Intimate Partner Violence

Pediatrics. 2010;125:1094-1100.

Clinical Context

IPV is defined as a pattern of coercive behaviors that might include repeated battering and injury, psychological abuse, sexual abuse, progressive social isolation, deprivation, and intimidation perpetuated by someone with a prior or current intimate relationship with the victim, according to the Centers for Disease Control and Prevention 1999 statement.

According to the Bureau of Justice Statistics, 2004 data for the United States showed that 1544 deaths were attributed to IPV, of whom 75% were women. According to the Family Violence Prevention Fund, IPV occurs in heterosexual, lesbian, gay, bisexual, and transgender relationships.

This report from the AAP addresses the effects of IPV exposure on children and recommendations for assessment and response to IPV.

Study Highlights

Child victims of IPV
The most vulnerable groups are girls and women aged 16 to 24 years: 1 in 5 high school students and almost half of college students report dating violence.
IPV occurs in 3% to 19% of pregnant women and is linked with effects on the offspring: preterm labor, low birth weight, intracranial injury, neonatal death, and increased healthcare use and costs.
Co-occurrence of child abuse and IPV has been reported in 30% to 60% of families.
IPV is the leading precursor of child abuse.
Younger children can be collateral victims of IPV if they are being held in a caregiver's arms during battering. Older children who intervene during the incident can also be collateral victims.
Childhood exposure to IPV
Adults with childhood exposure to IPV vs no IPV exposure are 6 times more likely to be emotionally abused, 4.8 times more likely to be physically abused, and 2.6 times more likely to be sexually abused.
IPV exposure and other adverse childhood experiences are linked with smoking, obesity, physical inactivity, depression, and suicide attempts.
Children of abused caregivers have an increased risk for adverse behavioral effects: anxiety, depression, withdrawal, somatic symptoms, attention issues, aggressive behavior, rule-breaking behavior, social functioning problems, difficulty with peer relationships, cruelty to others, poor academic performance, and symptoms of posttraumatic stress disorder.
Adolescents might have the same violence pattern in their relationships with others, and some children might abuse others.
Requirements for reporting IPV to child protective services differ by state based on the child's age, relationship of the child to the perpetrator, and proximity of the child to the violent incident.
Having the caregiver also file a report might be helpful.
Assessment for IPV
Early and repeated questions to identify IPV as part of anticipatory guidance and awareness of risk factors for IPV are recommended.
Universal screening vs a case-finding approach results in greater identification of abuse, but insufficient evidence exists to show difference in morbidity or mortality rates of the victim.
Usually there are no indications of abuse.
Most victims will obtain care for their children instead of for themselves.
Possible indications of abuse include depression, anxiety, not keeping medical appointments, not answering questions about discipline, and frequent visits for complaints not consistent with the medical evaluation.
Self-administered assessments vs verbal assessments are preferred by female victims and might overcome barriers to IPV detection.
Questioning for suspected IPV should be conducted in a sympathetic and sensitive manner in a private setting without the presence of any children, family, friends, and suspected abuser.
Documentation is appropriate with the awareness that the abuser could have access to the records.
A generic statement that IPV assessment occurred and resources offered per protocol is suggested.
Referrals
A community response can be coordinated by pediatricians, obstetricians, prenatal clinic and hospital nurses, social workers, public health administrators, and early childhood education programs.
Resources include the Family Violence Prevention Fund, the American Medical Association, state medical associations, and the AAP.
Knowledge of state laws for reporting partner violence and children exposed to IPV is essential.
Risk for injury or death might increase when the caregiver discloses abuse and tries to leave the abuser.
Firearms should be removed from the home.
Pediatricians should be aware of "stages of change," substance abuse issues, and the role of ethnic and cultural attitudes on disclosure.
Counseling for children should focus on understanding and avoiding violence.

Clinical Implications

IPV of pregnant women or in the household increases the risk for child abuse and short-term and long-term medical, behavioral, and mental health problems in the children.
Recommendations to assess IPV exposure in children include early and repeated questioning as part of anticipatory guidance, self-administered survey with appropriate verbal follow-up, sympathetic and sensitive manner, private setting, and appropriate documentation.