PEDIATRICS Vol. 101 No. 6 June 1998, pp. 1091-1092
AMERICAN ACADEMY OF PEDIATRICS:
The Role of the Pediatrician in Recognizing and Intervening on
Behalf of Abused Women
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Pediatricians are in a position to recognize abused women in pediatric settings. Intervening on behalf of battered women is an active form of child abuse prevention. Knowledge of local resources and state laws for reporting abuse are emphasized.
The abuse of women is a pediatric issue. The American
Academy of Pediatrics (AAP) and its membership recognize the importance of improving the physician's ability to recognize partner violence as
well as child abuse and other forms of family
violence.1 The American Medical Association's (AMA)
Council on Scientific Affairs estimates that in the United States, 2 million women are severely physically assaulted by their male partners
each year.2 Pregnant women may be at increased risk of
abuse and this abuse may cause damage to the fetus.3 When
sensitively and confidentially questioned, 8% of a random sample of
women attending a prenatal clinic reported abuse.4 In a
study of in-home homicides in three states, a history of domestic
violence was significantly correlated with increased risk of homicide
committed by a family member or intimate acquaintance.5
Intervention is crucial because children whose mothers are being
assaulted are also likely to be victims. Studies indicate that child
abuse occurs in 33% to 77% of families in which there is abuse of
adults.6-8 Identifying and intervening on behalf of
battered women may be one of the most effective means of preventing child abuse.7
Abuse of spouses and intimate partners is a pediatric issue even when
children are not being physically assaulted. Pediatricians should be
aware of the profound effects family violence has on children who
witness it or even overhear it. Witnessing violence in the home can be
as traumatic for children as being the victim of physical or sexual
abuse. Children whose mothers are abused may experience serious
emotional distress and manifest severe behavioral problems as a
result.6,8
Adolescents who observe abusive relationships at home may repeat
that dynamic in dating or other relationships. (Men and older persons
of both genders also can be victims of partner and intimate violence, but they are less likely to be seen in pediatric settings.)
Abused women are unlikely to seek care for their injuries from
pediatricians. However, mothers of children seen by pediatricians may
show signs of injury such as facial bruising. They may have other less
obvious signs of abuse such as depression, anxiety, failure to keep
medical appointments, reluctance to answer questions about discipline
in the home, or frequent office visits for complaints not borne out by
the medical evaluation of their child. Women may reveal the abuse to
the pediatrician if they are questioned in a sympathetic and sensitive
manner, in a confidential setting, away from the abuser, and provided
some assurance of safety.
A pediatrician who suspects that family violence is occurring or
who recognizes signs of possible inflicted injury should try to deal
with the issue as soon as possible, preferably while the family is in
the office. The pediatrician should talk to the woman alone, away from
the possible abuser and her children. The pediatrician should gently
introduce the topic in a way that assures her that the conversation is
confidential, the problem is acknowledged, other resources for help are
accessible, and her wishes about further disclosure or referral will be
respected. These introductory statements can be developed and reviewed
in advance for appropriateness with local battered women's advocates.
The following questions may be helpful: "We all have
disagreements at home. What happens when you and your partner disagree? Is there shouting, pushing, or shoving? Does anyone get hurt?" "Has
your partner ever threatened to hurt you or your children?" "Do you
ever feel afraid of your partner?" "Has anyone forced you to have
sex in the last few years?"
Questions about family violence should become part of anticipatory
guidance. Pediatricians must understand the dynamics of abusive
relationships. Excellent guidelines for managing situations of abuse
have been published,9-13 and pediatricians need to become familiar with them. There also are increasing numbers of continuing education opportunities available to learn intervention techniques.
Pediatricians should have a protocol or action plan that has been
reviewed with local authorities on domestic violence. Because of time
constraints in a busy office practice or emergency room setting, an
interdisciplinary approach to family violence may be most appropriate.
Pediatricians can call on nurses, social workers or advocacy groups
with expertise in assisting and counseling victims.7 The
AMA's 1996 Diagnostic and Treatment Guidelines on Domestic
Violence state that optimal care for the woman in an abusive
relationship depends on the physician's working knowledge of community
resources that can provide safety, advocacy, and support.9
The AMA and many state medical associations provide directories of
agencies that provide services or information about all forms of family
violence.11 The following national toll-free hotline is
available to all providers/victims needing information about local
resources on domestic violence Women may be threatened with death if they reveal that they are being
abused by their partners, and some of these threats are carried out.
Thus, the process of disclosure is often very frightening and may not
occur unless the woman feels that she can improve, and not worsen, her
situation. The risk of injury or death may increase when a woman is in
the process of leaving an abusive partner. Unlike the situation with
child abuse, there are no mandated state agencies that step in and act
to ensure a woman's safety as she leaves an abuser or afterwards. Only
a few states currently require that a medical professional report domestic violence or actively intervene while the victim is still under
the control and domination of the batterer. Knowledge of existing state
laws for reporting partner violence is essential.
It is important to use discretion when providing information
about family and partner violence to patients or their caretakers. If
the information is discovered by the abuser, the victim may be at
increased risk. If the woman feels safe, information about legal and
crisis counseling and shelters should be provided in written form.
Because of the strong association between homicide in the home and the
presence of both guns and partner violence, it could be lifesaving to
help an abused mother to recognize the value in removing firearms from
the home, if she is able to do so safely.5
The possible role of substance abuse contributing to family
violence should be considered. Pediatricians also need to be sensitive to ethnic and cultural attitudes about violence toward women, not
because such attitudes are acceptable, but because they may have a
profound influence on the willingness of women to discuss this problem.
Pediatricians can provide education to agencies that deal with
battered women about the risk of primary and secondary abuse to
children whose mothers are abused. Every effort should be made to
secure counseling for children who have been exposed to family violence. Such treatment may be provided in groups or individually, but
the focus should be on understanding violence and how to avoid it.
There is increasing evidence that children who grow up with violence
are prone to violent behavior themselves, and pediatricians are in a
position to break the cycle.
The AAP recognizes that family and intimate partner violence is harmful
to children. The AAP recommends that:
ARTICLE
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1-800-799-SAFE.
COMMITTEE ON CHILD ABUSE AND NEGLECT, 1997 TO 1998
Judith Ann Bays, MD, Chairperson
Randell C. Alexander, MD, PhD
Robert W. Block, MD
Charles F. Johnson, MD
Steven Kairys, MD, MPH
Mireille B. Kanda, MD, MPH
LIAISON REPRESENTATIVES
Larry S. Goldman, MD
American Medical Association
Gene Ann Shelly, PhD
Centers for Disease Control and Prevention
Karen Dineen Wagner, MD, PhD
American Academy of Child and
Adolescent Psychiatry
SECTION LIAISON
Carole Jenny, MD
Section on Child Abuse and Neglect
CONSULTANT
David L. Chadwick, MD
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FOOTNOTES |
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This statement has been approved by the Council on Child and Adolescent Health.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics. AMA, American Medical Association.
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REFERENCES |
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- Novello A. What You Can Do About Family Violence: A Federation Guide to the Physicians' Campaign Against Family Violence. Chicago, IL: American Medical Association; 1992:5-6
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Council on Scientific Affairs, American Medical Association
Violence against women: relevance for medical practitioners.
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Richardson AC,
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Bilateral subdural hematomas in a newborn infant.
Pediatrics.
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Newberger EH,
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Lieberman ES,
Abuse of pregnant women and adverse birth outcome: current knowledge and implications for practice.
JAMA.
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Kellermann AL,
Rivara FP,
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Gun ownership as a risk factor for homicide in the home.
N Engl J Med.
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[Abstract/Free Full Text] - Garbarino J, Kostelny, Dubrow N What children can tell us about living in danger. Am Psychol. 1991; 46:376-383 [CrossRef][Medline]
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Wright RJ,
Wright RO,
Isaac NE
Response to battered mothers in the pediatric emergency department: a call for an interdisciplinary approach to family violence.
Pediatrics.
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99:186-192
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Zuckerman B,
Augustyn M,
Groves BM,
Parker S
Silent victims revisited: the special case of domestic violence.
Pediatrics.
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96:511-513
[Abstract/Free Full Text] - American Medical Association. Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, IL: American Medical Association; 1992
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Sugg NK,
Inui T
Primary care physicians' response to domestic violence: opening Pandora's box.
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American Medical Association. Family Violence: Building a Coordinated Community ResponseA Guide for Communities. Chicago, IL: American Medical Association; 1996
- Stark E, Flitcraft A, Zuckerman D, et al. Wife Abuse in the Medical Setting: An Introduction for Health Care Personnel. Rockville, MD: National Clearinghouse on Domestic Violence; 1981. Monograph 7
- Children's Safety Network. Domestic Violence: A Directory of Protocols for Health Care Providers. Newton, MA: Education Development Center Inc; 1992
Pediatrics (ISSN 0031 4005). Copyright ©1998 by the American Academy of Pediatrics
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Statement of reaffirmation:
- AAP Publications Retired and Reaffirmed
Pediatrics 114: 1126-1126.[Full Text]
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