1. 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

2. 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

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

4. “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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

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

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

14. 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

15. 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”

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

17. 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.)

18. 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)

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

20. 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

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

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

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

24. 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

25. 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

26. 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”

27. 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

28. “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?”

29. 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

30. 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

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

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

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

34. 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

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

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

37. 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

38. 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.?

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

40. 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

41. 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?”

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

43. 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.)

44. 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

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

46. 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

47. 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

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