Family Violence

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

2. Slides Created for Pediatric Family Violence Awareness Project: Improving the Health Care Response to Battered Women and Children in MassachusettsbyLinda 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 • 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