Domestic Violence Rounds Presentation August 2015 Anne Kneale, PGY1.
-
Upload
oswin-gordon -
Category
Documents
-
view
221 -
download
0
Transcript of Domestic Violence Rounds Presentation August 2015 Anne Kneale, PGY1.
Domestic ViolenceRounds Presentation August 2015
Anne Kneale, PGY1
What stereotypes come to mind…?
Domestic Violence
Intimate Partner Violence (IPV) Actual or threatened psychological, physical, or sexual harm
By partner (actual or current)
Affects all socioeconomic backgrounds, ethnicities, sexual preferences
Very serious, preventable public health issue Underreported and often long-standing history at
diagnosis
Domestic Violence Rates
Women 80% of intimate partner violence is against women*
97% of spousal murder-suicides are against women*
Aboriginal women have rates twice as high as general population More likely to have severe or fatal abuse
Lesbian or bisexual relationships higher rates than heterosexual
Men Less likely to report abuse
1/17 reported relationship abuse in previous 5 years
Elderly, children, those with disabilities are vulnerable populations*Public Health Canada
Escalating Cycle of Abuse
http://www.bryonyhouse.ca
Abuse is about power and control
It escalates over time but perpetrator draws victim back in
Emotional rollercoaster
Case Presentation
Jessica, a 23-year-old G2P0 at 26 weeks presents to your office for a routine prenatal visit. She missed her last visit. Although this pregnancy was unexpected, it has been unremarkable so far. Her only complaint is chronic pelvic pain.
PMHx: IBS, depression, past therapeutic abortion, past chlamydia
SHx: Living with unemployed boyfriend, she works in retail. Stopped smoking and drinking when she found out she was pregnant
Meds: PNV
http://www.aafp.org
http://www.aafp.org
http://www.aafp.org
Case Presentation
PE: Flat affect with poor eye contact. Flinches when abdominal exam performed. Gravid abdomen of expected size for dates, FHR normal. No obvious bruises.
Clinical Presentation – Red Flags
Delay in seeking treatment
Inconsistent explanation of injuries
Frequent ED visits – may have fragmented care
Missed appointments
Repeated abortions – if reproductive coercion
Late initiation of prenatal care
Poor medication adherence
Affect inappropriate or uncomfortable with physical examinations
Partner overly involved
Social Isolation
Case Presentation
History and physical exam have aroused our suspicions
Assessment: How could we find out more about this patient’s psychosocial situation?
Screening
U.S. Preventive Services Task Force: Screen women of childbearing age for intimate partner
violence
Refer to intervention services (B recommendation)
Canadian Task Force on Preventative Health Care (2013) Available evidence does not justify routinely screening
Canadian residents
However, have a high index of suspicion Screen at meet-and-greet, during pregnancy, in the
emergency department, and if presenting with suspicious symptoms
Screening
Patients may be more likely to disclose when: Active listening, open-ended non-judgmental questioning
Privacy – if partner unwilling to leave room or overly involved red flag
No pressure to leave relationship/press charges
Do not ask why still in relationship or what patient did to bring on abuse
Patient autonomy respected
Terms like victim, battered avoided
Denial is very common – if suspicious, screen again at next visit
Screening Tools
No “gold standard” Lengthy tools impractical Start with framing and normalizing Sensitive and specific short surveys:
HITS (Hurt, Insult, Threaten, Scream)
STaT (Slapped, Threatened, and Throw)
HARK (Humiliation, Afraid, Rape, Kick)
CTQ-SF (Modified Childhood Trauma Questionnaire–Short Form)
WAST (Woman Abuse Screen Tool)
HITS Questions
How often does your partner: Physically hurt you? Insult you or talk down to you? Threaten you with harm? Scream or curse at you?
SAFE Questions
Stress/Safety - Do you feel safe in your relationship? Afraid/Abused - Have you ever been in a relationship
where you were threatened, hurt, or afraid? Friend/Family - Are your friends aware you have been
hurt? Emergency Plan - Do you have a safe place to go and
the resources you need in an emergency?
Partner Violence Screen
Reasonably sensitive and specific (71%, 84% )
One yes is a positive screen
Part of screening for depression and alcohol abuse
http://www.aafp.org
Other Screening Tools
Massachusetts Medical Society Committee on Violence: A single screening question asked routinely can increase detection
“Every couple has conflicts. What happens when you and your partner have a disagreement? Do conflicts ever turn into physical fights or make you afraid for your safety?”
Screening for Perpetrators
Challenging to detect and treat
Many have experienced childhood adversity/victimization in past
Associated with substance use
“Have you ever done anything while
under the influence which you regret?”
Case Presentation
Our patient answers:
“Rick has been more irritable and jealous lately. I just seem to push his buttons all this time. He didn’t take the news of the pregnancy well and I feel like I’ve been walking on eggshells ever since then. He has only slapped me around after he’s has a lot to drink. If I could help him get a job I’m sure things will go back to normal. He really loves me and I don’t think I could handle things on my own right now.”
Patients often minimize abuse and tend to blame themselves
Case Presentation
Our patient will soon have a new baby in the home. How can we assess safety and educate her about the effect of witnessing domestic violence on children?
http://www.aafp.org
Long-term Effects of Witnessessing IPV on Children
Depression, PTSD
Low self-esteem
Somatization
Poor socialization
Self-injury and substance use
More likely to become a victim and/or a perpetrator of abuse
RADAR Screen
R = Routinely screen
A = Ask direct questions Have your children witnessed anything violent or frightening in their home,
community, or school?
D = Document thoroughly Determine if safe to document in child’s chart or if restricted access possible
A = Assess safety of victim and children Are you afraid to go home? Do you need access to a shelter? Has the violence
increased? Has there been violence against the children?
R = Review options/referrals/reporting requirements Call Children’s Aid Society as necessary
http://www.uptodate.com
Mandatory Reporting
Child and Family Services Act Section 72 of the Act: promptly report any suspicions, under
reasonable grounds, that a child is or may be in need of protection to a children's aid society (CAS)
Physical Harm or Abuse/Neglect
Sexual Harm or Abuse
Emotional Harm
Abandonment
Criminal Acts
Not obligated to report to police
Physicians generally protected against legal action unless malicious
Case Presentation
Educate patient about the effects of witnessing domestic violence on children
Continue to follow up closely with patient throughout pregnancy, monitoring for worsening violence, and after delivery
Maintain a safe, non-judgmental presence for her to turn to
Refer her to community resources for counselling, education, shelters as needed
Ottawa Resources
Family Services Ottawa Woman Abuse Program
http://familyservicesottawa.org/adults/anti-violence-programs/
Women’s Crisis Line – Ottawa 613-745-4818
Ontario Assaulted Women’s Hotline 1-866-863-0511
Fem'Aide (French) 1-877-336-2433
Distress Centre of Ottawa and Region 613-238-3311
Chrysalis House
http://www.wocrc.ca/
Ontario Women’s Justice Centre
http://owjn.org/owjn_2009/
Children’s Aid Society of Ottawa
http://www.casott.on.ca/
References
Cronholm, PF, Fogarty CT, et al. Intimate Partner Violence. Am Fam Physician. 2011 May 15;83(10):1165-1172.
Ebell, MH. Routine Screening for Depression, Alcohol Problems, and Domestic Violence. Am Fam Physician. 2004 May 15;69(10):2421-2422.
Eyler, AE and Cohen M. Case Studies in Partner Violence. Am Fam Physician. 1999 Dec 1;60(9):2569-2576.
Franchek-Roa, KM. Intimate partner violence: Childhood exposure. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 8, 2015.)
Stiles, M. Witnessing Domestic Violence: The Effect on Children. Am Fam Physician. 2002 Dec 1;66(11):2052-2067
US Preventative Services Task Force. Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Recommendation Statement. Am Fam Physician. 2013 Apr 15;87(8):online.
Weil, A. Intimate partner violence: Diagnosis and screening. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 8, 2015.)
Questions?
"Safety and security don't just happen: they are the result of collective consensus and public investment. We owe our children – the most
vulnerable citizens in any society – a life free from violence and fear. In order to ensure this, we must become tireless in our efforts not only to
attain peace, justice and prosperity for countries, but also for communities and members of the same family. We must address the roots of violence.”
Nelson Mandela