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Screening for Family Violence: Overcoming the Barriers
The ability to recognize partner or child abuse and to use an appropriate intervention are medical skills that can be life saving. For physicians, the first step in this important process is screening patients for violence as recommended by the American Medical Association and American Academy of Pediatrics, but that process is not easy or straightforward. For many reasons, few family physicians or pediatricians routinely screen for family violence. In this issue of the Journal, Zink1 addresses one aspect of this topic.
There are many reasons this screening is not happening routinely: (1) it is a fairly new idea, and it takes time for new ideas to diffuse through the practicing community;2 (2) some physicians do not think it is an important issue;3,4 (3) others forget to screen because of time constraints;5 (4) some choose not to ask for fear of discovering something they are not prepared to treat or spend time managing;6 (5) some physicians still do not identify family violence as a health issue;7 and (6) some do not know how to comfortably approach the topic.8,9
There are, however, clinicians who are committed to addressing issues of violence among the families they serve. They want to screen patients and families as recommended, but they ask genuine and complex questions about how to best do the job. Zink adds information to this discussion. Through interviews with experts in the fields of domestic and child abuse, the author inquired how screening for evidence of family violence can be done safely and appropriately when children are present at the office visit. The author hoped that reading the answers to this question would move more clinicians to perform this important screening and would assist those who are already screening serve their patients more safely and effectively.
Zink learned through the summarized answers of the study’s experts that more research is needed to learn what questions are appropriate to ask in front of a child. However, there are some very important findings in her study that should be emphasized before it is [put in the] filed under “to be continued.”
Screening Suggestions
First, the experts agree that discussions about partner and child violence can happen in the presence of preverbal children. Those discussions need to happen immediately and should not be delayed until further research is published. Fifty percent of the families in which the mother is being battered also have on-going child abuse10 committed by the father, mother, or both.11,12
Second, all experts believed that further assessment (beyond screening) for potential family violence needs to happen when verbal children are not present. This is both a safety and a privacy concern because the children may report the conversation to the violent parent, who may then further injure the victim. Questions about this topic also need to be posed in a private and confidential manner, such as those about mental and reproductive health issues.13
Third, the experts in Zink’s study suggested the possibility of pencil and paper screening. Although fewer people reveal partner violence using paper and pencil than with personal interviewing, many do disclose this information using a written approach.14,15 If the written screen is followed with a one-on-one private assessment and documentation is maintained either in the mother’s chart or through a variation of the “blue dot” system on the child’s chart, confidentiality and safety can be maintained.
Fourth, the experts agreed unanimously that when child abuse is disclosed, all physicians must follow through to meet the local mandatory reporting obligations. In 5 states there are laws regarding mandatory reporting of intimate partner violence: California, Kentucky, New Mexico, New Hampshire, and Rhode Island; 2 other states permit reports, Mississippi and Pennsylvania.16
Fifth, few of the experts knew the signs and symptoms of children who witness violence. Descriptions of these behaviors are not widely available in the medical literature, so this was not unexpected. The red flags include symptoms of posttraumatic stress disorder (PTSD), and a decline in the child’s emotional stability, ability to function in school, and orientation to the future.17 In children, symptoms of PTSD can include flashbacks, difficulty with concentration or sleep, attachment problems, sudden startling or hypervigilance, and at-risk behaviors based on a sense of a limited future.18,19 Discussions of these findings and their relationships to other personal, family, and social health issues should be identified and published to raise awareness and further sensitize concerned clinicians.
The next step indicated by Zink is further research, so physicians can do our jobs safely and effectively. Those of us who do research in this area are called to action.
Make a Difference
In the meantime, we need to screen for partner violence and child abuse in our practices. The consensus of the experts is that we continue to do screening in private (ie, the partner and verbal children are not present) and that the documentation be confidential. This is important. Given our recent experiences with increasing personal, family, and school-based violence, it is clear our physical, mental, and social health all hang in the balance. Each of us can make a difference, one patient at a time.
1. Zink T. Issues to consider when screening for partner violence in front of children. J Fam Pract 2000;49:130-136.
2. Rogers EM. Diffusion of innovations. 4th ed. New York, NY: The Free Press; 1995.
3. McGrath ME, Bettachi A, Duffy SJ, Peipert JF, Becker BM, St Angelo L. Violence against women: provider barriers to intervention in emergency departments. The battering syndrome: a poor record of detection in the emergency department. Acad Emer Med 1997;4:297-300.
4. Reid SA, Glasser M. Primary care physicians’ recognition of and attitudes toward domestic violence. Acad Med 1997;72:51-3.
5. Skolnick AA. Physician, heal thyself — then aid abused women. JAMA 1995;273:1722-45.
6. Sugg NK, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60.
7. Elliott BA, Johnson MMP. Domestic violence in a primary care setting. Arch Fam Med 1995;4:113-9.
8. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-7.
9. Gerbert B, Caspers, N, Bronstone A, Moe J, Abercombie P. A qualitative analysis of how physicians with expertise in domestic violence approach identification of victims. Ann Intern Med 1999;131:578-84.
10. S, Edleson JL. In the best interest of women and children: a call for collaboration between child welfare and domestic violence constituencies. The prevention report. Iowa City, Iowa: The National Resource Center for Family Centered Practice; 1995;1-7.
11. MA, Gelles RJ. eds. Physical violence in American families. New Brunswick, NJ: Transaction Publishers; 1990.
12. LE. The battered woman syndrome. New York, NY: Springer; 1984.
13. C, Alpert E. Integrating routine inquiry about domestic violence into daily practice. Ann Intern Med 1999;131:619-20.
14. J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176-78.
15. D, Elliott BA. Screening for domestic violence in a rural family practice. MN Med 1997;80:43-5.
16. A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA 1995;273:1781-7.
17. J, Dubrow N, Kostelny K, Pardo C. Children in danger: coping with the consequences of community violence. San Francisco, Calif: Jossey-Bass; 1992.
18. JA. Post-traumatic stress disorder in children and adolescents: a review of the literature. In: Chess S, Thomas A, eds. Annual progress in child psychiatry and development. New York, NY: Brunner Mazel; 1987;42:59-83.
19. Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
The ability to recognize partner or child abuse and to use an appropriate intervention are medical skills that can be life saving. For physicians, the first step in this important process is screening patients for violence as recommended by the American Medical Association and American Academy of Pediatrics, but that process is not easy or straightforward. For many reasons, few family physicians or pediatricians routinely screen for family violence. In this issue of the Journal, Zink1 addresses one aspect of this topic.
There are many reasons this screening is not happening routinely: (1) it is a fairly new idea, and it takes time for new ideas to diffuse through the practicing community;2 (2) some physicians do not think it is an important issue;3,4 (3) others forget to screen because of time constraints;5 (4) some choose not to ask for fear of discovering something they are not prepared to treat or spend time managing;6 (5) some physicians still do not identify family violence as a health issue;7 and (6) some do not know how to comfortably approach the topic.8,9
There are, however, clinicians who are committed to addressing issues of violence among the families they serve. They want to screen patients and families as recommended, but they ask genuine and complex questions about how to best do the job. Zink adds information to this discussion. Through interviews with experts in the fields of domestic and child abuse, the author inquired how screening for evidence of family violence can be done safely and appropriately when children are present at the office visit. The author hoped that reading the answers to this question would move more clinicians to perform this important screening and would assist those who are already screening serve their patients more safely and effectively.
Zink learned through the summarized answers of the study’s experts that more research is needed to learn what questions are appropriate to ask in front of a child. However, there are some very important findings in her study that should be emphasized before it is [put in the] filed under “to be continued.”
Screening Suggestions
First, the experts agree that discussions about partner and child violence can happen in the presence of preverbal children. Those discussions need to happen immediately and should not be delayed until further research is published. Fifty percent of the families in which the mother is being battered also have on-going child abuse10 committed by the father, mother, or both.11,12
Second, all experts believed that further assessment (beyond screening) for potential family violence needs to happen when verbal children are not present. This is both a safety and a privacy concern because the children may report the conversation to the violent parent, who may then further injure the victim. Questions about this topic also need to be posed in a private and confidential manner, such as those about mental and reproductive health issues.13
Third, the experts in Zink’s study suggested the possibility of pencil and paper screening. Although fewer people reveal partner violence using paper and pencil than with personal interviewing, many do disclose this information using a written approach.14,15 If the written screen is followed with a one-on-one private assessment and documentation is maintained either in the mother’s chart or through a variation of the “blue dot” system on the child’s chart, confidentiality and safety can be maintained.
Fourth, the experts agreed unanimously that when child abuse is disclosed, all physicians must follow through to meet the local mandatory reporting obligations. In 5 states there are laws regarding mandatory reporting of intimate partner violence: California, Kentucky, New Mexico, New Hampshire, and Rhode Island; 2 other states permit reports, Mississippi and Pennsylvania.16
Fifth, few of the experts knew the signs and symptoms of children who witness violence. Descriptions of these behaviors are not widely available in the medical literature, so this was not unexpected. The red flags include symptoms of posttraumatic stress disorder (PTSD), and a decline in the child’s emotional stability, ability to function in school, and orientation to the future.17 In children, symptoms of PTSD can include flashbacks, difficulty with concentration or sleep, attachment problems, sudden startling or hypervigilance, and at-risk behaviors based on a sense of a limited future.18,19 Discussions of these findings and their relationships to other personal, family, and social health issues should be identified and published to raise awareness and further sensitize concerned clinicians.
The next step indicated by Zink is further research, so physicians can do our jobs safely and effectively. Those of us who do research in this area are called to action.
Make a Difference
In the meantime, we need to screen for partner violence and child abuse in our practices. The consensus of the experts is that we continue to do screening in private (ie, the partner and verbal children are not present) and that the documentation be confidential. This is important. Given our recent experiences with increasing personal, family, and school-based violence, it is clear our physical, mental, and social health all hang in the balance. Each of us can make a difference, one patient at a time.
The ability to recognize partner or child abuse and to use an appropriate intervention are medical skills that can be life saving. For physicians, the first step in this important process is screening patients for violence as recommended by the American Medical Association and American Academy of Pediatrics, but that process is not easy or straightforward. For many reasons, few family physicians or pediatricians routinely screen for family violence. In this issue of the Journal, Zink1 addresses one aspect of this topic.
There are many reasons this screening is not happening routinely: (1) it is a fairly new idea, and it takes time for new ideas to diffuse through the practicing community;2 (2) some physicians do not think it is an important issue;3,4 (3) others forget to screen because of time constraints;5 (4) some choose not to ask for fear of discovering something they are not prepared to treat or spend time managing;6 (5) some physicians still do not identify family violence as a health issue;7 and (6) some do not know how to comfortably approach the topic.8,9
There are, however, clinicians who are committed to addressing issues of violence among the families they serve. They want to screen patients and families as recommended, but they ask genuine and complex questions about how to best do the job. Zink adds information to this discussion. Through interviews with experts in the fields of domestic and child abuse, the author inquired how screening for evidence of family violence can be done safely and appropriately when children are present at the office visit. The author hoped that reading the answers to this question would move more clinicians to perform this important screening and would assist those who are already screening serve their patients more safely and effectively.
Zink learned through the summarized answers of the study’s experts that more research is needed to learn what questions are appropriate to ask in front of a child. However, there are some very important findings in her study that should be emphasized before it is [put in the] filed under “to be continued.”
Screening Suggestions
First, the experts agree that discussions about partner and child violence can happen in the presence of preverbal children. Those discussions need to happen immediately and should not be delayed until further research is published. Fifty percent of the families in which the mother is being battered also have on-going child abuse10 committed by the father, mother, or both.11,12
Second, all experts believed that further assessment (beyond screening) for potential family violence needs to happen when verbal children are not present. This is both a safety and a privacy concern because the children may report the conversation to the violent parent, who may then further injure the victim. Questions about this topic also need to be posed in a private and confidential manner, such as those about mental and reproductive health issues.13
Third, the experts in Zink’s study suggested the possibility of pencil and paper screening. Although fewer people reveal partner violence using paper and pencil than with personal interviewing, many do disclose this information using a written approach.14,15 If the written screen is followed with a one-on-one private assessment and documentation is maintained either in the mother’s chart or through a variation of the “blue dot” system on the child’s chart, confidentiality and safety can be maintained.
Fourth, the experts agreed unanimously that when child abuse is disclosed, all physicians must follow through to meet the local mandatory reporting obligations. In 5 states there are laws regarding mandatory reporting of intimate partner violence: California, Kentucky, New Mexico, New Hampshire, and Rhode Island; 2 other states permit reports, Mississippi and Pennsylvania.16
Fifth, few of the experts knew the signs and symptoms of children who witness violence. Descriptions of these behaviors are not widely available in the medical literature, so this was not unexpected. The red flags include symptoms of posttraumatic stress disorder (PTSD), and a decline in the child’s emotional stability, ability to function in school, and orientation to the future.17 In children, symptoms of PTSD can include flashbacks, difficulty with concentration or sleep, attachment problems, sudden startling or hypervigilance, and at-risk behaviors based on a sense of a limited future.18,19 Discussions of these findings and their relationships to other personal, family, and social health issues should be identified and published to raise awareness and further sensitize concerned clinicians.
The next step indicated by Zink is further research, so physicians can do our jobs safely and effectively. Those of us who do research in this area are called to action.
Make a Difference
In the meantime, we need to screen for partner violence and child abuse in our practices. The consensus of the experts is that we continue to do screening in private (ie, the partner and verbal children are not present) and that the documentation be confidential. This is important. Given our recent experiences with increasing personal, family, and school-based violence, it is clear our physical, mental, and social health all hang in the balance. Each of us can make a difference, one patient at a time.
1. Zink T. Issues to consider when screening for partner violence in front of children. J Fam Pract 2000;49:130-136.
2. Rogers EM. Diffusion of innovations. 4th ed. New York, NY: The Free Press; 1995.
3. McGrath ME, Bettachi A, Duffy SJ, Peipert JF, Becker BM, St Angelo L. Violence against women: provider barriers to intervention in emergency departments. The battering syndrome: a poor record of detection in the emergency department. Acad Emer Med 1997;4:297-300.
4. Reid SA, Glasser M. Primary care physicians’ recognition of and attitudes toward domestic violence. Acad Med 1997;72:51-3.
5. Skolnick AA. Physician, heal thyself — then aid abused women. JAMA 1995;273:1722-45.
6. Sugg NK, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60.
7. Elliott BA, Johnson MMP. Domestic violence in a primary care setting. Arch Fam Med 1995;4:113-9.
8. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-7.
9. Gerbert B, Caspers, N, Bronstone A, Moe J, Abercombie P. A qualitative analysis of how physicians with expertise in domestic violence approach identification of victims. Ann Intern Med 1999;131:578-84.
10. S, Edleson JL. In the best interest of women and children: a call for collaboration between child welfare and domestic violence constituencies. The prevention report. Iowa City, Iowa: The National Resource Center for Family Centered Practice; 1995;1-7.
11. MA, Gelles RJ. eds. Physical violence in American families. New Brunswick, NJ: Transaction Publishers; 1990.
12. LE. The battered woman syndrome. New York, NY: Springer; 1984.
13. C, Alpert E. Integrating routine inquiry about domestic violence into daily practice. Ann Intern Med 1999;131:619-20.
14. J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176-78.
15. D, Elliott BA. Screening for domestic violence in a rural family practice. MN Med 1997;80:43-5.
16. A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA 1995;273:1781-7.
17. J, Dubrow N, Kostelny K, Pardo C. Children in danger: coping with the consequences of community violence. San Francisco, Calif: Jossey-Bass; 1992.
18. JA. Post-traumatic stress disorder in children and adolescents: a review of the literature. In: Chess S, Thomas A, eds. Annual progress in child psychiatry and development. New York, NY: Brunner Mazel; 1987;42:59-83.
19. Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
1. Zink T. Issues to consider when screening for partner violence in front of children. J Fam Pract 2000;49:130-136.
2. Rogers EM. Diffusion of innovations. 4th ed. New York, NY: The Free Press; 1995.
3. McGrath ME, Bettachi A, Duffy SJ, Peipert JF, Becker BM, St Angelo L. Violence against women: provider barriers to intervention in emergency departments. The battering syndrome: a poor record of detection in the emergency department. Acad Emer Med 1997;4:297-300.
4. Reid SA, Glasser M. Primary care physicians’ recognition of and attitudes toward domestic violence. Acad Med 1997;72:51-3.
5. Skolnick AA. Physician, heal thyself — then aid abused women. JAMA 1995;273:1722-45.
6. Sugg NK, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60.
7. Elliott BA, Johnson MMP. Domestic violence in a primary care setting. Arch Fam Med 1995;4:113-9.
8. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-7.
9. Gerbert B, Caspers, N, Bronstone A, Moe J, Abercombie P. A qualitative analysis of how physicians with expertise in domestic violence approach identification of victims. Ann Intern Med 1999;131:578-84.
10. S, Edleson JL. In the best interest of women and children: a call for collaboration between child welfare and domestic violence constituencies. The prevention report. Iowa City, Iowa: The National Resource Center for Family Centered Practice; 1995;1-7.
11. MA, Gelles RJ. eds. Physical violence in American families. New Brunswick, NJ: Transaction Publishers; 1990.
12. LE. The battered woman syndrome. New York, NY: Springer; 1984.
13. C, Alpert E. Integrating routine inquiry about domestic violence into daily practice. Ann Intern Med 1999;131:619-20.
14. J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176-78.
15. D, Elliott BA. Screening for domestic violence in a rural family practice. MN Med 1997;80:43-5.
16. A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA 1995;273:1781-7.
17. J, Dubrow N, Kostelny K, Pardo C. Children in danger: coping with the consequences of community violence. San Francisco, Calif: Jossey-Bass; 1992.
18. JA. Post-traumatic stress disorder in children and adolescents: a review of the literature. In: Chess S, Thomas A, eds. Annual progress in child psychiatry and development. New York, NY: Brunner Mazel; 1987;42:59-83.
19. Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.