Published online December 31, 2007
PEDIATRICS Vol. 121 No. 1 January 2008, pp. e85-e91 (doi:10.1542/peds.2007-0904)
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ARTICLE

Screening for Intimate Partner Violence in a Pediatric Primary Care Clinic

Howard Dubowitz, MDa, Leslie Prescott, BAa, Susan Feigelman, MDa, Wendy Lane, MD, MPHa,b and Jeongeun Kim, PhDa

Departments of a Pediatrics
b Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. To estimate the prevalence of intimate partner violence among parents at a pediatric primary care clinic and to evaluate the stability, sensitivity, specificity, positive and negative predictive values, and likelihood ratios of a very brief screen for intimate partner violence.

METHODS. A total of 200 parents (mostly mothers) bringing in children less than 6 years of age for child health supervision completed the Parent Screening Questionnaire in a primary care clinic. The Parent Screening Questionnaire, a brief screen for psychosocial problems developed for the study, includes 3 questions on intimate partner violence. Mothers then completed the computerized study protocol within 2 months. This included the Parent Screening Questionnaire as well as the Revised Conflict Tactics Scale. Different combinations of the intimate partner violence questions were evaluated against the Revised Conflict Tactics Scale.

RESULTS. A total of 12.0% of the mothers answered "yes" to at least one of the screening questions. On the standardized Revised Conflict Tactics Scale, responses ranged from 9% reporting a physical injury in the past year to 76% reporting psychological aggression. There was moderate stability of the screening questions. A single question, "Have you ever been in a relationship in which you were physically hurt or threatened by a partner?" in relation to the "physically injured" Revised Conflict Tactics Scale subscale was most effective. Sensitivity was 29%, specificity was 92%, positive predictive value was 41%, and negative predictive value was 88%. The positive likelihood ratio was 3.8, and the negative likelihood ratio was 0.77.

CONCLUSIONS. Intimate partner violence is a prevalent problem. A very brief screen can reasonably identify some mothers who could benefit from additional evaluation and possible services. Additional research is needed to find a more sensitive screen and to examine whether identifying intimate partner violence leads to interventions that benefit mothers, families, and children.

Key Words: risk factors • intimate partner violence • domestic violence • prevention • screening • primary care

Abbreviations: IPV—intimate partner violence • PSQ—Parent Screening Questionnaire • PPV—positive predictive value • NPV—negative predictive value • LR+—positive likelihood ratio • LR–—negative likelihood ratio • CTS2—Revised Conflict Tactics Scale

Intimate partner (or domestic) violence (IPV) remains widely prevalent despite a seeming decline in reports.1 Studies conducted in adult primary care clinics have found that as many as 37% of women report an incident of IPV in their lifetime.2–4 A study of pregnant women at public prenatal clinics in Baltimore and Houston found that 17% of women were either physically or sexually abused during their pregnancy.5 Studies conducted in pediatric primary care practices have found similar rates of reported IPV. In a study screening for child safety concerns including violence in the home, 15% of the children had been exposed to IPV.6 Siegel et al7 found that 17% of mothers who brought their children for regular checkups to a hospital-based, suburban clinic reported IPV in the previous 2 years.

In addition to IPV being prevalent, research has documented the harmful effects of exposure to IPV on children. There is frequent co-occurrence of IPV and child maltreatment; estimates range from 33%8 to 77%.9 Children may become directly involved in physical altercations. Emotional and cognitive development are often impaired,10–15 impeding children's functioning in school and interpersonally. Children who witness IPV risk developing violent or coercive means of resolving conflict.16,17 Witnessing IPV is also associated with long-term mental health problems,13,18,19 especially when IPV co-occurs with child maltreatment.20

The prevalence and the negative effects of IPV on children make IPV an important concern for pediatricians.21 Although the American Academy of Pediatrics9 considers the identification of IPV to be an ethical and clinical imperative, many pediatricians believe that they do not have the time, that they do not have an effective screening tool, and/or that it is not within their role as pediatricians.22 Other studies have also found that pediatricians have received very little training on IPV; screening in pediatric clinics remains rare.23–25 Borowsky and Ireland26 found that only 5% of 554 pediatricians surveyed routinely screened for IPV at well-child visits.

Although there are clear barriers that pediatricians face in screening for IPV, there is a compelling professional interest to help address this important problem. The mandate of pediatrics is broad, concerned with the total health and well-being of children.27 A national effort, Bright Futures, translated these ideas into practice recommendations for pediatricians, urging consideration of the child's environment in the family and in the community.28 This comprehensive approach to children's health, combined with the widely accepted system of routine checkups, offers an excellent opportunity to help ensure children's safety, health, and well-being and to prevent child maltreatment.29

There is a need for a practical pediatric model that enables pediatric health care providers to identify and address IPV effectively. Previous studies focused on the feasibility of screening in pediatric settings.6,7 There remains a need to examine rigorously the validity of a brief screen that could be useful in a pediatric setting. The objectives of this study were (1) to examine the prevalence of IPV in families using a university-based pediatric primary care clinic, (2) to examine the stability of the Parent Screening Questionnaire (PSQ) questions for IPV, and (3) to examine the validity (ie, sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV], positive likelihood ratio [LR+], and negative likelihood ratio [LR–]) of the PSQ using the Revised Conflict Tactics Scale (CTS2) as the "gold standard."


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Participants
This study used a quasi-experimental design in a university-based, pediatric resident continuity clinic.30 Two clinic days were randomly selected for the intervention group and 2 for the control group. To be eligible for participation in the study, mothers had to have a child who was younger than 6 years and being seen for a well-child checkup by a resident. We focused on preschoolers as a time when pediatricians have relatively frequent contact and possibly closer relationships with families. Caregivers also had to speak English and could not already have another child in the study, and the child could not be in foster care. For this article, we considered only those in the intervention group, for whom the PSQ was administered (Fig 1). Of the 507 mothers who were approached, 382 (75%) agreed to participate and 308 (81%) completed the study protocol. Of the 308 mothers, 108 were excluded from the analyses because they did not complete the protocol within 2 months of their clinic visit or they chose not to answer all of the questions on the CTS2. This left 200 for the analyses.


Figure 1
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  		FIGURE 1 Participation rates of families who were eligible to participate in the study.

 
Demographic characteristics of the sample are shown in Table 1. Most of the parents were mothers, single, and unemployed, and they averaged 25 years of age. There was considerable variation in their educational level. The children averaged 11.8 months of age, with a median age of 5 months. Approximately half of the children were male, and most were black. Families had an average of 2.2 children and 2.2 adults in the home, and most were receiving Medicaid. The demographic characteristics for these 200 caregivers were similar to those of the 108 caregivers who had not completed the clinic PSQ within the 2-month window. These 2 groups did not differ on the PSQ questions (on the computerized protocol) pertaining to IPV.


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  		TABLE 1 Demographic Characteristics of Study Participants (N = 200)

 
Procedure
After triage for regular checkups, nurses asked mothers of children who were younger than 6 years to complete the PSQ and give it to their child's physician. The 3 screening questions for IPV were part of the 20-item PSQ. The PSQ was implemented as part of a Model Care intervention that included training residents to assess briefly and initially manage psychosocial problems, working with a social worker. Separately, research assistants approached eligible mothers and briefly explained the project, asking whether they were interested in receiving more information. When mothers were interested, the research assistant reviewed the informed consent, as approved by our institutional review board. Mothers who were interested in participating were given an appointment within the subsequent 2 weeks to complete an audio computer-assisted self-interview of the study protocol that included the PSQ. The interview included more comprehensive, standardized measures of the targeted problems, such as the CTS2 to examine the validity of the IPV screening questions. This computerized interview occurred, on average, 8 days after recruitment. Interviews took place in our laboratory and lasted approximately 1.5 hours, and mothers were compensated for their time and effort.

Measures
PSQ
In developing the PSQ, we reviewed the literature for screening measures for IPV but found none that was well validated. We therefore adopted 3 questions that seemed promising and suitable for the study population: "Have you ever been in a relationship in which you were physically hurt or threatened by a partner?" "In the past year, have you been afraid of a partner?" and, "In the past year, have you thought of getting a court order for protection?"

The PSQ was pilot-tested with ~40 mothers in community pediatric clinics. Their input helped reduce the number of questions and to clarify others. An advisory committee of community pediatricians guided the development of the PSQ. They recommended keeping it brief, with a yes/no response set. Because the PSQ solicits sensitive information, it was important to frame this in a supportive context; therefore, the screen started with the following introduction: "Dear Parent or Caregiver: Being a parent is not easy. We want to help families have a safe environment for kids. We are asking everyone these questions. Please answer the questions about your child being seen today for a checkup. They are about issues that affect many families. If there's a problem, we'll try to help."

CTS2
The CTS231 for couples was used to validate the IPV screen. The CTS2 is a widely used measure that comprises 78 statements that assess how intimate partners resolve conflict, including aggression initiated by the respondent toward the partner and vice versa. In this article, we considered only violence toward the mother. For each statement, the respondent reported on how frequently the behavior happened in the past year: never, once, twice, 3 to 5 times, 6 to 10 times, 11 to 20 times, or >20 times. Each response was weighted: 0, 1, 2, 4, 8, 15, and 25, respectively. Participants could also respond that the behavior had happened but not in the past year.

The CTS2 has 5 subscales: negotiation, psychological aggression, physical assault, injury, and sexual coercion. The coefficient {alpha} of the subscales were .67, .62, .79, .46, and .38, respectively. Insulting, name calling, destroying property, and shouting are examples of psychological aggression. Throwing something at, shoving, punching, choking, and beating up are examples of physical assault. Bruises, broken bones, and being knocked unconscious are examples of injury, and being forced to do various sexual acts is an example of sexual coercion. There is good concurrent, content, and construct validity for the CTS2.31

For the psychological aggression subscale, a cutoff point was determined by the distribution of the respondents' weighted scores. The top fifth of respondents with the highest scores were compared with the rest. Because of limited variability on the physical assault and injury subscales, any endorsement was compared with no endorsement, an approach supported by the author of the CTS2.

Data Analysis
Stability
"Stability" indicates the degree of agreement between 2 responses by the same participant to the same questionnaire under different settings. Because of the change in the test environment (paper and pencil in the clinic to a computerized interview in the laboratory), we could not use the customary term "reliability." To determine the stability of the IPV screen, we compared the same 3 IPV questions on the clinic PSQ and on the audio computer-assisted self-interview PSQ. Cohen's {kappa},32 a measure of stability, is interpreted as values of < 0.21 suggesting no to slight agreement, 0.21 to 0.6 suggesting fair to moderate agreement, and > 0.6 suggesting substantial to perfect agreement. We examined stability rather than test–retest reliability because the mode of administration was not identical, changing from paper and pencil to computer.

Validity
To determine the validity of the clinic PSQ screen for IPV, we compared each of the 3 questions individually and in combination against the subscales of the CTS2, examining the sensitivity, specificity, PPV, NPV, LR+, and LR–. The sensitivity and specificity are properties of the screen and assess how well it detects IPV or its absence. PPV is the likelihood that a person with a positive result on a screen truly has experienced IPV. NPV is the likelihood that a person with a negative result on a screen truly has not experienced IPV. The PPV and NPV are affected by the prevalence of IPV.

The LR is the ratio of having a certain test result (positive or negative) in someone with a condition (eg, IPV) compared with someone without the condition. The LR of a positive test result (LR+) indicates how much the likelihood of having a positive result on a screen increases when a person has experienced IPV (LR+ = sensitivity/[1 – specificity]), compared with the likelihood of having a positive result on a screen when a person has not experienced IPV. The LR of a negative test result (LR–) indicates how much the likelihood of having a negative result on a screen decreases when the person has not experienced IPV (LR– = [1 –sensitivity]/specificity). LRs > 10 or < 0.1 suggest large and often conclusive changes in the likelihood, 5 to 10 or 0.1 to 0.2 suggest moderate changes, 2 to 5 or 0.2 to 0.5 suggest small changes, 1 to 2 or 0.5 to 1.0 suggest tiny changes, and 1.0 suggests no change at all.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Prevalence
The prevalence rates of the different forms of IPV were high (Table 2). On the clinic PSQ, 11.0% responded that they had ever been physically threatened or hurt by a partner. The rate was only slightly higher when one defined prevalence as answering "yes" to ≥1 of the 3 screening questions. Three quarters of mothers later reported on the CTS2 that their partner had ever used ≥1 type of psychological aggression toward them, one third reported that their partner had ever physically assaulted them in the past year, and more than one quarter reported that their partner had ever been sexually coercive toward them.


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  		TABLE 2 Percentage of Respondents Who Endorsed PSQ Questions and CTS2 Subscales

 
Stability
Comparing the clinic IPV screen with the computerized version, {kappa} values of 0.54, 0.54, 0.76, and 0.51 were found for, "Have you ever been in a relationship in which you were physically hurt or threatened by a partner?" "In the past year, have you been afraid of a partner?" "In the past year, have you thought of getting a court order for protection?" and for the 3 questions combined (a "yes" response on ≥1 question was considered a positive screen result), respectively.

Validity
Overall, the sensitivity of the 3 screening questions was low, although the specificity was high, when compared with the CTS2 (Table 3). The question about being physically hurt or threatened by a partner had the highest sensitivity (29%), using the CTS2 injury subscale as the gold standard. The specificity was high (92%). The PPV for this question was moderate (41%), although the NPV indicated that the likelihood of someone's not having the problem if the screen was negative was high (88%). The results of a comparison of the screening questions with the physical assault and psychological aggression subscales or with an index that combined the 3 subscales were not quite as good. The LR+ of 3.8 indicates that someone who has experienced IPV (eg, physical injury) is 3.8 times more likely to have a positive screen result compared with someone without that experience. The LR– indicates that someone who has experienced IPV is 0.77 times less likely to have a negative screen result compared with someone who has not been victimized.


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  		TABLE 3 Sensitivity, Specificity, PPV, NPV, LR+, and LR– for the PSQ IPV Questions Compared With CTS2 Subscale Scores

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
This study confirms that IPV remains a highly prevalent problem. As expected, the rates varied for different forms of IPV. The rate was highest for psychological violence and lowest (but not low) for sustaining an injury. In contrast, only 12% of mothers had a positive result for IPV on the clinic PSQ. Several factors may explain this discrepancy. First, studies have shown that people are more likely to disclose sensitive information to a computer rather than to a person, perceiving greater privacy.33 Second, the questions on the PSQ are more general (eg, "In the past year, have you been afraid of your partner?") than the very specific questions on the CTS2 (eg, "How many times in the past year has your partner pushed you, slapped you, or beaten you up?"). General questions may not be as effective at eliciting information; asking about specific experiences helps jog one's memory. In addition, some mothers may have been involved in abusive relationships without feeling "afraid." Similarly, many mothers revealed psychological aggression or minor physical assault but did not report that they were being hurt or threatened by their partners. Some of the items on the psychological aggression subscale involved relatively minor acts, such as yelling, and mothers probably did not perceive them as "bad enough" to answer yes to the screening questions; therefore, the PSQ was not tapping some of the areas covered by the CTS2, especially those involving relatively minor violence. Despite these methodologic differences, it is evident that IPV is a substantial problem. Furthermore, these findings confirm that many mothers are willing to disclose this sensitive information in pediatric settings.6,7

Two other considerations may explain the relatively low rates of some forms of IPV. As mentioned previously, there has been a reported decline nationwide in IPV.1 In 1993, there were 5.8 nonfatal intimate partner victimizations per 1000 US residents aged ≥12 years; in 2004, there were 2.6. Most of these were against women. The Department of Justice1 estimated, however, that only 21% of female victims of violence contact an outside agency for help. Children are residents in 43% of the households with IPV involving female victims.1 Another consideration is that the highest risk group of women may not have consented to participate in the study after being told that it included problems such as IPV.

The stability of the PSQ screening questions over time was only moderate. This may be attributable to the data's being obtained in 2 different ways. As mentioned previously, there is a tendency to reveal more sensitive information on a computer.33 Second, there could have been as many as 2 months between the 2 measures, although the average duration was just 8 days; circumstances could have changed during that period. Third, caregivers may have hesitated to share sensitive information with their child's pediatrician. Nevertheless, the moderate stability indicates that the screening items performed adequately over time, under varying circumstances.

The sensitivity (5%–29%) was lower than we anticipated. High sensitivity is 1 goal of a screen to identify accurately those with the condition; however, as mentioned, IPV is a very sensitive subject, and detecting even a modest number of families who are experiencing IPV may be preferable to detecting very few or no such families. Without a screen, our review of the children's medical charts, before the study and for the control group, revealed that IPV was rarely identified (data not shown). Others have also found screening to be rare in pediatric clinics.23–26 The mothers who disclosed IPV on the PSQ could have been those who were ready to acknowledge and address the problem. Those who did not may not have been at such a point (ie, precontemplative stage)34; therefore, although high sensitivity is important when screening for IPV, it may be reasonable to detect and focus on those who are amenable to addressing the problem. In addition, it is possible that by just asking the questions, parents will learn to recognize pediatricians as a potential resource and turn to them at a future time. Raising an issue such as IPV may convey an important message to the mothers who bring young children to pediatric care that they, too, are important, that IPV is a problem, and that their pediatrician is interested in helping.

The study showed that just 1 screening question about being physically hurt or threatened by a partner seems to be as effective at screening for IPV as are 3 questions. This offers a very brief screen for IPV, although additional work is needed to achieve greater sensitivity. The screening questions had excellent specificity ranging from 91% to 98%. High specificity is key to identifying accurately those for whom IPV is likely to be a problem (ie, true-positive results); however, the trade-off for increased specificity is decreased sensitivity. Lower sensitivity will increase the number of false-negative results: parents who are experiencing IPV but do not disclose the problem.

The PSQ questions had acceptable PPVs. When the screen result was positive, the brief assessment that followed should have quickly identified those for whom IPV was not really a problem. In this case, undue anxiety should not be a substantial problem. The NPVs were uniformly high. It is helpful to know that a negative screen result usually indicates that IPV is not a problem. This saves physician time in not needing to probe this issue. The LR+ was moderately high, indicating those who were experiencing IPV were 3.8 times more likely to have a positive screen result compared with those without the problem.

The PSQ stated that we would try to help if problems were identified. When ≥1 of the IPV questions was answered positively, the resident or social worker expressed empathy, attempted to clarify the situation, and discussed available options. These included offering information regarding a "safety plan," crisis intervention by the social worker, and information on a hotline and shelter. The potential risks to the child were also assessed, as was the need for a report to child protective services.

There are a few limitations to this study. Families in the study came mostly from a very disadvantaged community where poverty and violence are commonplace; therefore, it is possible words such as "afraid" or "hurt" could have different meanings in their context. Caution is warranted not to extrapolate to different populations. This study focused on parents of preschoolers. It is possible that the PSQ could be a useful screen for parents of older children. Another issue concerns the relatively broad criteria that the CTS2 has for what constitutes IPV, particularly psychological aggression. For example, families with a single episode measured as having a positive result for that subscale (eg, "My partner yelled at me once in the past year," equals a positive psychological aggression screen result, or, "My partner grabbed me once in the past year," equals a positive physical assault screen result). In an attempt to stratify families who were experiencing IPV and those who were experiencing minor conflicts, we separated the top quintile for psychological aggression.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
IPV remains an all too common problem. Some mothers were willing to disclose this sensitive information in a low-income, university-based, pediatric primary care clinic. As anticipated, many mothers who were experiencing IPV did not reveal this information on the PSQ in the clinic. Nevertheless, identifying the subset who did disclose IPV may be valuable, if it leads to help. For others, a seed may have been sown: pediatricians are concerned with family problems, too, and, IPV is a problem that affects children. Having a screening tool is a valuable first step.22,35 This must be accompanied by physician training to help them address identified problems.36 Additional research is needed to examine screening questions and, most important, to evaluate whether screening leads to appropriate services and diminution of the problem of IPV.37


   ACKNOWLEDGMENTS
 
This research was supported by a grant from the Office on Child Abuse and Neglect, Administration for Children, Youth, and Families, US Department of Health and Human Services (90-CA-1695).


   FOOTNOTES
 
Accepted May 29, 2007.

Address correspondence to Howard Dubowitz, MD, Department of Pediatrics, University of Maryland School of Medicine, 520 W Lombard St, Baltimore, MD 21201. E-mail: hdubowitz{at}peds.umaryland.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics




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