All individuals and focus groups supported the mandatory reporting responsibility of child abuse and neglect even when partner violence has been identified. One member of a focus group suggested: “Encourage the mother to make the report about child abuse to Child Protection as a way to help empower her. If she is unwilling, the report must be made, but do it with her knowledge.”
Discussion
Our study demonstrated that current practice is based on clinical experience, and there is no clear consensus on how to screen mothers for intimate partner violence.
Feasibility in the Busy Office
Experts did not debate the value of screening women for domestic violence, but they discussed the best way to do such screening. Current practice is based on clinical experience; evidence-based guidelines will need to be developed on the basis of research that identifies the most appropriate screening questions to ask in front of the children and at the well-child visit. This research will need to focus on the most effective method (ie, interview vs questionnaire) and the specific questions to be asked.
The Perspective of the Patient, Mother, or Child
Whether to document a mother’s positive response to the screening in her child’s chart is still in question because the person committing the violence, if a legal guardian, has access to the child’s chart. Chart confidentiality issues need further deliberation by medical legal experts. Should the questionnaire become part of the permanent record if it contains questions about intimate partner violence? Is documentation about such violence appropriate in the child’s chart?
Physicians’ Skill and Knowledge
Physicians in this study lacked knowledge about how a child who witnesses violence between adults in the home presents to the medical office. There is a growing body of literature about the adverse effects on children of hearing and seeing violence between adults. Studies estimate that 11% to 20% of children witness violence between their parents or their mother and her intimate partner.13 Children who hear and see this violence display a variety of behavioral, physical, cognitive, and emotional problems and symptoms.13-22 This is important knowledge for those clinicians who see pediatric patients in an environment where universal screening is not feasible. Current domestic violence screening protocols and guidelines should be expanded to include guidance about the signs and symptoms of children of all ages who witness violence between the adults in their home.
Child Abuse and Mandatory Reporting
Only 3 of the 9 physicians in this study were aware of the link between child abuse and intimate partner violence. Physician education should include more information about this relationship so that documented child abuse will be followed up with questions about intimate partner violence, and intimate partner violence protocols will include screening questions for child abuse. However, this raises other difficulties, since child abuse requires mandatory reporting to authorities, usually child protection agencies, in all states. Bringing outside agencies into a volatile situation can be difficult when there is a risk of retaliation from the person committing the violence against the mother. Therefore, there should be procedures to manage child abuse reporting in situations of intimate partner violence.
Limitations
The limitations of our study include the small, regional sample. Results may not be generalizable because of the mandatory report requirement for intimate partner violence in some states.* The snowball technique we employed is widely used in the social sciences,12 but it may lead to persons who have common interests and experiences. However, in our study, a variety of opinions and experiences were identified. This was an exploratory study that mixed 2 different qualitative methods, in-depth individual interviews, and focus groups. These 2 processes may not lead to equivalent results as indicated by the fact that only one focus group changed it’s viewpoint on private screening as a part of the process. However, there were no obvious systematic differences between the responses from the 2 different settings.
Directions For Further Research
Our study examined important issues on a topic rarely raised in discussions about partner violence: the needs of the child. Exploring how to screen for partner violence with children present revealed that clinicians’ opinions are based on individual experience, and thus there are disagreements and differences in their procedures. More research is needed to develop evidence-based guidelines regarding intimate partner violence screening and intervention when children are involved. This research should be multidisciplinary including, at a minimum, lawyers, child psychologists, social workers, and physicians. In addition, the inclusion of the mother’s perspective will add to the understanding of the problem. Further research should explore: (1) Methodology — It will be important to examine the advantages and disadvantages of face-to-face interviewing and questionnaires; (2) Content — General screening questions for intimate partner violence that can be used with the children present or on a well-child examination questionnaire should be developed and evaluated. Interpretative guidelines that are culturally sensitive and consider the potential of a highly emotive but not abusive family should be included; and (3) Documentation — It is necessary to establish legal guidelines that clarify what kind of documentation or notation about the mother’s abuse by her adult partner is appropriate in the child’s chart.