Abraham Rice, MD Medical Director, Foster Care Clinic Contra Costa Regional Medical Center Domestic Violence in Pediatrics.

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Presentation transcript:

Abraham Rice, MD Medical Director, Foster Care Clinic Contra Costa Regional Medical Center Domestic Violence in Pediatrics

Take home messages DV is a pediatric issue DV / CEV is prevalent CEV are at high risk many bad outcomes We should screen for, diagnose and treat violence and it’s predictable sequelae

Problem of Children Exposed to Violence Between 7 – 15 million children witness DV per year. CEV more likely experience emotional and behavioral problems Greatly at risk for abuse and poverty CEV are a medical issue

Definition of Domestic Violence DV is “a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation and intimidation. These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim”

Effects of Domestic Violence Profound effects on neurodevelopment Earlier exposure = worse outcomes Emotional / Developmental / Academic / Behavioral / Physical problems AND potentially limited access to resources (medical care, mental health care, developmental support, academic support)

Emotional problems and CEV Depression Anxiety PTST ADHD

Attachment system theory of development 10/18/2015 Normal development is absolutely dependent on a bond with a loving caregiver Affect regulation may be the most essential aspect of a child’s development

Developmental problems and CEV Language (pre-verbal) Social / Emotional Abnormal affect regulation Aggressive, separation issues Developmentally appropriate symptoms Motor Hyperarousable, withdrawn

Behavioral problems and CEV Developmentally appropriate manifestations Infant Toddler Elementary school Adolescent

Physical Illness Asthma Diarrhea Caries Failure to thrive ACE study

Children Exposed to Violence are: Children with predictable, increased health care needs And should have… Have access to a medical home to meet those needs

Opportunity Pediatricians in ideal position to identify DV / CEV High risk time for women & frequent visits to MD Some women don’t seek care for self but do for children Women DO disclose when asked

American Academy of Pediatrics AAP Committee on Child Abuse and Neglect (1998) Policy Statement: The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women “the abuse of women is a pediatric issue” “intervening on behalf of battered women is an active form of child abuse prevention” “pediatricians are in a position to recognize abused women in pediatric settings” “questions about DV should become part of anticipatory guidance”

AAP recommends Need residency and CME education & training Pediatricians should attempt to recognize evidence of family or intimate partner violence in the office setting Pediatricians should intervene in a sensitive and skillful manner that maximizes the safety of women and children victims Pediatricians should support local and national multidisciplinary efforts to recognize, treat and prevent family and intimate partner violence

Fewer than 10% pediatricians routinely screen for DV Barriers: Education / Training Time Perception Sense of powerlessness Language / cultural sensitivity

DV screening practice Varies : written forms, as part of safety/environmental screen Recommendations: All women in pediatric settings should be screened for DV Should not screen when partner in the room Women do disclose DV when asked by a skilled provider in face to face Insufficient evidence to recommend specific screening practice

Screening for DV As part of child anticipatory guidance Introductory statement Direct vs. indirect questions Include questions to adolescents and older children Ask with children in room? (probably)

Disclosures of DV: Physician’s Role First assess safety of mother & children Articulate concern over woman and children’s safety

Disclosures of DV: Physician’s Role Connect any concerns over child to DV (behavior, academic, emotional) Offer information about resources and help – culturally and linguistically appropriate

Disclosures of DV: Physician’s Role DV shelter / support group / DV advocates or hotlines Offer to create a safety plan & schedule follow up appointment