Measurement
Most physician education focuses on the adult victim of domestic violence and her presentation in the medical office;1,7,8 our study focused on the child. The questions asked of the study participants Table 2 explored issues associated with screening for intimate partner violence in front of a child and the assessment of a child for the potential of actual abuse and the consequences of being a child witness.2,8-11 This includes the potential consequences of involving child protective services.
Interview Subjects and Procedure
Twelve experts who work with children and their parents in a health/mental health office or domestic violence agency were interviewed. These experts included 2 child psychologists; 1 social worker; 1 domestic violence state coordinator, and 8 experienced physicians (5 pediatricians, 3 family physicians). The snowball technique was used for identifying experts, where one participant referred the researcher to other participants.12 No one refused to participate in the study. Verbal consent was obtained and confidentiality was assured.
The average interview lasted 45 minutes and consisted of 5 open-ended questions. For the 2 long-distance participants, the interviews were conducted by phone. The participants set the pace of the interviews with their responses, and the researcher used close-ended questions to clarify any unclear answers. At the conclusion of each interview, the participant was asked for feedback. Suggestions were incorporated into subsequent interviews. Seven interviews were taped and transcribed; 5 were transcribed from the researcher’s notes because of technical problems.
Focus Group Subjects and Procedure
Three focus groups were convened involving a total of 17 experts. Domestic violence agency directors preferred a group format, and the director of social work suggested a focus group with her department Table 3.
Focus groups met once for approximately an hour and a half. The researcher used the same 5 open-ended questions as in the individual interviews to stimulate discussion. The researcher moderated the focus groups, encouraging all participants to share. The focus group sessions were transcribed using audiotapes and the researcher’s notes.
Data Analysis
Discussion content was reviewed and coded and categorized according to prominent themes. For example, opinions about screening for partner violence were divided into subcategories (eg, personal screening practices, use of general screening questions, use of questionnaires, age at which a child can stay with the parent during screening, age at which a child can be screened about the parents, and when to ask for privacy with the parent). The type of expert (physician, social worker, psychologist, domestic violence agency director) and method of interview (individual interviews or focus group) were noted for each subcategory. Frequency counts of prominent themes were used to characterize the data. Pertinent quotes were selected to illustrate the key issues.
Results
Demographics of Experts
Among those participants interviewed individually, the least experienced person had been in practice for 7 years; most had been in practice for more than 15 years. Eighty-three percent were white, and 83% were women. Of the physicians, 3 were family physicians, and 5 were pediatricians. Less is known about the length of practice of those participating in the focus groups, but all were currently employed in either a domestic violence agency or in social work. Of the focus group participants, 88% were women, and 88% were white.
Screening for Partner Violence with Children Present
All individuals and focus groups agreed that screening of the mother could be done with AMA-type questions (Table 1) in front of children aged younger than 2 or 3 years. A majority of the experts thought that general screening questions for domestic violence were appropriate in front of children of all ages. These screening questions were different from the questions recommended by the AMA. Suggested formats of the general screening questions were more general and family or child focused, such as: Everyone has conflicts; how do you resolve them? What happens in your house when people are angry? Has your child ever been exposed to anything that would make him nervous or upset? Does your child have nightmares as a result of family disruptions?
Several experts warned about being sensitive to cultural differences. One participant said, “Some homes may be more emotive or physical. Don’t focus only on hitting. Sometimes the controlling behaviors are worse, such as limiting access to the car, money, or food.”
Those who advocated general screening questions said: “Err on the side of getting more information. We have been too conservative.” “The children know what is going on anyway. The victim often denies the child knows. It is important for the kids to know that there are other ways to live and that help is available.”