Abraham Rice, MDMedical Director, Foster Care Clinic

Contra Costa Regional Medical Center

Domestic Violence in Pediatrics

Take home messagesDV is a pediatric issueDV / CEV is prevalentCEV are at high risk many bad outcomesWe should screen for, diagnose and treat

violence and it’s predictable sequelae

Problem of Children Exposed to Violence

Between 7 – 15 million children witness DV per year.

 CEV more likely experience emotional and

behavioral problems

Greatly at risk for abuse and poverty CEV are a medical issue

Definition of Domestic ViolenceDV is “a pattern of coercive behaviors that

may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation and intimidation. These behaviors are perpetrated by someone who is or was involved in an intimate relationship with the victim”

Effects of Domestic Violence Profound effects on neurodevelopment Earlier exposure = worse outcomes

Emotional / Developmental / Academic / Behavioral / Physical problems AND potentially limited access to resources (medical care, mental health care, developmental support, academic support)

Emotional problems and CEVDepressionAnxietyPTSTADHD

Attachment system theory of development

04/20/23

Normal development is absolutely dependent on a bond with a loving caregiver

Affect regulation may be the most essential aspect of a child’s development

Developmental problems and CEVLanguage (pre-verbal)Social / Emotional

Abnormal affect regulation Aggressive, separation issuesDevelopmentally appropriate symptoms

Motor Hyperarousable, withdrawn

Behavioral problems and CEVDevelopmentally appropriate

manifestationsInfantToddlerElementary schoolAdolescent

Physical IllnessAsthmaDiarrheaCariesFailure to thriveACE study

Children Exposed to Violence are:Children with predictable, increased health

care needs

And should have…

Have access to a medical home to meet those needs

Opportunity Pediatricians in ideal position to identify DV

/ CEV

High risk time for women & frequent visits to MD

Some women don’t seek care for self but do for children

Women DO disclose when asked

American Academy of PediatricsAAP Committee on Child Abuse and Neglect

(1998) Policy Statement: The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women

“the abuse of women is a pediatric issue”“intervening on behalf of battered women

is an active form of child abuse prevention”“pediatricians are in a position to recognize

abused women in pediatric settings”“questions about DV should become part of

anticipatory guidance”

AAP recommendsNeed residency and CME education & trainingPediatricians should attempt to recognize

evidence of family or intimate partner violence in the office setting

Pediatricians should intervene in a sensitive and skillful manner that maximizes the safety of women and children victims

Pediatricians should support local and national multidisciplinary efforts to recognize, treat and prevent family and intimate partner violence

Fewer than 10% pediatricians routinely screen for DV

Barriers:

Education / Training 

Time 

Perception 

Sense of powerlessness

Language / cultural sensitivity

DV screening practiceVaries : written forms, as part of

safety/environmental screen Recommendations: 

All women in pediatric settings should be screened for DV 

Should not screen when partner in the room 

Women do disclose DV when asked by a skilled provider in face to face

 Insufficient evidence to recommend specific screening

practice

Screening for DVAs part of child anticipatory guidance

Introductory statementDirect vs. indirect questionsInclude questions to adolescents and older

childrenAsk with children in room? (probably)

Disclosures of DV: Physician’s Role First assess safety of mother & children Articulate concern over woman and

children’s safety

  

Disclosures of DV: Physician’s RoleConnect any concerns over child to DV

(behavior, academic, emotional)

Offer information about resources and help – culturally and linguistically appropriate

Disclosures of DV: Physician’s RoleDV shelter / support group / DV advocates

or hotlines

Offer to create a safety plan & schedule follow up appointment