Family violence is a pervasive public health and criminal problem affecting children across all racial and ethnic groups and across all socioeconomic levels. Such violence may affect any or all members of a family, involving adult partners against each other, caregivers against children or elders, and siblings against each other.
The terms "domestic violence" and "intimate partner violence" often are used interchangeably to denote abusive (eg, physical, sexual, psychological) acts between adults in a close personal relationship. The ultimate goal of such violence is the domination by one person over the other. Approximately 20% to 30% of women and 7.5% of men in the United States have been physically or sexually assaulted during adult life.1 Our understanding of the scope of domestic violence and our efforts to address the problem have expanded significantly since 1994, when Congress enacted the Violence Against Women Act as part of the Violent Crime Control and Law Enforcement Act.
SCOPE OF THE PROBLEM
Each year, an estimated 4 million women in the United States are seriously injured by a partner.2 Abuse often begins during pregnancy, and physical abuse of the expectant mother may damage the unborn fetus.2 Women are 10 times more likely than men to be murdered by an intimate partner, an act referred to as femicide.3 When men are murdered by their female partners, it often comes in response to prior, ongoing, or escalating violence or abuse by the men.4
Adolescents experience date-related violence at a rate between 20% and 60%. The highest per capita rate of victimization (15.6 per 1,000) occurs in women between age 16 and 24.5 This rate is threefold greater than the general rate for adults of all ages.5
Enormous financial losses also are assodated with domestic violence. Medical costs account for $3 to $5 billion annually; an additional $100 million in business losses are related to absenteeism and reduced productivity.6
Studies estimate up to 10 million children are exposed to domestic violence annually.7 Many of these children also are injured, and child maltreatment is reported to occur in association with intimate partner violence in up to 60% of cases.8 One study from Nicaragua reported a sixfold increase in the risk of death for infants and children younger than 5 related to violence against their mothers. These deaths were from all causes, not just inflicted trauma. The authors hypothesize that maternal stress negatively affects the mother's ability to care for her child.9
Similarly, stress in the home increases the risk of both domestic violence and child maltreatment. Other factors, particularly maternal psychopathology and parental alcohol or drug abuse, also are associated with family violence.
An association among domestic violence, child maltreatment, and lower occupational or socioeconomic class may be a true phenomenon or related to reporting bias. There is an increased risk of physical violence against the child by a male caregiver, especially when the caregiver is the mother's boyfriend, rather than the child's biological father.
ORIGINS AND ETIOLOGY
Historic and religious patterns of male and female relations, with men occupying positions of authority and domination and women assuming a more submissive role, define the social and cultural expectations that have characterized our society. This pattern has been reflected in civil law, which previously subscribed to the notion that what occurred in the home was private and not subject to judicial or public review.10
Violence permeates our culture, particularly in movies, television, and video games. Violent behavior is learned and is condoned tacitly by both the media and society. When violence occurs in the home, it is inescapable.
Intimate partner violence follows a recognizable pattern titled Walker's Cycle of Violence Theory:11 tension building, acute battering, and honeymoon. Tension building is characterized by verbal criticism and lack of predictability. Women who seek medical care may complain of somatic symptoms such as headache and abdominal pain. Physical battery characterizes phase two, during which there also is destruction of property. The woman frequently sustains physical trauma, and law enforcement may be notified by either the victim or the couple's neighbors. The third and last phase, the honeymoon phase, is so named because the batterer apologizes, asks for forgiveness, and promises never to hit the woman again. The woman may believe that the battering will stop permanently, but unfortunately, the cycle repeats and the violence persists unless there is intervention.12
RECOGNITION AND DIAGNOSIS
Signs and Symptoms in Mothers Exposed to Domestic Violence
In spite of dramatic photos showing visible physical injuries in abused women, such injuries often go unobserved because the woman does not seek medical care. When cutaneous trauma is present, it may take the form of classic patterned injuries. Such injuries include abrasions, minor lacerations, and contusions. Black eyes (25%), fractured teeth (8%), and ruptured eardrums (4%) are the physical findings most commonly reported. Musculoskeletal injuries may include sprains and fractures.13
In addition to presenting with acute injuries, abused women may have other medical problems, such as those related to pregnancy or pre-existing medical conditions, psychiatric symptoms, or symptoms related to alcoholism or substance abuse.14 When women present having been physically assaulted during pregnancy, medical findings may include maternal hemorrhage, abruptio placenta, uterine rupture, preterm labor, fetal trauma including fractures, and small-for-gestational-age infants. 15
Women may be less likely, however, to initiate care for complaints related to domestic violence. In one study, only 23% of pregnant women injured by a partner received treatment for the injuries.16 Women who did seek care often delayed doing so; up to 70% of affected women waited at least 1 year before getting help.17
Even after medical assistance is ascertained, violence may go unaddressed. In one report from emergency departments, only 6% of battered women were identified as victims of domestic violence. Women presenting to emergency departments with trauma may falsify the etiology of the injury and attribute the findings to falls. Similarly, the examining physician may not inquire about the origin of bruises or may fail to challenge the mechanism of a fall.14 Women seeking medical care for problems unrelated to the abuse, and those bringing a child in for medical care, may mask any physical findings through the use of make-up or clothing.
A clinician may become concerned about an abusive situation based on the interaction between the woman and her partner, if he is present. A controlling partner, one who dominates the interview and answers all the medical questions, may be a batterer demonstrating a need for control. The physician should be particularly alert if the partner will not leave the woman alone with the clinician.
Signs and Symptoms in Children Exposed to Domestic Violence
A wide range of physical and behavioral health problems are reported in children who are exposed to parental interpersonal violence, particularly when the exposure is chronic. Most prevalent is posttraumatic stress disorder (PTSD), which has been noted in up to 85% of children exposed to intimate partner violence.18 Symptoms of moderate to severe PTSD include sleep disturbances, difficulty concentrating, easy distractibility, and hypervigilance. Depressive symptoms, violent behavior, school and learning problems, and nonspecific somatic disturbances also are reported. The latter may include complaints of headache, abdominal or chest pain, and gastrointestinal dysfunction. During adolescence, those who were exposed to household violence as younger children are more likely to abuse drugs and alcohol, engage in prostitution, commit sexual assaults, run away from home, and attempt suicide.19
Children also may present with injuries. Maltreatment directed at the child occurs in 33% to 55% of battering homes and was observed in nearly 70% of children in a battered women's shelter.20 Injuries may be intentional, or the child may be injured inadvertently when he or she comes between the combative adults or attempts to intervene in a parental dispute. Injured children should be thoroughly evaluated to assess the nature and extent of their injuries. Appropriate diagnostic studies are age-dependent and may include ophthalmologic examinations to detect retinal hemorrhages, skeletal surveys, bone scans, neuroimaging, and coagulation studies.
Signs and Symptoms in Adolescents Exposed to Domestic Violence
Adolescents may present because they are direct victims of date-related violence or because they have grown up exposed to violence in their household. When they are the victims of physical or sexual assaults, they may have physical findings such as cutaneous, musculoskeletal, or anogenital injuries.
A complete history of the events and a recording of the injuries are appropriate. Photographic documentation of injuries or a forensic examination, which includes collecting clothing or bodily fluids (specifically if there has been a sexual assault), should be considered.
SCREENING FOR DOMESTIC VIOLENCE
While no laboratory tests assist the physician in diagnosing domestic violence, studies should be carried out to determine the extent of any injuries in children who are maltreated or adolescents who are the victims of date-related violence. Such studies would include appropriate x-rays of any suspected fracture or other imaging studies.
The pediatrician will, in general, not examine a mother who is accompanying her child. However, some screening methods can occur when either a woman or her child is being evaluated medically. The physician may query about domestic violence because of a suspicion related to the presence of visible findings in the mother or symptoms in the child.
Some healthcare providers recommend screening all families for domestic violence because a minority of battered women seek care for injuries or have observable physical findings. Because the benefit of routine screening, and the absence of any harm related to such screening, are not firmly established, routine screening for domestic violence remains controversial.21
The US Preventive Services Task Force (USPSTF), in a report that elicited a great deal of controversy, noted that no studies specifically examined the use of screening questionnaires by clinicians to detect family violence and its effect on the health and well-being of children, women, and the elderly.22,23 The report suggested there was evidence that intervention in families at higher risk for abuse reduced harm to children. However, comparable studies were not available for women or older adults, and no studies actually evaluated whether there was any harm associated with screening for family violence.
The USPSTF made no recommendation about whether to screen but said clinicians should remain alert to the signs and symptoms of domestic violence. Others, even in the absence of such studies, have strongly endorsed universal and routine face-to-face screening of women for family violence and have maintained that such screening increases the identification of victims of family violence and reduces morbidity and mortality.24'25 The frequency with which questions related to domestic violence should be asked (eg, at every visit, twice a year, annually) has not been fully elucidated.21
A number of screening instruments have been proposed for use during periodic pediatric health maintenance visits. Such instruments usually include a series of questions to evaluate the risk of domestic violence (Sidebar 1, see page 397). The issue of domestic violence may be introduced by stating: "Because violence is common in the lives of many women, I ask all women or mothers I see about violence in their homes." Opening the dialogue with even a single question may be sufficient to elicit information about whether domestic violence is a concern. One study reported that a query about restraining orders against a partner or former partner found that about 30% of women with children in a pediatric clinic had initiated one. A pneumonic, HITS, may help the clinician recall the key components of domestic violence screening: "How often did your partner Hurt, Insult, Threaten, Scream?"26
If a woman does disclose that she is a victim of domestic violence, the clinician must ascertain whether the woman is concerned about her safety or the safety of her children, and whether there is danger of suicide or homicide. Imminent danger, real or perceived, mandates immediate intervention.
While reports suggest that 90% of children in violent homes are aware of the violence,20 there are differing opinions about whether questions about violence should be asked in the presence of the child. There is consensus that questions related to domestic violence may be asked if the child is younger than 3. One must be prepared, however, for any emotional responses from the mother that such questions may elicit. When children are older, questions related to domestic violence are best asked when children are not in the room. Inquiries about family violence should never be asked in the presence of the potential perpetrator.
There are various approaches to documenting information about domestic violence in the chart. If the suspected batterer has access to the child's medical record (a biological or custodial parent), the confidentiality of any documented disclosure will be jeopardized, and the discloser may be placed in danger. To circumvent this problem, all charts could include a universal statement noting that questions related to intimate partner violence were asked, as is part of the routine procedure, and information about community resources was provided. Alternatively, the chart could note that family issues were addressed and advice was given. Finally, a separate section of the child's chart may be maintained for confidential information that is not provided to insurance carriers.
There are two key components to the effective management of domestic violence: recognition that the entity exists, and determination of effective interventions. Unfortunately, barriers persist to the recognition of domestic violence by clinicians. Often, there is limited formal education of medical students and residents, and lectures frequently focus on physical injuries of battered women, an infrequent presenting scenario.
Physicians' time constraints and lack of familiarity about community resources are two additional barriers. Feelings of helplessness, hopelessness and powerlessness to intervene also are cited.27
Paradoxically, prior personal experience with domestic violence adversely affects the likelihood that clinicians will recognize intimate partner violence within their practices. Sugg27 reported that 31% of female physicians and 14% of male physicians who experienced personal abuse and violence reported this as an obstacle to diagnosing domestic violence in their practice. Some clinicians mistakenly believe that domestic violence is confined to lower socioeconomic groups or certain races and that it not a problem for their patients.
While screening of women in the pediatric healthcare setting is possible and may uncover a fairly high incidence of domestic violence, one statewide survey of pediatric and family practices found few physicians screened mothers routinely at the child's visit. Physicians who had received training in recognition of domestic violence were more likely to screen than providers who did not have such training.28"34
Tools have been developed to address the gaps that may exist in the education of healthcare providers. One such tool is a CD-ROM program created as an instructional tool to help identify and intervene in intimate partner violence in the pediatric acute care setting. Titled "It's Time to Ask," the program is available through Children's Mercy Hospital in Kansas City, MO.35
Strategies that have been proposed to reduce the prevalence of domestic violence and to prevent its recurrence are enumerated in Sidebar 2. However, there are conflicting data about the efficacy of any of these approaches. For example, the effect of incarceration on the likelihood of recidivism has not been established. While some investigators note that arrest of the perpetrator reduces subsequent domestic violence, others report the risk is reduced only if the offender is employed but increased if the offender is unemployed.36,37 Unemployment of an abuser and the presence of guns in the home correlate with femicide.3 Understandably, it is difficult to conduct sociological studies that involve multiple variables and multiple outcomes. Re-abuse as an outcome may be an invalid endpoint, because women have no control over the actions of their partners.
The role of the physician, in addition to recognizing and acknowledging domestic violence, includes assisting families in accessing services and community resources to address not only the violence but also other family issues, such as alcoholism and substance abuse, that may be perpetuating stress within the household. When there is imminent danger to women and children, their safety must be secured.2
While screening questions take only minutes to ask, the time needed to attend to the responses and provide appropriate intervention may take hours. Use of a multidisciplinary and multicultural team facilitates the clinician's task. Such teams are knowledgeable about a plethora of community resources and often provide the woman with significant emotional support.
Domestic violence is a chronic condition, and treatment requires ongoing support and intervention. The diagnosis of domestic violence in healthcare settings potentially can decrease the mortality and morbidity associated with domestic violence. When physician time or staffing do not allow for a full team approach, the office personal can at least initiate a call or have the woman call a domestic violence hotline or shelter before she leaves the office. Clinicians should not be surprised, however, that some women may be reluctant to do so because they are fearful of retribution or believe that they have no other means of financial support than their present partner.
The obligation to report domestic violence and the type of report required varies by state. In some states, a report is mandated only if a potentially deadly weapon such as a gun or knife has caused an injury. On the other hand, a number of states require an automatic report to child protective services when domestic violence is suspected, even if there are no injuries to the child. When there is mandated cross-reporting to child protective services, mothers may be fearful of disclosing domestic violence lest children be removed from their custody.38
Opponents of routine screening linked to mandated reporting note that women fece the greatest physical danger (including the risk of being murdered) immediately after the domestic violence is disclosed or when they make an effort to leave their abuser.2 The risk of being murdered by one's intimate partner is highest during the 6 months following a separation.
When domestic violence is identified but specific assistance or guidance is not provided, mothers and children may be placed in harm's way. The Department of Health and Human Services has created a national toll-free domestic violence hotline (1-800-799-SAFE; 1-800-787-3224 for TDD for the hearing impaired) that provides women and physicians with information related to community resources. All women can be given this number, in addition to specific information that may assist them in case they experience violence within the home or in personal relationships. Because the discovery of such information by an abuser may put women at risk, they should be advised to keep the information in a secure place. Women can be advised about what should be kept readily available should they feel the need to leave home suddenly (Sidebar 3, see page 399). If the woman does leave, all weapons should be hidden or removed and no information that may serve to alert the abuser as to where she is going (eg, a list of battered women's shelters) should be left behind.2
Unless appropriate intervention is provided on an ongoing basis, a woman is usually subjected to repeated threats, intimidation, domination, control, and physical assault. With time, fear, isolation, and risk of entrapment increase, as does the risk of death.
Although no clear-cut intervention strategy is predictably successful for all families, studies suggest permanent restraining orders against batterers, programs aimed at batterers (eg, anger management), arrest of perpetrators, and strict surveillance of batterers in the military, have the best outcomes.
Prevention is the key to reducing domestic violence. Primary prevention strategies involve creating curricula in schools and programs to foster the development of communication skills that allow individuals to address differences verbally rather than confront them physically. Community programs to address job skills, unemployment, alcohol, and substance abuse can also reduce domestic violence by tackling some of the problems that sit at its core. Physicians can provide secondary prevention by early identification and intervention, thereby interrupting the cycle of violence.
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