Primary prevention should have the highest priority in attempting to eliminate family violence.
A high percentage of mothers of abused children are themselves victims of battering.
Children who witness violence are at risk for the same psychosocial and developmental sequelae as children who are the direct victims of abuse.
The pediatrician may identify family violence through screening.
The pediatrician can be an advocate for the prevention and management of family violence.
There is no escape from violence in America, even for children. Public health leaders have identified violence as a problem of epidemic proportions. Family violence has been described as endemic; its existence is a constant feature of many American families, with the home as its major setting. Family violence accounts for at least 21,000 hospitalizations, 99,800 hospital days, 28,700 emergency department (ED) visits, and 39,000 physician visits each year. The United States Department of Justice estimates that from 1987 to 1990, the aggregate cost of domestic violence amounted to$ 67 billion per year. Losses due to violence against children exceed$ 164 billion annually.
In 1962, Dr Henry Kempe raised the consciousness of the nation and pediatricians to the problem of child abuse with the publication of his paper “The Battered Child Syndrome.” Over the subsequent decades, pediatricians have become well educated and familiar with the problems of child abuse, sexual assault, and neglect. Yet, overwhelming evidence indicates that violence in childhood is much more complex than abuse and neglect. Children are exposed to violence in their communities and in their homes. Children suffer from witnessing violence in a variety of ways, including the development of posttraumatic stress disorder (PTSD). Children also are the perpetrators of violence.
For pediatricians, this realization means that to have a significant effect on both the short-term and long-term consequences of violence, we cannot view the child in isolation—rather, the child is part of a family in a community. There is also the sobering responsibility of nurturing the child to become an adult who will be neither the victim nor the perpetrator of violence. Key skills for pediatricians are the recognition, diagnosis, treatment, and referral of victims of family violence. Important factors are recognition of: 1) maternal circumstances that may indicate domestic violence, 2) effects of domestic violence on children, and 3) common characteristics of violent children and adolescents. The pediatrician also has a central role as an advocate for effectively evaluating community-based violence prevention policies and programs.
Definitions (Table 1⇓ )
Family violence refers to the intentional intimidation, physical and/or sexual abuse, or battering of children, adults, or elders by a family member, intimate partner, or caretaker. The term includes child maltreatment, adult intimate-partner violence, and elder mistreatment.
The Surgeon General of the United States estimates that 2 to 4 million women are victimized each year and that domestic violence occurs in as many as one of every four American families. The cumulative lifetime prevalence of exposure is as high as 54%. Severe violence with the potential to cause injury is experienced by 2% to 4% in 1 year, and it is estimated that between 8% and 39% of women who are injured through abuse seek medical care. Twenty-five percent of the women presenting for treatment in EDs have a history of partner violence in the past year. Multiple episodes are common. It has been reported that 50% of women who are victims of domestic violence experience more than one incident per year.
Domestic violence is the most frequently experienced type of violent crime; 17% of homicides in the United States occur within the family, and more than 50% of the women murdered each year in the United States are killed by a current or former partner. Firearms, usually handguns, are the weapons used most commonly against women in fatal events. Although the incidence of violence in homosexual populations is not known, it appears to be as common as that seen in heterosexual relationships. Recent work suggests that the occurrence of physical injuries during domestic disputes may be nearly equal between men and women, although severe injuries and deaths are greater by far among women.
The National Committee to Prevent Child Abuse (NCPCA) estimated that in 1996, 3,126,000 children were reported to child protective service agencies, an increase of 45% since 1987. Nationwide, an average of 31% of reports were substantiated in 1996, accounting for close to 1,000,000 victims. A related caregiver is the perpetrator of child abuse in more than 90% of the cases. Neglect is the most common type of reported and substantiated form of maltreatment. Data on substantiated cases of abuse from 31 states reporting to the NCPCA in 1996 demonstrated that 60% involved neglect, 23% physical abuse, 9% sexual abuse, 4% emotional abuse, and 5% other. In 1996, more than 1,000 children were confirmed as child abuse deaths—an average of three per day. Current information reveals that 41% of the children who died due to abuse between 1994 and 1996 had prior or current contact with child protective service agencies; 82% of these children were younger than 5 years of age and 42% were younger than 1 year. Children who witness family violence are emerging as a previously underrecognized large group; 3.3 to 10 million children annually witness acts of family violence.
Although difficult to ascertain, the incidence of elder mistreatment is estimated to range from 51,000 to 186,000 cases per year. Elders are most likely to be abused by someone with whom they live. The perpetrators of elder abuse commonly have a history of personal problems and may be financially or emotionally dependent on the older person.
These impressive statistics underestimate the true scope of the family violence problem. Most estimates are based on medical records, surveys, or actual filed reports of abuse, but abuse is significantly underreported. Reasons for underreporting include fear of retaliation, desire to maintain family privacy, guilt or shame, or desire to protect the abuser. Clinician underreporting may be due to discomfort with the subject or a fear of “opening Pandora’s box.”
It is commonly stated that “violence begets violence.” The link between victimization and later perpetration has been referred to as “the cycle of violence” and is one way to describe intergenerational transmission of violence. The family violence model developed by sociologists Murray Straus and Richard Gelles suggests that violence that is learned in childhood becomes the norm for settling conflict in certain families. Patterns of violence become enmeshed among all family members and are difficult to change. Other contemporary investigators, such as Perry, emphasize neurodevelopmental factors in the cycle of violence. They examine the interplay between developmental trauma and brain development, arguing that early life experiences influence synaptogenesis and ultimately behavioral response.
Clearly, there is a strong link between violent behavior and a history of personal victimization, although this relationship is far from simple. Physical abuse experienced as a child is related to later violent criminality. Child neglect also predicts such criminality, although the strength of the relationship is weaker. It has been demonstrated that the intergenerational transmission of violence is not inevitable; most children are resilient and grow up to be neither victims, abusers, nor violent criminals. Protective factors responsible for this resilience are poorly understood and studied but may include innate personality characteristics; the availability of affectionate, stable, alternate adult caretakers; school success; and the presence of a supportive network of family, friends, and community.
Viewed another way, the cycle of violence represents a recurring pattern of behavior. It begins with a building of tension, proceeds to the violent act, and is followed temporarily by a period of contrition on the part of the batterer. The period of contrition may represent a window of opportunity for intervention. Without intervention, this cycle can recur and escalate in both frequency and severity.
Child abuse and adult domestic abuse are intricately linked; 30% to 59% of mothers of abused children are victims of battering. Men who abuse their female partners also are more likely to abuse their children. Although reliable statistics do not exist, it has been estimated that the children of battered women are 6 to 15 times more likely to be abused. The impact of spouse battering on children encompasses a wide range of physical and emotional sequelae, including PTSD, depression, anxiety disorders, hypervigilance, nightmares, and a host of somatic complaints. Nearly 35% of the sons and 20% of the daughters of abused women have behavioral problems and retarded social skills during childhood.
Children who witness violence are known as silent or invisible victims. They are underrecognized and undertreated as victims by both parents and physicians. Typically, the focus in the aftermath of a violent event is on the physically injured victim or the perpetrator. Parents commonly believe that children are too young, do not understand, or have not noticed what they have witnessed. Yet many investigators have shown that children who witness violence are at risk for the same psychosocial and developmental sequelae as children who are the direct victims of abuse.
Many other risk factors for domestic violence have been studied. The use of alcohol, drugs, or both by either perpetrator or victim substantially increases the risk of violence in the domestic setting. Investigations that have focused on domestic violence against pregnant women show that these women are more likely to enter the health-care system because of the potential detrimental effects on their pregnancy. Overall, though, the prevalence of domestic violence probably is not higher among pregnant women than among the population as a whole.
The presence of a gun (especially a handgun) in the home greatly increases the risk of homicide to occupants. This risk is increased further for women if there is a history of domestic violence. The Centers for Disease Control and Prevention’s research on weapon involvement and injury outcomes in family and intimate assaults determined that firearm-associated assaults were 12 times more likely than non-firearm-associated assaults to result in death.
Boys who are exposed to violence in their homes as children are at major risk for becoming batterers. Male batterers exhibit certain characteristics that include but are not limited to high degrees of suspiciousness and jealousy, personality disorders, depression, substance (including alcohol) abuse, impulse control disorders, poor social skills, and anger and hostility. Men who abuse their female partners are also more likely to abuse their children.
It is likely that the pediatrician will be among the first medical professionals to encounter the violent child or adolescent. These children often share common characteristics, which include exposure to domestic violence, exposure to harsh parental attitudes or discipline, lack of peer relationships, impulsivity and hyperactivity, perceptions that the world is hostile, and little awareness of options for conflict resolution. The clinical implications of these conditions are clear.
Pediatricians always should consider family violence as a possible factor when developmental delays or behavioral problems such as eating or sleeping disturbances, irritability, or anxiety are observed. When children present with a history of violence or suspected physical abuse or symptoms consistent with witnessing abuse, the possibility that they are accompanied by a battered mother cannot be ignored. Many potential scenarios exist, such as abused children who have been injured in a separate incident, hurt in the act of protecting their mother, or injured when caught in the middle of an assault directed at their mother. Even when the child has not presented because of physical injuries, it is important to determine if the mother exhibits symptoms of depression or physical injury. An interdisciplinary approach to family violence emphasizes that the examination of the child represents a point of medical intervention for both; protection of the child victim includes recognition that the mother could be battered and also needs help.
Management by the Pediatrician: Barriers and Opportunities
Our nation is creating violent children at a rate far faster than we ever could treat, rehabilitate, or incarcerate. This sentiment fosters agreement among experts that a science-based, public health approach that focuses on primary prevention should be our highest strategic priority. Groves has written,“ Violence is a topic that belongs in any pediatric assessment, along with questions about lead paint and immunizations.” Certainly pediatricians are familiar with the benefits of primary prevention based on other aspects of their practice, yet the medical focus for violence has tended to be on treatment rather than prevention. Protocols for recognition and treatment of child abuse in the health-care setting infrequently prompt a search for domestic violence, and vice versa. Techniques and approaches to screening for exposure to violence rarely are part of undergraduate medical education or pediatric residency. For practicing pediatricians, the perceived barriers to responding to domestic violence have been identified as lack of training and protocols, lack of experience, and perhaps most concerning, a belief that responding to battered mothers is not in the purview of pediatrics.
Other myths, many of which involve attitudes toward the mother, function as barriers to intervention (Table 2⇓ ). Many clinicians cannot understand why an abused woman would not leave her partner and seek a safer environment for herself and/or her children. It is important to appreciate the many potential reasons that this is not feasible in the eyes of the victim. The risk of homicide significantly increases when the woman attempts to leave the relationship. The woman may be unemployed and have no means of economic support, child care, housing, or other resources. She may anticipate a custody battle and the ultimate loss of her children, which she may believe to be worse than ongoing abuse. Additionally, she may fear the isolation that this action may cause. She also may believe that the violence is her fault or love her partner and believe his stated remorse and willingness to change.
Whether in the clinical setting providing direct care or in the community as a child advocate, pediatricians can be very influential in preventing and controlling family violence. A supplement to Pediatrics in October 1994 is devoted to the role of the pediatrician in preventing violence. Although all the action steps and strategies from that publication cannot be duplicated in this review, certain points can be emphasized (Table 3⇓ ). Selected primary prevention strategies can be integrated into routine office practice as part of a health supervision visit. For example, pediatricians might discuss positive, noncorporal approaches to discipline; ways to engage children in discussions about community and media violence; alternatives to physical aggression for dealing with conflict; suggestions about how adolescents can develop and maintain healthy peer relationships; and the effects on children of witnessing violence at home. The American Academy of Pediatrics Guidelines for Health Supervision III presents a number of such strategies in developmentally appropriate terms to help the pediatrician open a dialogue in these sensitive areas.
Screening for family violence has been advocated for emergency departments and primary care practices. Time constraints for physicians necessitate that brief, accurate, age-specific screening tools be used (Table 4⇓ ). Three brief questions can detect a large number of adults who have a history of partner abuse. When screening identifies a family at risk, the pediatrician can begin an ongoing dialogue with the mother to let her know that safety concerns exist, that she does not deserve to be hurt, and that support resources are available. A critical consideration is to guide women who are identified as at risk in seeking help in safe ways (Table 3⇑ ).
Posters and printed materials on family violence can be displayed with other information in waiting rooms, examination rooms, and bathrooms. These can be a confidential and nonthreatening way of opening the door to discussion. Knowledge of community resources and effectively evaluated interventions is critical and part of the physician’s clinical service role (Table 5⇓ ). Models exist for programs that provide parenting skills, school intervention programs, emergency department screening and interventions, crisis intervention for children who witness violence (psychological first aid), and education and training for medical students and practitioners.
As a credible and respected child advocate, the pediatrician can play a significant role in the community by encouraging community/legal/law enforcement changes that can make large differences. These include: 1) requiring law enforcement to assess child welfare routinely when called for a domestic disturbance, 2) improving communication and joint response of law enforcement and child protective services, 3) including children who witness violence in the legal definition of violence victims, 4) establishing community advocacy programs to make battering completely unacceptable, and 5) improving resources for parents seeking to leave abusive relationships.
Family violence is an enormous problem that necessitates an interdisciplinary approach with an emphasis on primary prevention. As the natural advocates for children, pediatricians frequently are presented with opportunities for intervention with families who are experiencing or at risk for violence. Although the pediatrician’s focus is the child, primary violence prevention requires a global approach that includes the family. It is only by a willingness to acknowledge these difficult issues and become involved that we can make an enduring difference.
Second Step: A Violence Prevention Curriculum (JAMA. 1997:277:1605)
Family and Intimate Violence Protection Team of the CDC (JAMWA. 1996;51:83)
Universal Violence Prevention Screening Protocol—George Washington University Emergency Department. (JAMWA. 1996;51:93)
Violence Prevention Risk Assessment (JAMWA. 1996;51:94)
Advocacy for Women and Kids in Emergencies (AWAKE) (JAMWA. 1996;51:99)
Pediatric Family Violence Prevention Project (JAMWA. 1996;51:99)
Emerge Batterer Treatment Program (JAMWA. 1996;51:125)
Domestic Violence Module. University of California, Los Angeles School of Medicine (Academic Medicine. 1997;72:S75)
American Academy of Pediatrics. Guidelines for Health Supervision III. 1997 Elk Grove Village, IL.
American Psychological Association. Violence and the Family: Report of the American Psychological Association Presidential Task Force on Violence and the Family, 1996
Domestic violence and women’s health. JAMWA. 1996;51:75-128
Kempe CH, Silverman FN, Steele BF, et al. The battered child syndrome. JAMA. 1962;181:105-112
Perry BD. Incubated in terror: neurodevelopmental factors in the “cycle of violence.” In: Osofsky J, ed. Children in a Violent Society. 1997 New York, NY.: Guilford Press
Salber PR, Taliaferro E. The Physician’s Guide to Domestic Violence. 1995 Volcano, Calif.: Volcano Press
Spivak H, Harvey B. The role of the pediatrician in violence prevention. Pediatrics. 1994;94(suppl):577-651
Widome CS. The cycle of violence. Science. 1989;244:160-166
Wright RJ, Wright RO, Isaac NE. Response to battered mothers in the pediatric emergency department: a call for an interdisciplinary approach to family violence. Pediatrics. 1997;99:186-192
Zuckerman B, Augustyn M, Groves B, Parker S. Silent victims revisited: the special case of domestic violence. Pediatrics. 1995;96:511-513
- Copyright © 1998 by the American Academy of Pediatrics