SAN DIEGO — Physicians who treat children must have plans for identifying families with violence problems and then dealing with it, Betsy McAlister Groves, a licensed social worker, said at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.
In 40%–60% of families in which there is domestic abuse, there also is child abuse, the social worker said.
Many physicians are uncomfortable tackling family violence issues. But guidelines published in 2004 give specific recommendations for what primary care physicians ought to do in their practices, said Ms. McAlister Groves, the founding director of the Child Witness to Violence Project at the Boston Medical Center.
The consensus guidelines were put together by experts from 15 states and had the support of the Family Violence Prevention Fund, and are available at www.endabuse.org/programs/display.php3?DocID=206
The recommendations suggest that physicians implement three steps:
▸ They should provide screening by asking the parent if there is violence in the home.
▸ They should have resources available so that patients and/or parents can be educated and exposed to the message that family violence is extremely destructive.
▸ They should know where to send families for help and/or reporting.
In her talk, Ms. McAlister Groves told the story of a woman who came to this country as a mail-order bride—who initially spoke no English—whose husband turned out to be abusive. The impetus, eventually, for her to seek help was a poster in the waiting area of her pediatrician's office that stated simply that no one deserves to be hit.
She told another story about a 13-month-old girl who was being held by her mother when the woman was hit by her boyfriend. For the next 3 weeks, that child had such intense separation anxiety that the mother could not even go to the bathroom by herself.
This story illustrates that even very young children are profoundly affected by violence, Ms. McAlister Groves said.
According to her figures, 85% of children who witness an incidence of violence against their mother experience symptoms of posttraumatic stress disorder, and the latest figures indicate that perhaps one-third of children are exposed to some domestic violence.
“If a parent is vulnerable, a child is also vulnerable,” she said.
There is a role for the pediatric health provider to help parents and children talk about this, she added.
Among other recommendations in these guidelines:
▸ Who and when to ask. New patients should be asked about violence in the home, and regular patients should be queried at least once a year at routine appointments, such as well-child visit, or if there is reason to be concerned. The parent should be asked, not the child, until the child is perhaps 12 years old.
Direct questions are best, such as “Have you ever been hurt or threatened by your partner?” and “Has your child witnessed a violent or frightening event in your neighborhood or home?” But the physician should use his or her own style, and often, indirect questions will suffice, such as “What happens when there is a disagreement in your home?” and “Do you feel safe in your home?”
You can preface your questions by explaining that you are asking because the problem of domestic violence is so common that these questions have become routine.
“The majority of women I have talked to are not offended by questioning,” Ms. McAlister Groves said.
▸ Should the child be in the room? There is debate over whether the child should be in the room when the questions are asked, Ms. McAlister Groves said. It is better to ask indirect questions with the child in the room than to miss asking patients.
▸ Who should ask these questions? Written questions should not take the place of verbal questioning, and the inquiry can be made by anyone in the office who has had the proper training.
▸ Know how to respond to answers to your questions. If you are going to ask, then you need to know what to do with this information. All but 10 states require reporting of specific injurious incidents, and some require reporting when you hear about domestic violence. Physicians and other practitioners should familiarize themselves with their state's reporting laws and should know where to refer the parent for help; it is a good idea to have information on hand about domestic violence and its impact on children.
When you hear about violence, ask if the mother and child are safe currently. If you plan to report an incident, inform the parent that you are going to make a report.