Background. Child abuse and wife abuse are linked. Studies indicate 30% to 59% of mothers of children reported for child abuse also are battered. In homes where domestic violence occurs, the children are at increased risk of physical abuse or neglect. Children who witness battering of their mothers are at risk for psychosocial sequelae including developmental delays and posttraumatic stress disorder.
Objective. To determine pediatric emergency medicine fellows' level of preparedness to respond to battered mothers, and to assess obstacles and attitudinal barriers to their effective response.
Study Design. Self-reported written survey.
Methods. A 30-item anonymous questionnaire was mailed to 162 pediatric emergency medicine fellows in the United States and Canada in 1995. A response rate of 77.2% (n = 125) was achieved.
Results. Before fellowship, 97.6% of respondents had training (including formal courses, conferences, and direct patient contact) on child abuse/neglect although only 29.6% received similar instruction on woman battering. There was a marked disparity between patient contact experience for child abuse/neglect and woman battering throughout training. Before fellowship, 89/122 (73%) reported direct involvement in at least 10 cases of child abuse/neglect. Seventy-one (57.3%) of 124 fellows had not handled any cases of woman battering before fellowship; 106/124 (85.5%) had been directly involved in fewer than 10 cases. During fellowship 81 (67.5%) of 120 respondents had been involved in at least 10 cases of child abuse/neglect and 46/120 (38.3%) had handled at least 20 cases. In contrast, 72 (73.5%) of the 98 responding fellows had not handled any cases of woman battering during fellowship. Furthermore, 86/100 fellows reported no formal training on woman battering in their fellowship curricula. Only 5/118 (4.2%) reported having protocols in place for responding to battered women in the pediatric emergency department. Items most frequently selected from a list of potential obstacles to responding to battered women included: lack of a protocol (82/113), lack of formal training in the field (103/118), and lack of experience with woman battering cases (100/117). The majority, 75/118 (63.6%), believed that responding to battered mothers did not belong in the purview of pediatrics. Potential attitudinal barriers confirmed with the greatest frequency included: frustration that nothing could be done and lack of time to respond appropriately to battered mothers in the pediatric emergency department.
Conclusions. Battered mothers are rarely identified in the pediatric emergency department even though the physicians report handling a significant number of child abuse/neglect cases. Education on domestic violence, including the implications of woman battering for childrens' health, should be incorporated in the training curricula of pediatric emergency department physicians to raise awareness of the need to explore for the presence of concurrent abuse in both children and their mothers. Identifying battered women through their children will impact greatly on the welfare of both mother and child.
- US =
- United States •
- PED =
- pediatric emergency department •
- PEM =
- pediatric emergency medicine •
- CAN =
- child abuse/neglect •
- ED =
- emergency department •
- WB =
- woman battering
It is currently estimated that between 2 and 4 million women are physically battered annually in the United States (US) by their male partners.1,2 At least 25 to 30% of all American women are at risk for domestic violence during their lifetime.3 Woman battering and child abuse are intricately connected. Within a group of children that had been flagged as suspected victims of child abuse or neglect, 45% of their mothers had also been battered.4 A study in Massachusetts assessed a sample of 200 substantiated child abuse cases and found documentation of abuse of the mother in 30%.5 A medical record review done at Boston City Hospital showed that 59% of mothers of abused children were suspected victims of battering.6 In addition, child abuse occurs disproportionately in homes where domestic violence exists. Children of battered mothers are 6 to 15 times more likely to be abused.7,8 In cases of severe wife abuse, the coexistence of child abuse may be as high as 77%.1
Moreover, children who witness family violence significantly outnumber those who are direct victims of abuse.9 In the US, from 3.3 million10 to 10 million11 children are estimated to witness parental violence annually. Studies indicate that 40 to 60% of child abuse victims have witnessed abuse of their mothers on one or more occasions.12 The impact of domestic violence on children reaches beyond suffering direct physical abuse or neglect. Witnessing the battering of their mothers may be as traumatic to children as being a direct victim of abuse, and both result in similar psychosocial and developmental sequelae.13-15 Indeed, the witnessing of one's mother being battered has been called the most insidious form of child abuse.16
Historically, distinct programs and practitioners have taken responsibility for responding to battered women and abused children. The demonstrated coexistence of spouse abuse and child abuse, together with the documented impact of children witnessing domestic violence, has prompted strong argument for developing an interdisciplinary approach to the victims of family violence by all professionals who are in a position to respond.17,18 Early efforts to educate healthcare professionals stressed the need for inclusion of the effects of woman battering on children.19 The Joint Commission on Accreditation of Healthcare Organizations has broadened its standards on responding to victims of abuse in recognition of the need to manage victims of family violence across departmental settings in medicine.20 Such efforts are grounded in the recognition that physicians often can best protect the child victim (whether they are a witness or direct victim) by recognizing that the mother is battered and also needs attention, counseling and protection.
Often the first place a battered woman presents for help is in the health care system with the hospital emergency department frequently being the frontline.21 Consequently, much research has been done to examine the response to woman battering in the adult emergency department,22-27 often focusing on women who present to the emergency room with injuries.22,24-25 Pediatric emergency department (PED) physicians are in a unique position to identify and respond to battered mothers through their children, even though the mother is not the primary patient. Indeed, some women who are battered for years may only seek help in the medical community when injury to their child occurs. In this study we surveyed PED physicians in training to measure their level of preparedness to respond to battered mothers, and to determine the potential obstacles and attitudinal barriers to their effective response.
The survey was conducted by the Injury Control Center at the Harvard School of Public Health. Pediatric emergency medicine (PEM) training programs were identified by combining the fellowship programs listed in Pediatric Emergency Care28 and the National Resident Matching Program list of positions beginning in 1993 and 1994. The names and addresses of all individuals participating in PEM fellowships in the US and Canada were obtained from the list of attendees of the National Pediatric Emergency Medicine Fellows Conference (1994 and 1995) and through direct telephone contact with the training programs.
We developed a 30-item, self-administered questionnaire to obtain information on the extent of training PEM fellows receive on adult domestic violence and child abuse, and to quantify their level of preparedness for identifying and dealing with battered women, as well as children who are neglected or abused. Respondents also were provided with lists of potential obstacles and attitudinal barriers to identify those most frequently cited as impediments to recognizing and responding to battered women and victims of child abuse/neglect (CAN). Herein we report the results on responding to battered women. Data on the fellows' self-assessment of their preparedness to identify and manage victims of CAN will be published elsewhere.
One hundred sixty-two questionnaires were mailed in March 1995 with a second mailing to all nonresponders approximately 1 month later. Response was anonymous. One hundred twenty-five fellows returned the survey for a response rate of 77.2%.
These data were analyzed using the Epi-info database. Chi-square analysis was used to examine differences between groups. For those data on the number of CAN and woman battering (WB) cases managed by the physicians, we report both the mean ± SD and the median due to extreme values in the former and the positively skewed distribution for the latter. We did not remove potential outliers but left all reported values in to allow the reader their own interpretation.
Demographic characteristics of the respondents and the details of their training background are reproduced in Table 1. The surveyed population was 54.7% women, which is consistent with national estimates of the gender distribution in pediatrics. Among the respondents, 59.2% were women. Nearly all respondents were first and second year fellows while only 3 (2.4%) were doing a third year of training that, at the time of this survey, was not a requirement. The majority (90.4%) had completed residency training in pediatrics. Most fellows (63.2%) trained in a free standing children's hospital without an adult emergency department (ED) in the same facility.
Information was obtained on the extent of training received in CAN, WB and other aspects of adult domestic violence before their current fellowship training. Although 97.6% of the responding fellows reported prior instruction in CAN during medical school and residency, less than one-third had received training on woman abuse/battered women (29.6%) or adult sexual abuse (28.8%). The reported proportion receiving training on dating violence and elder abuse was even lower (25.6 and 15.2%, respectively). The mean number of hours devoted to all topics combined was 16.8 (range 1 to 136 hours); 65/111 (58.6%) reported ≤10 hours of training in all categories combined.
Few PED training programs offered organized lectures or conferences on WB in their current curriculum (Table 2). Notably, half (51.8%) of the responding fellows believed some formal instruction would be moderately to very helpful to add to the curriculum.
Table 3 contrasts the physicians' experience through direct management of CAN and WB cases. Before starting fellowship most of the respondents had been directly involved in a significant number of CAN cases (mean ± SD 27.6 ± 58.2, median 15). Only one fellow reported never having handled a case where child abuse was suspected. More than one-half, 89/122 (73%), recalled being directly involved in at least 10 CAN cases; 56/122 (45.9%) handled at least 20 cases. This can be contrasted to their reported involvement in WB cases. Seventy-one of the 124 fellows (57.3%) reported never being involved in a case of suspected WB before fellowship; 106/124 (85.5%) had been involved in fewer than 10 such cases. The number of cases reported for either category was not significantly different between men and women.
A similar disparity between the reported experience with CAN cases vs WB cases was seen during fellowship. When asked how many suspected CAN or WB cases they had been directly involved with, the respective means ± SD were 21.4 ± 32.1 and 1.1 ± 2.6 (median 10 and 0, respectively). A significant majority, 72/98 (73.5%), reported never being involved in a WB case since starting fellowship. There was no association between sex of the responder or type of hospital setting in which they were training and the number of WB or CAN cases managed.
The PED fellows were asked to qualitatively rate their preparedness to recognize and respond to battered mothers based on their formal training to date. These results are shown in Table 4. Of note, fewer than 20% rated their abilities above fair, and more than 40% believed their training had prepared them poorly or not at all.
Only 5/118 responders (4.2%) reported having a written protocol for responding to battered women in the PED. Only one respondent indicated they did not know if a protocol existed. Of those PEDs with a battered woman protocol in place, four of five also had quality assurance to check on the frequency and thoroughness of the protocol's use.
Several obstacles to identifying battered women and making appropriate referrals were identified by the PED fellows from a provided list (Table 5). Those obstacles identified most frequently as minor or major obstacles and least frequently as not an obstacle were: 1) lack of a protocol, 2) lack of formal training on this topic, and 3) lack of experience with WB cases. The majority, 75/118 (63.6%), indicated that responding to battered women was not in the purview of pediatrics.
Responses on all aspects of training and potential obstacles were examined based on the gender of the responding physician. Table6 shows the responses that were significantly different between men and women. Overall, women were more likely than men to identify obstacles. Proportionately more women than men indicated that lack of a WB protocol, unavailability of a social worker 24 hours per day, and lack of formal training on WB were at least minor obstacles. More women than men indicated that the care of battered women was not in the purview of pediatrics by citing this as an obstacle.
Interestingly, when asked what they would do if they suspected that a child's mother was being battered, almost all (119/125) responded that they would refer them to a social worker who could then make appropriate referrals. This was equally true whether they were training in hospitals with an adult ED in their facility or in a free-standing pediatric hospital. No data were obtained on whether the social workers were trained to respond to and refer battered women.
The survey provided a list of personal attitudinal barriers to responding to battered women including: 1) frustration that nothing could be done, 2) feeling overwhelmed, 3) not having enough time to handle it, 4) fear for their personal safety, 5) feeling helpless and 6) feeling angry at the mother, 7) none, and 8) an open-ended other category. Responders were allowed to check more than one answer. Ten fellows left this item blank and one noted the entire question was not applicable. Fifty-nine of the 114 (51.8%) responders checked none as the category, indicating that there were no attitudinal barriers to responding to battered women in the PED. Of those fellows who identified obstacles 20/55 (36.4%) felt frustrated that nothing could be done and 31/55 (56.4%) indicated that there was not enough time to handle this appropriately in the PED. There were fewer than 10 responders in each of the remaining categories. There were no significant differences between the responses given by men and women or between first year fellows and those in their second/third year of training.
A number of fellows responded to the open-ended other category. Interestingly, 16 fellows reiterated that caring for battered women was not in the scope of pediatrics stating: “lack resources for adults in a pediatric hospital”; “I do not treat the mother as a patient”; “we do not care for adults; we can only make referrals to social workers; ” “not sure how to approach this given that the women arenot our patients”; “I feel it is out of my jurisdiction as a pediatrician”; “not primarily involved with care of adult patients”; and “I feel it is not part of my job”. A few reemphasized their lack of training and remarked: “no training: I am in a pediatric facility”; “not my area of comfort/expertise”; and “unsure what to do, lack formal training.” Others expressed frustration over not being able to control the mother's behavior: “they protect the batterer and won't agree to seek help for themselves”; “some responsibility is placed back on mother to file, leave, etc.”; “there is resistance of mother to questioning/intervention”; “mothers are adults and havesome responsibility for their own care”; and “one is faced with an adult who determines their own destiny.”
Many lines of research stress the important link between child abuse and adult domestic violence, specifically battering of the child's mother. Stark and Flitcraft29 have indicated that identifying battered mothers may be the single most important means of identifying child abuse. Conversely, when child abuse is suspected, the potential that the child's mother is being battered cannot be ignored. Also, the need to intervene for children who are secondary victims of domestic violence, as they witness the battering of their mothers, is emerging as a crucial factor in responding effectively to family violence. Given the complex relationship between battered women and their children, it can be argued that identifying battered mothers may be the best way to protect their children. Those in a position to identify child witnesses and victims of domestic violence are in an excellent position to respond to battered mothers. The pediatric emergency room is recognizably one medical care setting where this unique opportunity exists. This study, however, demonstrates that battered women are rarely identified in the PED. We also identify major obstacles to effective intervention, including lack of training and experience, and confirm internal barriers cited by the responding physicians.
These data underscore an important training gap in medical education pertaining to domestic violence, as the fellows identified a clear disparity between training on child abuse and training on battered women. Although nearly all had received education and training on CAN in medical school and/or residency, less than one-third of the respondents noted any training on WB. During PEM fellowship training, the program that included material on battered women was by far the exception to the rule.
This disparity can likely be accounted for by several factors. Physicians are better educated about child abuse and neglect compared to other forms of domestic violence, in part, as a result of the adoption of mandatory child abuse reporting laws in the 1960s. With the implementation of such laws came an increase in reporting and a consequent rise in demand for professional and community education and programs to facilitate systematic response to victims of child abuse.30 The lack of required training on adult domestic violence, including woman battering, in medical schools has previously been documented. In a study of all 143 accredited US and Canadian medical schools surveyed in 1987 to 1988, 58% of the 116 responding schools did not require instruction about battering in their curriculum.31 The skewed training on child abuse in our survey was also likely influenced by the fact that nearly the entire study population trained in pediatrics before fellowship, and thus had limited contact with adult patients. Importantly, a majority of the PED fellows cited the lack of formal training on WB as a major obstacle to recognizing and responding to battered mothers.
The most frequently confirmed obstacle to identifying battered women was lack of experience with WB cases. The low numbers of WB cases seen during fellowship paralleled those reported for the prefellowship experience. Also, a remarkable disparity between the number of CAN cases and WB cases handled by the physicians surveyed was observed throughout training. The latter finding is especially striking when taken in the context of research indicating abused children are likely to have abused mothers.4-6 Despite the established link between CAN and WB, the majority of respondents believed that attending to battered mothers was not in the purview of pediatrics. These data suggest that CAN and WB are viewed as separate entities in the PED, with patient care responsibilities defined by traditional medical specialty boundaries. We would argue that this approach not only neglects the needs of the battered mother, but indirectly impedes effective response to the needs of the child as well. To overcome this obstacle, training on family violence must be balanced with respect to the issues of WB and CAN, and must include the implications of their co-occurrence.
Many of our findings on perceived obstacles to responding to battered women parallel those revealed in a study of primary care physicians' response to domestic violence.32 Sugg and Inui32 conducted open-ended interviews with 38 physicians and found that the most frequently identified perceived barriers to the recognition of domestic violence and intervention in the primary care setting were: ( 1) time constraints (71%), (2) powerlessness (50%), (3) lack of comfort (39%), (4) loss of control (42%), and (5) fear of offending the patient (55%). In that same study, many physicians who expressed a sense of powerlessness also pointed to their lack of training on domestic violence during medical school and residency or in continuing medical education courses—61% revealed they had no training while 8% said they had good training on this issue. Expressed frustration over not being able to control the behavior of the domestic violence victim by making them change their circumstances and/or seek help, was cited in our survey and by the primary care physicians. We would agree with Sugg and Inui,32 that physician's education on domestic violence may be most lacking with respect to understanding the dynamics that maintain women in abusive relationships. To overcome the latter obstacle, we must overcome the prejudices that exist toward women in battering relationships by educating all physicians about the battered woman's syndrome.16 Healthcare professionals who receive formal training on domestic violence are less likely to hold the battered persons responsible for their situation.33
Another important obstacle identified in this study is that battered women protocols are rare in the PED. Evidence supports the effectiveness of protocols in increasing the appropriate identification of battered women in the emergency room. In one study of female trauma victims in the emergency department, the implementation of such a protocol increased the proportion of all patients identified as battered from 5.6 to 30%.24 Although protocols facilitate the response to battered women, they do not preclude the need for continued education on identifying domestic violence. In a follow-up study McLeer et al25 found that without continued presence of staff who were knowledgeable about and interested in the issue of family violence, the level of identification of domestic violence in the emergency room returned to the low levels seen before implementing the protocol.
The findings of McLeer et al25 point to another potential barrier impeding the pediatric emergency room fellow's response to woman battering that was not directly addressed in this study. That is, the senior pediatric faculty overseeing the fellowship training also have not received training around the issues of adult domestic violence or the link between child abuse and woman battering. Therefore, they will not feel equipped to respond appropriately and may not consider pursuing the presence of battering of a child's mother. Thus, the fellows would not be encouraged to inquire about domestic violence in the child's home in the context of their postgraduate training.
The most frequently noted attitudinal obstacle was “lack of time in the emergency room to respond to the battered mother.” The time constraints of treating a battered child, much less a battered woman, are indeed enormous and understandably daunting in the context of a busy PED. Implementation of programs and policies involving many care providers (including nurses, social workers, advocacy groups, etc.) to facilitate response to suspected battered women and children would help take the burden off the physician and alleviate time constraints. One specific consideration would be to develop programs nationally modeled after the Advocacy for Women and Kids in Emergencies (AWAKE) program pioneered at Children's Hospital of Boston. An interdisciplinary team assesses the mother of any child reported for abuse, and an advocate is assigned to refer suspected battered mothers to the appropriate services. The advocate continues to advise the mother as she interacts with the different agencies and guides the woman through the process. The role of the physician is crucial for such a program to succeed, as the physician needs to be trained to identify these patients and make the initial referral.
As we formulate approaches to family violence in an interdisciplinary fashion we must be mindful of the unique issues existing around responding to abused children and battered women, paying particular attention to how they differ. Mandatory child abuse reporting laws are grounded in the belief that children are unable to make informed decisions giving the state a paternalistic guardianship role. When alleged child abuse is reported, the state child welfare agency immediately steps in to investigate the circumstances, refer the family for appropriate services or, in cases of substantiated abuse, remove the child from the abusive home. Therefore, although not without flaws, there are existing programs in place to facilitate a systematic response with the goal of protecting the child victim. As of March 1994 there were existing laws in 45 states and the District of Columbia that mandated reporting injuries resulting from a gun, knife, or other deadly weapon or injuries sustained during a crime, violent act, or nonaccidental act.34 To varying extents these statutes are potentially applicable to woman battering cases. Hyman et al34 elegantly outline the ethical and moral issues faced by healthcare professionals when considering the implications of mandatory reporting of woman battering. They discuss the many significant ways that reporting of woman battering differs from child abuse reporting. Mandatory reporting for woman battering may threaten the safety of battered women. Patient autonomy and confidentiality—basic components of the ethical standard for all physician-patient relationships—are also threatened through this approach. Strategies sensitive to these differences need to be a part of any approach taken to responding to battered mothers.
Internal barriers to responding to battered women may be different for male and female physicians. In this group of pediatricians, the reported frequency of certain obstacles were significantly different based on the physician's gender. Sugg and Inui32 also found gender differences in the responses given by male and female primary care physicians when exploring attitudes about domestic violence. It may be that we need to explore how societal determinants of gender roles effect a physician's response to domestic violence. Further research is necessary to explore this issue as it may be important to account for such gender differences when designing curricula to enhance appropriate response to domestic violence.
These findings have broad implications for medical education and indicate a need for curricular changes both in medical schools and at the postgraduate level regarding response to family violence. Without adequate training WB will continue to be largely a missed diagnosis, especially in specialties such as pediatrics where the battered woman is not the physician's primary responsibility. Although pediatric emergency room physicians were surveyed in this study, one could argue that the curricular changes that are called for should be implemented in all medical settings. All physicians must recognize the therapeutic potential of treating the family as a whole when domestic violence is recognized. Curricular changes designed to educate physicians on WB and CAN as a combined discipline, stressing the implications of WB for children, will better equip physicians from all training backgrounds to respond to women and children who are in battering relationships. The necessary educational changes, together with the implementation of policies in the PED facilitating an interdisciplinary approach to family violence, would increase the rate of detection of battered women. Such interventions are warranted as the identification of battered women through their children will impact greatly on the welfare of the child, as well as helping the mother. Indeed, in most cases, the children may best be protected by protecting their mothers.
This study was supported by the Harvard Injury Control Center, which is supported by a grant from the Centers for Disease Control and Prevention. During this study R.J.W. was a research fellow in medicine at Brigham & Women's Hospital, Boston, MA supported by the National Institutes of Health training grant HL07427.
- Received February 13, 1996.
- Accepted April 17, 1996.
Reprint requests to (R.J.W.) Channing Laboratory, Harvard Medical School, 181 Longwood Ave, Boston, MA 02115.
- ↵Straus MA, Gelles RJ. How violent are American families? Estimates from the National Family Violence Resurvey and other studies. In: Straus MA, Gelles RJ, eds. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8145 Families. New Brunswick, NJ: Transaction; 1990
- ↵Rosenberg M, Stark E, Zahn M. Interpersonal violence: homicide and spouse abuse. In: Last JM, ed. Public Health and Preventive Medicine. 12th ed. Norwalk, CT: Appleton-Century-Crofts; 1986
- ↵Pagelow M. Family Violence. New York, NY: Praeger Publishers; 1984
- Stark E,
- Flitcraft AH
- McKibben L,
- DeVos E,
- Newberger E
- ↵Stark E, Flitcraft AH. Violence among intimates: an epidemiological review. In: Hasselt, VN, et al, eds. Handbook of Family Violence. New York, NY; Plenum Press; 1987
- ↵Women and Violence. Hearings before the U. S. Senate Judiciary Committee, August 29, 1990 and December 11, 1990. Senate Hearing 101–939, pt. 2, p. 142
- ↵Carlson BE. Children's observations of interparental violence. In: Roberts AR, ed. Battered Women and their Families. New York, NY: Springer; 1984
- ↵Straus MA. Children as witness to marital violence: a risk factor for lifelong problems among a nationally representative sample of american men and women. Presented at the Ross Roundtable on Children and Violence, Washington, DC, 1991
- ↵Straus MA, Gelles RJ, Steinmetz S. Behind Closed Doors. New York, NY: Anchor Press; 1980
- Hughes, HH
- Augustyn M,
- Parker S,
- McAlister Groves B, Zuckerman, B
- ↵Jaffe PG, Wolfe DA and Wilson SK. Children of Battered Women. Newbury Park, CA: Sage Publications, 1990
- ↵Walker LE. Battered Women. New York, NY: Harper & Row; 1979
- ↵Gelles R, Cornell CP. Prevention and treatment: society's response and responsibility. In: Intimate Violence in Families. Newbury Park, London; Sage Publications, 1990
- ↵Klingbeil KS, and Boyd VD. Emergency room intervention: detection, assessment, and treatment. In: AR Roberts (ED.), Battered Women and their Families. New York, NY: Springer; 1984
- ↵Calhoun D. Wife abuse: an opportunity for prevention. Injury Prev Network Newslett. San Francisco, CA; 1988;5:1–5
- ↵Stark E, Flitcraft A, and Frazier W. Wife Abuse in the Medical Setting: An Introduction for Health Personnel. Washington, DC: Office of Domestic Violence; 1981
- ↵Stark E, Flitcraft AH. Spouse abuse. In: Rosenberg ML, Gemley MA, eds. Violence in America: A Public Health Approach. New York: Oxford University Press; 1991
- ↵Newberger EH. The helping hand strikes again: unintended consequences of child abuse reporting. In: Newberger EH, Bourne R, eds. Unhappy Families: Clinical and Research Perspectives on Family Violence. Littleton, MA: PS Publishing; Department of Health and Human Services, Public Health Service; 1986
- Rose K,
- Saunders DG
- Copyright © 1997 American Academy of Pediatrics