Transcript Family Violence - Serving the Underserved

Family Violence
By
Carmen Davis
Reviewed by
Jennifer Robertson
and the Harvard Medical School Violence
Education Steering Committee
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Slides Created for
Pediatric Family Violence Awareness
Project: Improving the Health Care
Response to Battered Women and Children
in Massachusetts
by
Linda McKibben and Liz Roberts
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Funded by a federal Healthy Tomorrows Partnership for Children Program
Grant (MCHB and the AAP)
Co-Sponsored by: MHRI, DPH, Carney Hosp., and the Medical Foundation
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Session
Groundrules
• Assume there are survivors,
abusers in room
• Pay attention to your
reactions
• Take care of yourself
• Respect confidentiality
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“Identifying and Treating
Battered Adult and Adolescent
Women and Their Children...”
• Special Populations, children and
adolescents
• Risk Assessment and Safety
Planning
• Using the Courts: Restraining
Orders
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Project Goals
• Teach pediatricians/maternal and
child health care providers to identify
women at risk for violence
• Through routine screening of
mothers of patients and women as
patients
• During primary care preventive visits
• Recognition of patterns at all visits
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Improving Family
Violence Detection Skills
• Become knowledgeable about
community resources
• Acknowledge effects of maternal
abuse on children
• Identify routinely by asking all adult
and adolescent women privately
• Be familiar with characteristics of
batterers
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Battering is Common
• 3-4 million women are battered each
year in the US
• Battering is the most common cause
of injuries in women
• >50% are battered at some time in
their lives; >1/3 repeatedly
• 17-25% of pregnant women are
battered
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Battering Harms
Children
• 80% of children in violent homes are
aware of the problem
• 3-10 million children per year witness
abuse of their mothers
• Partner violence and child abuse overlap
40-60%
• Boys who witness violence are 1000%
more likely to abuse their adult partners
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The Myth of Mutual
Abuse
• 95% of cases are male violence
against women
• A global pattern supported by
cultural traditions and history
• Same-sex violence has coercive
pattern, one partner controlling
another
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Resulting Barriers to
Accurate Identification
• Higher rates of reported
abuse in families of color or
poor families
• Less likely that middle class,
white families are screened
appropriately
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What is Adult Partner
Abuse?
• Pattern of behavior resulting in
coercive control
• 4 major forms of abuse, usually
concurrent:
– Emotional
– Economic
– Physical
– Sexual
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Another Common
Misconception about
Partner Violence
• Partner violence is
primarily a problem of
poor communities and
communities of color
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Partner Abuse Occurs
in All Groups
• Cultural Differences include:
–Patterns of abuse
–Community responses
–Individual responses
–Resources available
–Appropriate interventions
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Victims Do Not Cause
Their Abuse
• Certain characteristics of
victims (esp. women) are
thought to lead to their abuse
– codependency- victims need it
– masochism- victims like it
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Supportive Message
for Survivors
• “I’m afraid for your safety”
• “I’m concerned about your
children’s safety and well-being”
• “I’m here for you if you need
help in the future. Here are some
other numbers too”
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Misconceptions about
Causes
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Substance abuse
Lack of self control
Poor self esteem
Child abuse
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Unhelpful/ Blaming
Messages for Survivors
• “What did you do...to make
him/her do that?”
• “Why do you keep going
back?”
• “Don’t let him hit you in the
stomach.” (Spoken to a
pregnant woman.)
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Anyone Can Be
Battered
• No consistent factors distinguish
battered from non-battered
women
• Surgeon General Koop
recommended that all women be
screened for risk for partner
abuse (1985)
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Providers’ Barriers
• Lack of training
• Loss of control
• Fear of offending
• Time and situational constraints
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Confusion is part of
the pattern!
• Partner may appear disorganized;
the batterer appears “in control”
• Partner appears fearful
• At other times, she appears to
protect him
• Clinic/Hospital staff can be split
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Identification Barriers
(Clients/Patients)
• Tendency to deny and
minimize abuse
• Fear of losing children
• Disclosure may take time
• Role of shame, guilt and fear
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Recognizing Batterers’
Patterns
• Batterers may be charming or
aggressive
• Batterers may present as
victims or accusers
• Batterers often come with
their victims
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Providers’ Roles
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Routine screening of women
Danger assessment
Safety Planning
Referrals
Documentation
Follow-up
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Interviewing Guidelines
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PRIVACY
Project concern and confidence
Sit down
Eye contact if culturally appropriate
Address patient, not interpreter
Avoid blaming advice or questions
Avoid stigmatizing terms
Use gender neutral language
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Screening Schedule
• Upon intake and annually thereafter
• Each trimester of pregnancy
• Pediatrics:
– Prenatal
– Intake
– Annual physicals
– At least every six months in the
first two years of her child’s life
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Safety Recommendations
• Avoid interventions with
batterers
– Do not share woman’s concerns
– Do not warn the batterer that you
know
– Do not do “couples counseling”
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Routine Screening
• Approach as a routine health
concern
• Screen for partner violence through
women, not their children
• Use two to three direct questions
• Give information about resources to
everyone asked
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“I ask all my patients, do you
feel safe in your home?”
• “Is anyone hurting you,
harassing you, or making you
feel afraid?”
• “At any time, has your partner
ever pushed, hit or kicked you?”
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Should I Ask All My
Patients?
• Screening men for battering
may endanger their partners
and children
• No protocols or guidelines
for effective, safe screening
of men exist
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Clinical Presentations
in Women
• Any injury, esp. To face, central body,
breasts and genitals; bilateral or
multiple injuries
• Delay between occurrence of injury
and seeking of care
• Explanation inconsistent with
injuries
• Chronic pain with no clear etiology
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Pediatric Indicators
• Problems with child support
and visitation
• Conflicts around child rearing
• Divorce and separations
• Remember to ask directly
about partner violence
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Assessment of
Survivors
• Emotional, economic control
• Suicidality, homocidality
– Distinguish fantasies vs. plans
• Sexual coercion, rape
• Depression, PTSD,
Substance abuse
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More Clinical
Presentations
• Sexual assault, recurrent
STDs
• Unwanted or any adolescent
pregnancy
• Substance abuse, depression
• Abuse of her child (most
commonly by her batterer)
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Following Disclosure
• Get permission to consult
• Follow-up visits more frequently
• Assess safe ways of making
contact
• Remain non-judgmental
• Articulate your concern and
continuing support
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Danger Assessment
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Weapons and criminal history
Threats and stalking
Batterer’s resources
Substance abuse, mental illness
Child abuse
Batterer’s suicidality
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Escalation
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Severity of injuries
Frequency of attacks
Isolation of victim(s)
Nature of threats
Use of weapons
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Other Possible Effects
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Behavior - aggressive, withdrawn
Developmental delays - school failure
Emotional - suicidality
Health Effects - chronic diseases, dental
neglect, immunization delay
• Risk-taking - substance abuse, sexuality
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Filing More Safely
• Report your concern for her safety
• File against the violent partner if
situationally appropriate
• Gather information about how DSS
may safely contact her
• For example, what kind of car does
the batterer drive, license plate #,
etc.?
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Assess Safety to Child
• Child abuse
– Discuss mandated reporter status
first
– Assess evidence of physical,
sexual child abuse and child
neglect
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Child Abuse Reporting
• Legally mandated when child
physical,sexual, emotional abuse or
neglect
• Reporting is NOT mandatory for all cases
of domestic violence
• Use clinical judgment otherwise Escalation, danger assessment
• Tell the woman and help safety plan
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Suspected Child Abuse
and Domestic Violence
• Ask mother privately
• “Whenever I am concerned about the
safety of children, I am also worried
about the safety of others in the
home....
• Has your partner/ the child’s father
ever hurt or threatened you?”
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Safety Planning
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Extra clothes
Car keys
Important papers
Cash
Create signal with neighbors/
children to get help
• Children’s special toys or objects
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Framing Your
Documentation
• “Patient declines restraining order
because of partner’s threat to kill
her.” (She’s afraid. She’s protecting her
kids. Her plan is rational.)
Versus
• “Patient refuses restraining order.”
(She’s non-compliant. She’s not protecting
her kids.)
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Documentation for
Pediatrics
• Document that screening of mother
occurred in child’s chart (DV screened)
• Preferably document outcome of
screening in woman’s chart or in social
work notes
• Document referrals and concerns
nonspecifically if batterer has access to
child’s records
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Referrals
• Clinic/ Hospital Resources
– Social Work Services
– Advocates
• Community Resources...
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• Battered women’s shelters and
hotlines
• Support groups for women and
children
• Victim/ witness advocates from
courts
• Certified batterers’ intervention
programs
• Child visitation center
• DSS Domestic Violence Specialists
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Messages for Children
• Mothers are not to blame
• It’s not the child’s fault
• Each of us are responsible for
our own behaviors
• Feelings need not lead to
violence
• Love is not ownership
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Primary Prevention
• Dating Violence Intervention
Project
• School-based curriculum for
adolescents
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