and the Harvard Medical School Violence Education Steering Committee Family Violence By Carmen Davis Reviewed by Jennifer Robertson and the Harvard Medical School Violence Education Steering Committee S U

Slides Created for Pediatric Family Violence Awareness Project: Improving the Health Care Response to Battered Women and Children in Massachusetts by 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

Session Groundrules Assume there are survivors, abusers in room Pay attention to your reactions Take care of yourself Respect confidentiality

“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

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

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

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

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

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

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

What is Adult Partner Abuse? Pattern of behavior resulting in coercive control 4 major forms of abuse, usually concurrent: Emotional Economic Physical Sexual

Another Common Misconception about Partner Violence Partner violence is primarily a problem of poor communities and communities of color

Partner Abuse Occurs in All Groups Cultural Differences include: Patterns of abuse Community responses Individual responses Resources available Appropriate interventions

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

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”

Misconceptions about Causes Substance abuse Lack of self control Poor self esteem Child abuse

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.)

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)

Providers’ Barriers Lack of training Loss of control Fear of offending Time and situational constraints

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

Identification Barriers (Clients/Patients) Tendency to deny and minimize abuse Fear of losing children Disclosure may take time Role of shame, guilt and fear

Recognizing Batterers’ Patterns Batterers may be charming or aggressive Batterers may present as victims or accusers Batterers often come with their victims

Providers’ Roles Routine screening of women Danger assessment Safety Planning Referrals Documentation Follow-up

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

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

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”

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

“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?”

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

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

Pediatric Indicators Problems with child support and visitation Conflicts around child rearing Divorce and separations Remember to ask directly about partner violence

Assessment of Survivors Emotional, economic control Suicidality, homocidality Distinguish fantasies vs. plans Sexual coercion, rape Depression, PTSD, Substance abuse

More Clinical Presentations Sexual assault, recurrent STDs Unwanted or any adolescent pregnancy Substance abuse, depression Abuse of her child (most commonly by her batterer)

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

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

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

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

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.?

Assess Safety to Child Child abuse Discuss mandated reporter status first Assess evidence of physical, sexual child abuse and child neglect

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

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?”

Safety Planning Extra clothes Car keys Important papers Cash Create signal with neighbors/ children to get help Children’s special toys or objects

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.)

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

Referrals Clinic/ Hospital Resources Community Resources... Social Work Services Advocates Community Resources...

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

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

Primary Prevention Dating Violence Intervention Project School-based curriculum for adolescents