BACKGROUND: The goal of our study was to understand the important issues to consider when screening women for intimate partner violence in front of their children.
METHODS: Interviews and focus groups were conducted with experienced family physicians and pediatricians and family violence experts (child psychologists, social workers, and domestic violence agency directors). Session transcripts were coded and categorized.
RESULTS: Experts disagreed on the appropriateness of general screening for intimate partner violence in front of children older than 2 to 3 years. The majority thought that general questions were appropriate, if the in-depth questioning of the abused parent was done in private. Screening for child abuse when domestic violence is identified (and for domestic violence when child abuse is discovered) was recommended. Documentation about intimate partner violence in the child’s medical chart raises questions about confidentiality, since the person committing the abuse may have access, if he or she is a legal guardian. Physicians need more education on the symptoms of children who are exposed to violence between adults.
CONCLUSIONS: More research is needed to understand appropriate questions and methods of screening for intimate partner violence in front of children. The tension is between practical recommendations for routine screening and preserving the safety of the parent and the children. Intimate partner violence screening by physicians is important. Interrupting the cycle of violence may give a child a better chance at maturing into a healthy adult.
In 1992 the American Medical Association (AMA) and other professional organizations, including the American Academy of Family Practice (AAFP), began advocating the screening of adult women for intimate partner violence.1 In 1998, the American Academy of Pediatrics (AAP) recommended screening for intimate partner violence and the abuse of women as part of anticipatory guidance at the well-child visit and whenever family violence is suspected.2 That recommendation follows the AMA’s guideline, which recommends screening the adult victim alone without the partner or children present in the room1Table 1. The feasibility of this recommendation, separating the mother and children, needs to be considered. Physicians are already challenged to find time to screen for the expected preventive issues. For example, a study examining family physicians’ practice patterns showed that less than 0.3% discussed violent injury prevention with patients.3 It may be unrealistic and logistically difficult for the physician to ask for privacy with the mother* for routine intimate partner violence screening. If this is the requirement, then screening may not occur. In addition, office staff may not be able to provide supervision for young children while mothers are being screened.
This raises the question: Who is the patient? It is not uncommon to excuse the child from the mother’s Papanicolaou test because the mother is the patient. Does it make sense to excuse children from their own well-child visit? It may be appropriate to have privacy with the mother for in-depth discussions, but routinely excusing children from their own office visit to screen the mother for partner violence is not practical. Similarly, chart documentation is complicated. Abuse of the mother does not belong in the child’s chart, since both parents or legal guardians have legal access.6 However, if the information is obtained during a well-child visit, where can it be documented?
Screening and documentation must be done in a confidential manner that ensures the mother’s safety. Failure to do this may have life-threatening consequences for her and the children. If a child shares information with the person committing the violence about “what Mommy discussed with the doctor today,” there may be retaliation toward the mother and the child. The same is true if the partner reads about his abusive behavior toward the mother in the child’s medical chart.
Are there ways of asking general screening questions in front of the children? What issues need to be clarified so intimate partner violence identification becomes routine and safe?
There is little in the literature about this subject. Qualitative research methods are useful for exploring issues that have gaps between knowledge and practice and for highlighting the areas that need more research. The purpose of this study was to weigh the benefits of routine screening for intimate partner violence against the risks to the mother’s safety that can occur when children are present during the screening. Our findings should help develop practical screening recommendations that preserve the safety of the mother and her children. This allows physicians to identify troubled families and link them to resources.
Methods
Experts from the Midwest participated in individual interviews and focus groups using open-ended questions. Sampling was done to the point of theoretical saturation (ie, no new information was being generated). Responses were coded and categorized into themes, and frequency counts were done. The Institutional Review Board at the University of Cincinnati approved the study protocol.