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