pediatrics
June 1998, VOLUME101 /ISSUE 6

The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women

  1. Committee on Child Abuse and Neglect

Abstract

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.9The 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—1-800-799-SAFE.

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:

  1. Residency training programs and continuing medical education (CME) program leaders incorporate education on family and intimate partner violence and its implications for child health into the curricula of pediatricians and pediatric emergency department physicians;

  2. Pediatricians should attempt to recognize evidence of family or intimate partner violence in the office setting;

  3. Pediatricians should intervene in a sensitive and skillful manner that maximizes the safety of women and children victims; and

  4. Pediatricians should support local and national multidisciplinary efforts to recognize, treat and prevent family and intimate partner violence.

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

Footnotes

  • 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.

AAP =
American Academy of Pediatrics
AMA =
American Medical Association

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