethal violence. Push, hit, slap, shove Assault with hands, objects weapons Acts/Threats to maim kill pets, partner, family Choke, strangle, bite, burn, throw down stairs Sexual Assault and Rape

Definitions (contd) Emotional Abuse and Coercion Restriction of routines, activities, relationships Forced Isolation Restriction of access to medical/MH care Stalking and intense monitoring of behavior Threatened loss of valued things Threats to harm loved ones Restricted access to money, other support

Definitions (contd) Verbal Abuse: Name Calling, Degradation/Insults Intense Criticism. AMA (1992) “…pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation and intimidation perpetrated by someone who is or was involved in an intimate relationship with the victim (p. 40).”

Epidemiology-Population Studies Rates vary by sample and definition. IPV affects 1-2 million women in the U.S. annually Lifetime rates of IPV for American Women range from 21-34% during adulthood.

Prevalence of Intimate Partner Violence in Pediatric Settings Studies assessing incidence rates are sparse; Most studies to date have examined how often families are assessed for IPV and barriers to assessment; When assessment occurs, depending on the sample, incidence rates have ranged from a low of 2.5% IPV in past year to a high of 40% IPV in the past two years.

Epidemiology-Risk Factors Younger women at increased risk Single, separated, divorced higher rates Violence in dating/courtship increasing problem (32% in large national college sample) High School dating: 13-25% Fewer years married higher rates

Epidemiology-Risk Factors IPV cuts across socioeconomic lines. Higher rates associated with poverty, e.g, 60% lifetime prevalence in AFDC sample. BJS-highest rates w/lowest income, 12 per 1,000 (Black) and 8 per 1,000 (White). Trapped by Abuse, Trapped by Poverty.

Patterns/Dynamics All Abusive Behavior Functions to Maintain Domination, Power and Control. Physical abuse tends to occur w/ verbal and emotional abuse. Emotional/verbal abuse often precedes physical violence

Patterns/Dynamics contd. Abuse tends to escalate in Frequency and Severity over time. Perceived/Actual Separation Increased Risk of Assault and Lethal Outcomes Stalking as a variant of IPV “Why Doesn’t She Just Leave?”(Most Do) Leaving is a process, not an event (Average 6x) “Why Doesn’t He Just Let Her Go?”

Patterns/Dynamics contd. Barriers to reporting/leaving include: Economic dependence, fear of harm, self-and other- blame; minimizing/discounting abuse by self or others; lack of available resources, poor experience with help-providers; mistrust authority; shame; hope/beliefs things will change; ambivalence, love, intermittent abuse; kids;religion; invested in working out the relationship; fear of DFS involvement and beliefs that system’s effort to “help” will hurt her (e.g., lose custody).

Impact: Injuries > Women (3%) than Men (.4%) need medical attention for injuries sustained from marital aggression (Nat’l Sample) Significantly more severe injuries sustained by women (marital aggression sample).

Impact:Mental Health Posttraumatic Stress Disorder Depression and Suicidality Substance Abuse Psychosexual Problems Anxiety Disorders Diminished Coping Reduced Self-Efficacy and Self-Esteem.

Impact:Economic Effects Costs due to Medical Care Costs due to Missed Work Miller et al (1996) estimated the costs of IPV as $67 billion/year (15% of total crime costs). Due to medical, functional impairment, decreased quality of life. Excludes disability and welfare costs and those resulting from the long-term psychological impact of IPV.

Impact: Effects on Children At least 3.3 million children exposed to IPV/yr Children observe, overhear abusive incidents and witness results (bruises, injuries, etc). Effects are: short-term and long-term, affecting emotional, cognitive and social development both during childhood and extending into adulthood % of children who witness also suffer abuse themselves; also increased risk of neglect and emotional abuse.

Impact: Effects on Children (contd) Damage in 4 general areas: Immediate traumatic effects; Adverse effects on development; Greatly increased stress, especially fear of harm to themselves and their mothers; Consequences of exposure to violent/abusive role models greatly increases risk of current and future perpetration.

American Academy of Pediatrics In 1998, The American Academy of Pediatrics issued a position statement declaring that “The abuse of women is a pediatric issue.” Regular screening, regardless of the presence of signs or symptoms, identifies women who are victims. Women consistently state that screening is expected and desired. Well child visits are “windows of opportunity” but guidelines have been lacking.

Consensus Recommendations

Issues in Screening in a Pediatric Medical Setting Who is the client? Is it an invasion of family privacy? There is no time. How do I screen with older children in the room? What if she says “yes”? What can I do to make a difference?

RADAR Remember to Ask Ask Directly Document Findings Assess Safety Review Options

Pediatric-Psychology Partnership for Abuse Prevention Scope/Funding: Health Resources and Services Administration, Graduate Psychology Education Program Objectives Train clinical psychology graduate students to provide psychological health services to underserved women and children affected by intimate partner violence (IPV). Methods Standardized information in core curricula Development of Enhanced Clinical Vertical Team Development of Clinical Practicum Site

Setting up the Questions Use anticipatory guidance as a frame Child in versus Child out of the room Types of questions Model Responses Safety planning Consistent Care

Questions We are conducting safety screenings with all women within this clinic who are coming in with children two years of age and under. When moms (or grandmas, etc) are being physical hurt or threatened, we know that this can impact the health and wellbeing of them and their children.

Examples of Questions Warm-up 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?

Questions Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, thank you for sharing the information with me. Could you let me know who has hurt you in this way? Provision of Safety Information

Examples of Questions Direct Questions Have you ever been hurt or threatened by your partner/husband or boyfriend? Do you ever feel afraid of (controlled or isolated by) your partner/husband/boyfriend? Has your child witnessed a violent or frightening event in your neighborhood or home?

Safety Planning You don’t have to: “Fix the situation” Provide validating messages: I am concerned about your safety and the well being of you and your child Help is available You have choices/options

Safety Planning contd Where would you go if you wanted to leave; Hide Money; Hide extra set of house keys and car keys Establish secret code with family and friends; Ask neighbor to call police if violence begins; Remove weapons before violence begins; Review existing community resources on resource card.

National Domestic Violence Hotline SAFE (7233)

One day she lifted the lid - and out flew plagues innumerable, sorrow and mischief for mankind. In terror Pandora clapped the lid down, but too late. One good thing, however, was there - Hope.. Source: