Pediatricians have a role in reporting domestic violence

by Crystal Phend

One of the most effective ways to prevent child abuse may be for pediatricians to identify domestic violence against a child’s caregiver, according to a report from the American Academy of Pediatrics.

Intimate partner violence in the home has a profound effect on kids, Jonathan D. Thackeray, MD, of Columbus Children’s Hospital in Columbus, Ohio, and colleagues wrote in the May issue of Pediatrics.

They pointed to elevated risk of abuse, neglect, and development of adverse health, behavioral, psychological, and social disorders later in life.

Children are not only collateral victims in these attacks, but are at risk as intimate partner violence is considered the leading precursor of child maltreatment, according to the clinical guidance report.

Studies have shown that child abuse and intimate partner violence happen together in 30% to 60% of families in which one occurs.

While most often approached as a women’s health problem, “it is clear that intimate partner violence is a pediatric issue,” Thackeray’s group wrote.

The pediatric setting is ideal for identification since most abused caregivers will seek care for their children but not for themselves, Thackeray’s group wrote.

The signs are usually subtle — such as depression, anxiety, failure to keep medical appointments, reluctance to answer questions about discipline in the home — but are often absent altogether, they said.

Because of this, universal screening is advocated by some. But as the U.S. Preventive Services Task Force has concluded, there’s not enough evidence to support this approach over a “case finding” method.

Until better evidence accrues, “it seems reasonable to incorporate early and repeated questioning regarding intimate partner violence as part of anticipatory guidance while remaining mindful of clinical presentations that suggest risk,” according to the AAP report.

Broaching the subject can be uncomfortable for both pediatricians and caregivers, so a self-administered assessment whether written or computerized may be preferred, it noted.

Some nonjudgmental introductory statements suggested were:

* “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?”

Pediatricians also need to plan ahead for what to do when someone screens positive for such abuse.

Once a woman or man discloses partner abuse, their risk of injury and death at the hands of the abuser rises and, unlike situations involving children, no state agencies are required to step in to protect adults.

“Thus, the process of disclosure is naturally very frightening and may not occur unless the caregiver feels that he or she is not in significant jeopardy,” Thackeray’s group wrote in Pediatrics.

The AAP recommended that pediatricians be familiar with local laws on reporting and partner with obstetricians, prenatal clinic and hospital nurses and social workers, public health administrators, and early childhood education programs to coordinate a community response.

Efforts to intervene should be carried out in a “sensitive and skillful” manner, attempting to maximize the safety of caretakers and their children.

The AAP report suggested discretion when putting a disclosure of abuse in medical records that may be accessible by the abuser or providing printed information, which could put the abused partner at risk if discovered at home.

Crystal Phend is a MedPage Today Senior Staff Writer.

Originally published in MedPage Today. Visit MedPageToday.com for more pediatrics news.

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  • SmartDoc

    Three major problems with this unfortunate, poorly thought out opinion piece editorial (beyond the obvious non-reimbursement issues):

    1) Some, perhaps many, cases of alleged domestic violence are completely fraudulant manipulations as part of a divorce action. Do we now want to now drag pediatricians into this notorious chronic injustice mess?

    2) Should we abide by this editorial’s assertions, we are creating a new tort for the poor pediatricians, already under intense attack by the out of control malpractice lawyer industry.

    3) Victims of slander can sue. If the medical record contains these allegations, and such allegations are untrue, then very substantional damages (money) are due from the pediatrician. Such damages are not covered by your malpractice insurance (or any other insurance that I am aware of).

    Think of an innocent father, who has lost his home and his children on faked abuse charges, seeking damages years later that a pediatrician’s incorrect medical record was the source of his removal from the home and the loss of his childrens’ affection. Would you want to be the pediatrician defending that record in court?

  • http://www.silvercensus.com/ Steffan Lozinak

    Though I agree that children shouldn’t be subjected to domestic violence and I agree that domestic violence should generally be reported… I feel that this doctors reporting such things in a way violates doctor patient confidentiality and could lead to patients not being honest with their doctors or even worse, avoiding going to the doctor when they need to in the first place. Now if the situation is obvious and life threatening like in the case of purposeful malnutrition then yes it should be reported. But where exactly the line is as to when report and when not to is difficult to say.

  • javafreik

    SmartDoc: My question to you is this: which is more important to you: protecting your patients – or your rear?

    Providing resources to those in need does not jeopordize you. However, not doing anything to help protect a child that may (or may not be) in a DV situation is irresponsible.

    Slander is a difficult case to prove – so if you can’t prove it, don’t state it. But, that shouldn’t be a concern for a pediatrician – as a concern is not stating a questionable fact. Correct?

  • ct tech

    One has to be careful when deciding whether or not to report or get involved with a case of intimate partner violence. The abusing partner may escalate the violence if an outsider is brought in, or if he (usually) is concerned that the victim may be considering leaving, as this is the most dangerous time for the victim. This is why although child abuse and elder abuse is reportable in many/most states, intimate partner violence is not.

  • Jonathan D. Thackeray

    “SmartDoc” has posted similar comments at http://www.pediatrics.org regarding this Clinical Report. As lead author, I’ll have to respectfully disagree with the “poorly thought out opinion piece” portion of his comments. However, there are specific concerns raised in his comments which necessitate a formal response. This response has been posted at http://www.pediatrics.org and I would encourage all who have an interest in this issue to read it.

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