AAP: Use ‘multiple layers’ to combat intimate partner violence

WASHINGTON – Pediatric practices can combat the toxic stress created by intimate partner violence – and often prevent child maltreatment – by providing “multiple layers of opportunity” for disclosure and access to resources, Dr. Kimberly Randell said at the annual meeting of the American Academy of Pediatrics.

Each year, approximately 15.5 million children – disproportionately younger children – are exposed to intimate partner violence (IPV) (J Fam Psychol. 2006;20[1]:137-42). Their mothers, IPV victims, will seek care for their children when they don’t seek care for themselves, and they will address IPV for their children, she said.

“These are women who are coming in for the 2-, 4-, 6-month visits, but haven’t seen their ob for the postpartum visit ,and they may not see their primary care physician for several more years,” said Dr. Randell, who coordinates the IPV program at Children’s Mercy Hospital in Kansas City, Mo. “They’ll address IPV in the context of how it affects their kids.”

Between 1 in 3 women and 1 in 4 men will experience intimate partner violence (IPV) at some point in their lifetime, according to The National Intimate Partner and Sexual Violence Survey 2010 Summary Report by the Centers for Disease Control and Prevention. Families experiencing IPV “look no different from families who aren’t,” making it worthwhile to universally screen for the problem as part of anticipatory guidance. There is no hard evidence favoring written or verbal assessment – “it all depends on what works best for your practice,” Dr. Randell said.

However, she implored pediatricians to line up advocacy resources, educate staff, and develop processes for intervention. “We know that if you just hand someone a pamphlet or a help line number and say ‘call when you’re ready,’ the odds are they’re not going to call,” Dr. Randell said.

Instead, tell the mother you would like to connect her with a community partner who specializes in IVP and can help her figure out a plan for her and her child’s safety. Ideally, a nurse or staff member in the pediatric office who is educated about IVP could be the initial link – someone “to whom you can make a warm hand-off.”

In this case, she explained, the pediatrician can “say something like, ‘I’d like you to talk with Jennifer. She knows a lot about situations like these and can offer some resources. We can even make the call from the office today.’ ”

Phone calls made from the office, when agreed to, are “very safe calls,” Dr. Randell emphasized.

Ideally, pediatric offices can partner with a local IPV agency for education and referrals. Other possibilities are the social work department at a local children’s hospital or the National Domestic Violence hot line (1-800-799-7233, 1-800-787-3224 TTY). Dr. Randell advised using the term “help line” instead of “hotline” because, in her experience, families associate a “hotline” with children “being taken away.”

Physicians worry about damaging trust by asking about IPV, but numerous studies show most mothers agree that pediatric health care providers should ask.

Introducing questions about IPV with a “framing statement” can minimize any perception of judgment. An example: “Because violence at home is common and affects children’s health and safety, I now ask all families in my practice about exposure to violence.”

The framing statement can then be followed with an indirect question such as “Do you feel safe at home and in your relationship?” or a more direct question, such as:

• “Has your child ever seen a violent or frightening event at home or in your neighborhood?”

• “Have you ever been hurt or threatened by your partner?”

• “Do you ever feel afraid of or controlled by or isolated by your partner?”

IPV is an adverse childhood experience that not only creates toxic stress, but puts children at significantly higher risk – up to 15 times the risk – for all forms of childhood maltreatment. Men also experience IPV, but women are most frequently the nonoffenders, she noted.

Pediatricians should know their states’ child abuse and IVP reporting laws, and inform the nonoffending parent of any limits on confidentiality. “If your state has mandatory reporting for exposure to IVP, you need to let the parent know,” she said. “They need to be able to take this into consideration when they’re deciding if it’s safe or the right time to disclose.”

Dr. Randell advised physicians to try to involve the parent when reporting IPV, either per mandatory reporting laws or per results of a child safety assessment. Explain that you’d like them to make the report with you,” she said. “This can be an important step in maintaining a trusting relationship and empowering her.”

Care must be taken in documenting IPV disclosure because the abusive parent often has access to the child’s chart and/or receives insurance statements. Dr. Randell offered several tips:

Use limited, coded documentation in the chart.

• Do not use IPV-related billing codes or mention the terms “domestic violence” or “IPV.”

• Do not use the word shelter or include notes about safety plans.

• Do not screen in the presence of verbal children, or children aged 3 years and older.

Children may inadvertently tell the abuser that mom has been talking to someone, she explained. “And it’s also probably bad for kids to hear mom denying [IPV] because it reinforces that this is a behavior that we keep secret and don’t talk about.”

Posters, pamphlets, and other environmental cues are an important layer for helping families who are experiencing IPV, largely because these items provide women with the opportunity to access resources without having to disclose IPV.

In focus groups at Children’s Mercy, mothers who had experienced or were experiencing IPV said they wanted information “not only on what IPV looks like … but about how it impacts kids, about resources, and about safety planning,” Dr. Randell said. “And they wanted things that are hopeful ... They don’t want to be labeled [as victims].”

There are several validated screening instruments for IPV (such as the Partner Violence Screen and the Woman Abuse Screening Tool), but the tools have significantly variable sensitivities and specificities and have not been studied in pediatric settings. General psychosocial screening tools used in pediatrics, such as the Pediatric Symptom Checklist and the Strengths and Difficulties Questionnaire, may provide clues of possible trauma, including IPV, she noted.

Among the resources recommended by Dr. Randell:

• The Harvard Center for the Developing Child (www.developingchild.harvard.edu).

• Futures Without Violence (www.futureswithoutviolence.org).

• AAP’s policy statement on IPV: pediatrics.aappublications.org/content/125/5/1094).

WASHINGTON – Pediatric practices can combat the toxic stress created by intimate partner violence – and often prevent child maltreatment – by providing “multiple layers of opportunity” for disclosure and access to resources, Dr. Kimberly Randell said at the annual meeting of the American Academy of Pediatrics.

Each year, approximately 15.5 million children – disproportionately younger children – are exposed to intimate partner violence (IPV) (J Fam Psychol. 2006;20[1]:137-42). Their mothers, IPV victims, will seek care for their children when they don’t seek care for themselves, and they will address IPV for their children, she said.

“These are women who are coming in for the 2-, 4-, 6-month visits, but haven’t seen their ob for the postpartum visit ,and they may not see their primary care physician for several more years,” said Dr. Randell, who coordinates the IPV program at Children’s Mercy Hospital in Kansas City, Mo. “They’ll address IPV in the context of how it affects their kids.”

Between 1 in 3 women and 1 in 4 men will experience intimate partner violence (IPV) at some point in their lifetime, according to The National Intimate Partner and Sexual Violence Survey 2010 Summary Report by the Centers for Disease Control and Prevention. Families experiencing IPV “look no different from families who aren’t,” making it worthwhile to universally screen for the problem as part of anticipatory guidance. There is no hard evidence favoring written or verbal assessment – “it all depends on what works best for your practice,” Dr. Randell said.

However, she implored pediatricians to line up advocacy resources, educate staff, and develop processes for intervention. “We know that if you just hand someone a pamphlet or a help line number and say ‘call when you’re ready,’ the odds are they’re not going to call,” Dr. Randell said.

Instead, tell the mother you would like to connect her with a community partner who specializes in IVP and can help her figure out a plan for her and her child’s safety. Ideally, a nurse or staff member in the pediatric office who is educated about IVP could be the initial link – someone “to whom you can make a warm hand-off.”

In this case, she explained, the pediatrician can “say something like, ‘I’d like you to talk with Jennifer. She knows a lot about situations like these and can offer some resources. We can even make the call from the office today.’ ”

Phone calls made from the office, when agreed to, are “very safe calls,” Dr. Randell emphasized.

Ideally, pediatric offices can partner with a local IPV agency for education and referrals. Other possibilities are the social work department at a local children’s hospital or the National Domestic Violence hot line (1-800-799-7233, 1-800-787-3224 TTY). Dr. Randell advised using the term “help line” instead of “hotline” because, in her experience, families associate a “hotline” with children “being taken away.”

Physicians worry about damaging trust by asking about IPV, but numerous studies show most mothers agree that pediatric health care providers should ask.

Introducing questions about IPV with a “framing statement” can minimize any perception of judgment. An example: “Because violence at home is common and affects children’s health and safety, I now ask all families in my practice about exposure to violence.”

The framing statement can then be followed with an indirect question such as “Do you feel safe at home and in your relationship?” or a more direct question, such as:

• “Has your child ever seen a violent or frightening event at home or in your neighborhood?”

• “Have you ever been hurt or threatened by your partner?”

• “Do you ever feel afraid of or controlled by or isolated by your partner?”

IPV is an adverse childhood experience that not only creates toxic stress, but puts children at significantly higher risk – up to 15 times the risk – for all forms of childhood maltreatment. Men also experience IPV, but women are most frequently the nonoffenders, she noted.

Pediatricians should know their states’ child abuse and IVP reporting laws, and inform the nonoffending parent of any limits on confidentiality. “If your state has mandatory reporting for exposure to IVP, you need to let the parent know,” she said. “They need to be able to take this into consideration when they’re deciding if it’s safe or the right time to disclose.”

Dr. Randell advised physicians to try to involve the parent when reporting IPV, either per mandatory reporting laws or per results of a child safety assessment. Explain that you’d like them to make the report with you,” she said. “This can be an important step in maintaining a trusting relationship and empowering her.”

Care must be taken in documenting IPV disclosure because the abusive parent often has access to the child’s chart and/or receives insurance statements. Dr. Randell offered several tips:

Use limited, coded documentation in the chart.

• Do not use IPV-related billing codes or mention the terms “domestic violence” or “IPV.”

• Do not use the word shelter or include notes about safety plans.

• Do not screen in the presence of verbal children, or children aged 3 years and older.

Children may inadvertently tell the abuser that mom has been talking to someone, she explained. “And it’s also probably bad for kids to hear mom denying [IPV] because it reinforces that this is a behavior that we keep secret and don’t talk about.”

Posters, pamphlets, and other environmental cues are an important layer for helping families who are experiencing IPV, largely because these items provide women with the opportunity to access resources without having to disclose IPV.

In focus groups at Children’s Mercy, mothers who had experienced or were experiencing IPV said they wanted information “not only on what IPV looks like … but about how it impacts kids, about resources, and about safety planning,” Dr. Randell said. “And they wanted things that are hopeful ... They don’t want to be labeled [as victims].”

There are several validated screening instruments for IPV (such as the Partner Violence Screen and the Woman Abuse Screening Tool), but the tools have significantly variable sensitivities and specificities and have not been studied in pediatric settings. General psychosocial screening tools used in pediatrics, such as the Pediatric Symptom Checklist and the Strengths and Difficulties Questionnaire, may provide clues of possible trauma, including IPV, she noted.

Among the resources recommended by Dr. Randell:

• The Harvard Center for the Developing Child (www.developingchild.harvard.edu).

• Futures Without Violence (www.futureswithoutviolence.org).

• AAP’s policy statement on IPV: pediatrics.aappublications.org/content/125/5/1094).

WASHINGTON – Pediatric practices can combat the toxic stress created by intimate partner violence – and often prevent child maltreatment – by providing “multiple layers of opportunity” for disclosure and access to resources, Dr. Kimberly Randell said at the annual meeting of the American Academy of Pediatrics.

Each year, approximately 15.5 million children – disproportionately younger children – are exposed to intimate partner violence (IPV) (J Fam Psychol. 2006;20[1]:137-42). Their mothers, IPV victims, will seek care for their children when they don’t seek care for themselves, and they will address IPV for their children, she said.

“These are women who are coming in for the 2-, 4-, 6-month visits, but haven’t seen their ob for the postpartum visit ,and they may not see their primary care physician for several more years,” said Dr. Randell, who coordinates the IPV program at Children’s Mercy Hospital in Kansas City, Mo. “They’ll address IPV in the context of how it affects their kids.”

Between 1 in 3 women and 1 in 4 men will experience intimate partner violence (IPV) at some point in their lifetime, according to The National Intimate Partner and Sexual Violence Survey 2010 Summary Report by the Centers for Disease Control and Prevention. Families experiencing IPV “look no different from families who aren’t,” making it worthwhile to universally screen for the problem as part of anticipatory guidance. There is no hard evidence favoring written or verbal assessment – “it all depends on what works best for your practice,” Dr. Randell said.

However, she implored pediatricians to line up advocacy resources, educate staff, and develop processes for intervention. “We know that if you just hand someone a pamphlet or a help line number and say ‘call when you’re ready,’ the odds are they’re not going to call,” Dr. Randell said.

Instead, tell the mother you would like to connect her with a community partner who specializes in IVP and can help her figure out a plan for her and her child’s safety. Ideally, a nurse or staff member in the pediatric office who is educated about IVP could be the initial link – someone “to whom you can make a warm hand-off.”

In this case, she explained, the pediatrician can “say something like, ‘I’d like you to talk with Jennifer. She knows a lot about situations like these and can offer some resources. We can even make the call from the office today.’ ”

Phone calls made from the office, when agreed to, are “very safe calls,” Dr. Randell emphasized.

Ideally, pediatric offices can partner with a local IPV agency for education and referrals. Other possibilities are the social work department at a local children’s hospital or the National Domestic Violence hot line (1-800-799-7233, 1-800-787-3224 TTY). Dr. Randell advised using the term “help line” instead of “hotline” because, in her experience, families associate a “hotline” with children “being taken away.”

Physicians worry about damaging trust by asking about IPV, but numerous studies show most mothers agree that pediatric health care providers should ask.

Introducing questions about IPV with a “framing statement” can minimize any perception of judgment. An example: “Because violence at home is common and affects children’s health and safety, I now ask all families in my practice about exposure to violence.”

The framing statement can then be followed with an indirect question such as “Do you feel safe at home and in your relationship?” or a more direct question, such as:

• “Has your child ever seen a violent or frightening event at home or in your neighborhood?”

• “Have you ever been hurt or threatened by your partner?”

• “Do you ever feel afraid of or controlled by or isolated by your partner?”

IPV is an adverse childhood experience that not only creates toxic stress, but puts children at significantly higher risk – up to 15 times the risk – for all forms of childhood maltreatment. Men also experience IPV, but women are most frequently the nonoffenders, she noted.

Pediatricians should know their states’ child abuse and IVP reporting laws, and inform the nonoffending parent of any limits on confidentiality. “If your state has mandatory reporting for exposure to IVP, you need to let the parent know,” she said. “They need to be able to take this into consideration when they’re deciding if it’s safe or the right time to disclose.”

Dr. Randell advised physicians to try to involve the parent when reporting IPV, either per mandatory reporting laws or per results of a child safety assessment. Explain that you’d like them to make the report with you,” she said. “This can be an important step in maintaining a trusting relationship and empowering her.”

Care must be taken in documenting IPV disclosure because the abusive parent often has access to the child’s chart and/or receives insurance statements. Dr. Randell offered several tips:

Use limited, coded documentation in the chart.

• Do not use IPV-related billing codes or mention the terms “domestic violence” or “IPV.”

• Do not use the word shelter or include notes about safety plans.

• Do not screen in the presence of verbal children, or children aged 3 years and older.

Children may inadvertently tell the abuser that mom has been talking to someone, she explained. “And it’s also probably bad for kids to hear mom denying [IPV] because it reinforces that this is a behavior that we keep secret and don’t talk about.”

Posters, pamphlets, and other environmental cues are an important layer for helping families who are experiencing IPV, largely because these items provide women with the opportunity to access resources without having to disclose IPV.

In focus groups at Children’s Mercy, mothers who had experienced or were experiencing IPV said they wanted information “not only on what IPV looks like … but about how it impacts kids, about resources, and about safety planning,” Dr. Randell said. “And they wanted things that are hopeful ... They don’t want to be labeled [as victims].”

There are several validated screening instruments for IPV (such as the Partner Violence Screen and the Woman Abuse Screening Tool), but the tools have significantly variable sensitivities and specificities and have not been studied in pediatric settings. General psychosocial screening tools used in pediatrics, such as the Pediatric Symptom Checklist and the Strengths and Difficulties Questionnaire, may provide clues of possible trauma, including IPV, she noted.

Among the resources recommended by Dr. Randell:

• The Harvard Center for the Developing Child (www.developingchild.harvard.edu).

• Futures Without Violence (www.futureswithoutviolence.org).

• AAP’s policy statement on IPV: pediatrics.aappublications.org/content/125/5/1094).