PEDIATRICS Vol. 110 No. 3 September 2002, pp. 509-516
Parental Screening for Intimate Partner Violence by Pediatricians and Family Physicians
From the Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota
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ABSTRACT |
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Objective. To ascertain and compare the knowledge, practices, and training needs of pediatricians and family physicians regarding intimate partner violence screening and intervention.
Methods. Surveys were mailed to national random samples of 1350 pediatricians and 650 family physicians evenly divided between senior residents, practitioners completing their residency training within the last 5 years, and practitioners completing their training >5 years ago.
Results. The overall response rate was 37% (41% for pediatricians, 30% for family physicians). Among practicing physicians, only 8% of family physicians and 5% of pediatricians routinely screened a parent for intimate partner violence during well-child and teen visits. Family medicine residents were significantly more likely to routinely screen for intimate partner violence (18%), whereas pediatric residents were not (7%). All groups demonstrated deficits in knowledge of appropriate management of situations of domestic abuse; for example, over 60% of family medicine and 75% of pediatric residents and practitioners agreed with the inappropriate response of always urging a woman to leave her abusive partner immediately. Many physicians indicated a need for more information about domestic violence, ranging from 40% of family medicine residents to 72% of pediatric residents. Residency training and continuing medical education in the prevention of child/adolescent violence and having an office protocol for managing cases involving domestic violence increased the likelihood of parental screening for intimate partner violence.
Conclusions. Few child and adolescent primary care physicians routinely screen parents for intimate partner violence and most need more information on this topic. Residency training and continuing medical education on violence prevention, including screening and intervention skills in intimate partner violence, and office protocols for managing cases of domestic violence could increase screening rates.
Key Words: intimate partner violence • domestic violence • screening • pediatricians • family physicians
Abbreviations: AAP, American Academy of Pediatrics • AAFP, American Academy of Family Physicians
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INTRODUCTION |
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Recent estimates indicate that
1.5 million women are raped and/or physically assaulted by an intimate partner every year in the United States, with many victimized more than once.1 About 85% of victimizations by intimate partners are against women, and 30% of all women murdered in the United States are killed by male partners.2 The number of children exposed to intimate partner violence is unknown, but undoubtedly substantial. Estimates show that over 10 million American children witness parental violence annually.3 A study conducted in the pediatric primary care clinic at Boston City Hospital found that 10% of the children had witnessed a shooting or stabbing, half of which occurred in their own home.4 All of the children were under the age of 6, with an average age of 2.7 years. In a study of pediatric emergency medicine fellows in the United States and Canada, Wright et al5 found that the majority of fellows believed that responding to battered mothers did not belong in the purview of pediatrics. However, research has revealed several reasons why such intervention is critical and firmly within the boundaries of pediatric practice. First, children in families where there is violence are at higher risk of being abused themselves, with the coexistence of child abuse in families in which there is abuse of adults as high as 77%.6–8 Consequently, identifying and intervening on behalf of battered women may be one of the most effective means of preventing child abuse, and identifying battered mothers may also be an important means of identifying child abuse.5,9 Second, witnessing violence at home may be as traumatic for children as being the direct victim of abuse, particularly in terms of long-term psychological, developmental, and behavioral effects.8,10,11 In fact, the witnessing of one’s mother being battered has been called the most insidious form of child abuse.12 Children who witness violence often experience severe emotional and behavioral problems, including posttraumatic stress disorder, poorer performance in school, somatization syndromes, symptoms of anxiety and depression, and substance abuse.10,11,13,14 Finally, children who witness violence in the home are more likely to become perpetrators or victims of violence themselves in adolescence or adulthood, both in their intimate relationships as well as on the streets.15,16 In this way, the intergenerational cycle of violence is perpetuated.
Because of the prevalence and associated morbidity of intimate partner violence, a number of major national health care organizations have issued recommendations for providers to screen their patients for intimate partner violence in the office setting and intervene in an appropriate manner.17–20 Recognizing that intimate partner violence is harmful to children and that pediatricians are in a position to identify battered mothers of children they see, the American Academy of Pediatrics (AAP) has recommended that screening for intimate partner violence and appropriate intervention be incorporated into child and adolescent health care as well.21,22 Guidelines for managing situations of intimate partner violence have been published.23–25 Yet previous studies conducted at the state and regional level indicate that most physicians, including pediatricians, family physicians, internists, and obstetrician/gynecologists, do not routinely screen patients for intimate partner violence.26,27 If screening revealed an abusive situation, it is unclear how knowledgeable physicians are about appropriate referrals for victims of intimate partner violence and how to intervene in a manner which is sensitive and maximizes the safety of victims of abuse and their children.
In this study, we assess and compare the knowledge, attitudes, training needs, and practices of national random samples of residents and practitioners in pediatrics and family medicine regarding intimate partner violence. In addition, we identify factors that increase the likelihood of screening a parent for intimate partner violence when providing health supervision to children and adolescents.
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METHODS |
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Participants
The participants for this study were national random samples of 1350 pediatricians and 650 family physicians obtained from their respective specialty societies, namely the AAP and the American Academy of Family Physicians (AAFP). The study was part of a larger study assessing youth violence prevention training and counseling practices of residents and practitioners in pediatrics28 and family medicine. Roughly twice as many pediatricians as family physicians were included in the study to mirror the percentage of youth receiving care from these physicians. Approximately two thirds of office visits by youth ages 0 to 17 are with pediatricians and approximately one-third are with family physicians.29 The samples were divided equally between participants in their final year of residency training, practicing physicians completing their residency training within the last 5 years, and those completing their residency training >5 years ago. Practitioners were board-certified in general pediatrics or family medicine, without subspecialty certification.
Survey
A 4-page survey was sent with a cover letter hand signed by the principal investigator (I.W.B.). Letters to pediatricians were also signed by the Executive Director of the AAP; and letters to family physicians were cosigned by a prominent member of the AAFP. A reminder postcard was mailed 1 week later to all physicians, and a second survey was mailed 4 weeks after the initial mailing to all nonrespondents. The survey included questions regarding the respondents’ current practices and knowledge in the area of intimate partner violence screening and intervention. Published recommendations by the American Medical Association were used to develop the questions.18 To assess the frequency of screening, respondents were asked, "When providing health supervision to children and adolescents, how often do you ask a parent if they ever feel unsafe at home (eg, Are you ever afraid of your partner? Do you have any concerns regarding physical or mental abuse at home?)." Respondents were given choices on a 5-point Likert scale of almost always, usually, sometimes, rarely, or never. Routine screening was defined as a response of "almost always" or "usually." Knowledge and attitudinal items were assessed using a 5-point Likert scale that allowed for varying degrees of agreement or disagreement with the statement and a neutral choice. Agreement with the statement was defined as a response of "strongly agree" or "agree." Additional items addressed demographic information, practice characteristics, and training. The survey was pretested with a convenience sample of residents and practitioners in pediatrics and family practice, and revisions made to ensure survey clarity and ease of completion. The study was approved by the Institutional Review Board: Human Subjects Committee at the University of Minnesota.
Data Analysis
The data were initially examined for the frequency distribution of items. 
2 tests were used to examine the significance of differences in variables reflecting intimate partner violence screening and counseling knowledge when data were stratified by specialty for senior residents and practitioners. Because there were no significant differences between practicing physicians completing their residency training within the last 5 years and practicing physicians completing their residency training >5 years ago for any of the variables studied, practicing physicians were combined in a single group for each specialty.
Linear regression analyses were used to assess factors that increase the likelihood of screening for intimate partner violence. The dependent variable, frequency of screening, was kept as a continuous variable for the multivariate analyses.
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RESULTS |
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Surveys were returned by 62 (29%) of the 216 family practice residents and 182 (40%) of the 450 pediatric residents (Table 1). Among the practitioners, 373 (41%) of the 900 pediatricians and 130 (30%) of the 434 family physicians returned surveys. Thus, the overall response rate was 37%. Nine pediatric and 2 family medicine respondents who were retired or practicing as a subspecialist were excluded. Data on the age, gender, and time out of residency for all of the pediatricians who received a survey indicated that there were no significant differences between the total sample and the survey respondents. For family physicians, response rates were not statistically different for time out of residency. Sample data were not available to compare family medicine respondents and nonrespondents with respect to other variables; however, data from the AAFP indicate that family medicine resident and practitioner respondents did not significantly differ from their national membership with respect to gender.30
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Pediatric residents and practitioners were more likely than family medicine residents and practitioners, respectively, to be female, to practice in an urban area, and to deliver most of their ambulatory patient services in a hospital or academic setting. (Table 1). A higher percentage of family medicine residents and practitioners compared with pediatric residents and practitioners, respectively, practiced in a private solo or group setting. Among both residents and practitioners, family physicians were significantly more likely to report receiving training (eg, any lectures, grand rounds, case conferences) in the prevention of child/adolescent violence in medical school than were pediatricians. Almost three fourths of family medicine and pediatric residents received such training in residency. Among practitioners, family physicians were more likely to report receiving youth violence prevention training in residency than were pediatricians, but these practitioners were equally likely to have received violence prevention training through continuing medical education. Over one third of practitioners, both family physicians and pediatricians, indicated that they had not received formal training in child/adolescent violence prevention.
Routine screening of a parent for intimate partner abuse during well-child and teen visits ranged from 5% for pediatric practitioners to 18% for senior family medicine residents (Table 2). Among senior residents, family physicians were significantly more likely to routinely screen a parent for intimate partner violence and to know how to make referrals to appropriate people and places for women who are victims of abuse. Pediatric residents were significantly more likely than family medicine residents to agree that they know the symptoms in children that may indicate exposure to conflict and violence in their homes, and to indicate a need to obtain more information on domestic violence. Among practicing physicians, family physicians were significantly more likely to agree that they know how to make appropriate referrals for victims of intimate partner abuse and to indicate that their predominant ambulatory practice setting has a protocol for managing cases involving domestic violence. Pediatricians were significantly more likely than family physicians to feel that families would be offended if they screen for domestic violence, to know when and to whom to refer a child who has witnessed violence, and to indicate that they needed more information on domestic violence.
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In pediatrics and family medicine, both residents and practicing physicians demonstrated a lack of knowledge regarding appropriate management of situations of domestic abuse. A majority of all respondents incorrectly agreed that women who have been abused by their partner should always be urged to leave the abuser immediately (Table 2). Family medicine residents and practitioners were significantly less likely than pediatric residents and practitioners, respectively, to agree with this inappropriate and potentially dangerous intervention strategy, but still over 60% of family physicians agreed with this approach.
We used linear regression to identify factors that increase the likelihood of screening a parent for intimate partner abuse during health supervision visits for children and adolescents (Table 3). Family physicians, female physicians, older physicians, and those practicing in an urban area were significantly more likely to screen a parent for intimate partner abuse. Physicians working in community health centers were more likely to screen a parent for intimate partner violence than those working in a private solo or group practice, and those whose predominant ambulatory practice setting had a protocol for managing cases involving domestic violence were more likely to screen. Regarding education, receiving residency training in the prevention of child/adolescent violence increased the likelihood of screening for intimate partner violence, while receiving such training in medical school was not significantly associated with the likelihood of screening for intimate partner violence after controlling for the other factors in the model.
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A separate linear regression analysis including pediatric and family medicine practitioners only and controlling for gender, age and physician specialty, showed that continuing medical education in the prevention of child/adolescent violence also increased the likelihood of screening for intimate partner violence (ß = 0.16; P < .001). The number of patients typically seen per hour by the practitioner (ß = -0.07; P = .13) and involvement of practitioners in teaching residents or medical students at their primary practice setting (ß = -0.08; P = .08) were not significantly associated with the likelihood of screening a parent for intimate partner violence.
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DISCUSSION |
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The results of this national study demonstrate that most child and adolescent primary care physicians do not routinely screen parents for intimate partner violence. Training in violence prevention in residency and continuing medical education, as well as office protocols for managing cases involving domestic violence, increase the likelihood of screening a parent for intimate partner violence during health supervision visits. Deficiencies in knowledge of appropriate physician responses to a positive screen for intimate partner violence also underscore the need for improved training in providing care to victims of intimate partner violence.
The primary limitation of this study was the potential for response bias, with a response rate of 41% for pediatricians and 30% for family physicians. For comparison, response rates for other national physician surveys on topics related to violence and injury include 15% for a survey of fellows of the American College of Obstetricians and Gynecologists on domestic violence screening,31 69% for a survey of AAP fellows on firearm counseling,32 and 74% for a survey of AAP members on bicycle helmet counseling.33 Although the response rates for family physicians were significantly lower than for pediatricians in our study, comparison of other available demographic data revealed no significant differences between respondents and nonrespondents. Physicians with more of an interest in violence prevention may have been more likely to respond to the survey. In addition, physicians may overreport their provision of preventive services in practice. Thus, our data may overestimate actual screening practices. Although no national studies are available for comparison, our findings are consistent with another survey of child and adolescent health physicians in one community which found that 8.5% of practitioners routinely screened for domestic violence as part of anticipatory guidance.27
We found that family medicine physicians are more likely to routinely screen for intimate partner violence than pediatricians, even after controlling for violence prevention education, having an office protocol, and other factors. Differences in screening were marked among senior residents, with family medicine residents 2 and a half times more likely to routinely screen for intimate partner violence than pediatric residents (18% vs 7%; P <.05). This difference by specialty may reflect family physicians’ role as adult health care providers, resulting in greater comfort, experience and skill addressing problems that directly involve adults. Some of the parents screened by family physicians may also be patients of these physicians. Erickson et al27 found that family practitioners were more likely to screen at least high-risk patients for domestic violence than were pediatricians among the medical staff of a children’s hospital. Others have found that family physicians are more likely to report routine counseling of smoking parents of young children34 and of smoking adolescents35 than pediatricians. Greater familiarity with adult care may likewise explain this specialty difference in smoking cessation counseling, as family physicians likely draw on their experience with adult smokers.
Although family medicine residents were significantly more likely to routinely screen for intimate partner violence (18% vs 8%; P < .05) and less likely to indicate a need for more information on domestic violence (40% vs 57%; P < .05) than practicing family physicians, there were no significant differences in level of screening and need for information about domestic violence between pediatric residents and their practicing pediatric colleagues. Thus, there is evidence that residency education in family medicine in the area of domestic violence has increased to better prepare family physicians to address the emerging health issue of intimate partner abuse and the witnessing child. Disturbingly, our findings suggest that, despite an increasing awareness of the profound health effects of witnessing family violence on children, pediatric residents have not received the information they need to recognize and intervene to help battered women and their children.
Many studies document the increased detection of intimate partner violence through verbal or even written screening of patients.36–43 Screening tools that have been used include the Conflicts Tactics Scale,44 the Abuse Assessment Screen,45 the Index of Spouse Abuse46 and the Partner Violence Screen.38 Framing questions may serve to put the parent as well as the health care provider at ease.47 For example, the provider might preface direct questions about intimate partner violence with a statement like, "I know that there is a lot of violence in our world these days and I am concerned about how it is affecting our children. I have begun to ask all of my patients and their parents about their experiences with violence."11,23 In this way the provider assures family members that they are not being singled out for this line of questioning, and communicates that the provider considers the topic of violence to be within the scope of problems to be addressed in a medical visit. Assessing a child’s exposure to violence includes questions such as, "Has your child witnessed violence on television? Has he/she witnessed violence on the streets or in your neighborhood? Has he/she witnessed violence in the home?" This line of questioning may feel most comfortable for child health care providers. A direct question to a parent, such as "Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?" is a validated measure of 1-year prevalence rates of partner violence.38 Additional investigation is necessary to elucidate the accuracy and acceptability of screening questions for partner violence when children are present.48 Although screening for intimate partner violence through a written questionnaire probably underestimates the prevalence of partner violence when used alone,36,49 written questions have been found to increase detection over usual rates and may increase screening for intimate partner violence by health care providers.39,42,50,51 Computer-assisted assessment may also represent a useful tool for gathering information about sensitive topics such as intimate partner violence.52,53
Appropriate follow-up to screening includes ongoing support, risk-assessment, safety planning, and appropriate referrals for parents and children.18,23,47 Intervention most often takes place over multiple visits and involves working in a multidisciplinary team, making appropriate medical, mental health, advocacy, and legal referrals. The provider must be sensitive to the emotional vulnerability of victims, the long process of change in readiness to end an abusive relationship, the increased risk of severe injury to a woman immediately after leaving an abusive partner,2 and the need to accept the victim’s timetable. Currently, there is limited information on the effectiveness of screening and intervention to improve health outcomes for women and children and prevent intimate partner violence.54 Anecdotal evidence of benefit has been described,55–57 and a small nonrandomized cohort study of pregnant and postpartum abused women found less violence in the group given brief safety and empowerment counseling by nurses.58
Our findings clearly demonstrate the importance of violence prevention training in enhancing domestic violence screening by youth health care professionals. Comprehensive training guidelines have been published and excellent resources for training are available.59–62 Research on the most effective strategies to influence physician behavior should be used in designing residency and continuing medical education on family violence.63,64 Effective approaches utilize interactive strategies, such as systematic practice-based interventions that include enabling and reinforcing factors such as written questionnaires, posters, buttons, peer support and feedback.42,51,65 Training should reach all members of the medical team, including nurses and medical assistants.66 Screening for other family psychosocial issues that effect children’s health, including parental depression, substance abuse, history of physical abuse as a child, and social support, is also infrequently done in pediatric practice.67 Enhancing family psychosocial screening and treatment in the pediatric setting will require training and institutional changes that are sensitive to the pediatrician’s role and expertise in providing health care services specifically to children, but necessity to provide these services in the context of the family.
We found that having a clinic/office protocol for managing domestic abuse cases was also independently associated with a greater likelihood of screening for domestic violence among child and adolescent primary care providers. Among the medical staff of a children’s hospital, lack of an office protocol was perceived as a barrier to screening for domestic violence by 60% of respondents.27 Wright et al5 found that only 4.2% of the pediatric emergency medicine fellows in their study reported having a written protocol for responding to battered women in the pediatric emergency department, and lack of such a protocol was frequently cited as an obstacle to identifying battered women and making appropriate referrals. A study of adult female trauma patients in an emergency department found that the introduction of a protocol for recognizing injuries caused by battering increased the identification of battered women from 5.6% to 30% of these patients.68 However, in an 8-year follow-up study, the percentage of women identified as battered returned to preprotocol levels.69 Possible associated issues included the departure of faculty interested in the issue of family violence, the absence of medical student and resident training in family violence, and the lack of a monitoring system within the emergency department to ensure continued use of the protocol. As in the emergency department setting, in order for protocols for responding to domestic abuse cases to aid in the appropriate identification and management of battered women in the primary care setting, protocols must coexist with provider education and ongoing surveillance to communicate institutional expectations for use of the protocols.
There are many barriers to screening for intimate partner violence. Lack of education or training was the most common barrier to domestic abuse screening, recognition, and intervention identified by physicians in several studies.5,27,31 Other barriers identified by physicians to addressing domestic violence in the primary care and emergency department settings include lack of time, lack of experience with domestic abuse cases, personal discomfort with discussing intimate partner violence, fear of offending patients, belief that patients will not disclose intimate partner violence, frustration that they cannot help the victim, feeling that abuse is not a problem in their patients, and belief that the role of the provider does not include addressing intimate partner violence.5,26,27,31,70 Patient barriers to discussing intimate partner violence have been described as well, including fear of retaliation by the perpetrator, low self-esteem and feelings of shame, and fear of losing custody of children.26,71,72 However, the majority of Americans believe that physicians could help reduce family violence,73 and most survivors of abuse report that they would discuss intimate partner violence with their health care provider if asked in a caring and confidential manner.71,72,74 Furthermore, most mothers favor screening for intimate partner violence at pediatric visits,75 and screening for maternal domestic violence can be successfully incorporated into busy community pediatric practices, revealing overall rates of maternal domestic violence of 17% to 31%.41,75
A recent study showed that abused mothers brought their infants to well-infant care visits as frequently as nonabused mothers, although most of the women did not receive medical care for injuries related to the abuse.76 Child health care providers have a unique opportunity to identify battered women who may not seek help for themselves, but will bring their children in for medical care. Given the significant health effects of intimate partner violence for women and their children, screening and intervention are vital components of pediatric primary care practice. Residency training and continuing medical education on compassionate, knowledgeable screening and intervention for intimate partner violence coupled with use of clinic protocols for managing cases of domestic violence could increase screening rates. Additional research is needed to identify effective screening and intervention strategies in the pediatric setting.
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ACKNOWLEDGMENTS |
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This analysis was supported, in part, by a grant from the Viking Children’s Fund, Eden Prairie, Minnesota.
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FOOTNOTES |
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Received for publication Feb 7, 2002; Accepted Apr 3, 2002.
Address correspondence to Iris Wagman Borowsky, MD, PhD, Division of General Pediatrics and Adolescent Health, University of Minnesota Gateway, 200 Oak St, SE, Suite 160, Minneapolis, MN 55455. Email: borow004{at}tc.umn.edu
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