Q&A: Pediatricians have ‘unique opportunity’ to identify intimate partner violence

Key takeaways:

• One in four women has reported at least one experience with intimate partner violence.
• Approximately one in four children are exposed to violence from a caregiver in their lifetime.

A new clinical report published by the American Academy of Pediatrics can help pediatricians identify intimate partner violence and aid those affected by it, an expert said.

According to the AAP, the CDC defines intimate partner violence (IPV) as “physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner” and “may also include other aspects of intimidation and control, including financial ... and immigration-related abuse.”

According to an analysis published last year in The Lancet, one in four women aged younger than 50 years has reported at least one experience of intimate partner violence.

We spoke with Jonathan Thackeray, MD, FAAP, chief medical community health officer at Dayton Children’s Hospital and a member of the AAP’s Council on Child Abuse and Neglect, about the AAP’s new clinical report and the role of pediatricians in supporting patients and families impacted by IPV.

Healio: What is new in the report?
Thackeray: There are two key pieces of the 2023 clinical report that represent new information for pediatricians.
The first is a discussion about the unique barriers faced by those who have both experienced IPV in addition to various forms of oppression and inequity, including immigrants, people of color and individuals living in poverty. Survivors who identify as LGBTQ+, for example, may experience discrimination by health care providers and find it more difficult to access culturally sensitive resources. If pediatricians can improve their understanding of how racism, xenophobia, homophobia and other oppressive societal practices impact a survivor’s ability to seek help, to be believed and to access resources, then they can begin to better support children and their families.

The other new information represents a shift in the AAP’s recommendation for how best to identify IPV. Historically, a traditional screening approach has been endorsed, in which the pediatrician asks about IPV in the home and the caregiver chooses either to disclose or not. This update endorses a new approach of “universal education,” which aims to normalize conversations between the pediatrician and the caregiver about IPV within the context of regular ongoing well-child visits and prioritizes sharing of available resources regardless of whether a disclosure of IPV is made. With this approach, a caregiver can choose to disclose IPV only if he or she chooses to do so, and may access available resources without ever having to disclose to the pediatrician.

Healio: What role does a pediatrician have in this discussion?
Thackeray: Pediatricians have the unique opportunity to identify IPV survivors in pediatric settings, to evaluate and treat children exposed to IPV and to connect families with available local and national resources. They are trained to promote safety and well-being, and are comfortable having difficult conversations with families when necessary.

Approximately one in four children are exposed to caregiver IPV in their lifetime, and we know that exposure to IPV as a child is associated with a number of adverse physical, behavioral and developmental effects. For example, anxiety, depression, aggressive behaviors, developmental delays and even chronic health conditions are all associated with exposure to IPV. These effects often persist into adulthood, and IPV exposure has been associated with many risk factors for the leading causes of death, including smoking, severe obesity and suicide attempts.

The pediatrician’s role, therefore, is to provide universal education and to make caregivers aware of local resources, and to do so in an inclusive, sensitive and nonjudgmental manner. Making families aware of local resources presents the opportunity to improve all aspects of a child’s health and well-being and to maximize the safety of caregivers.

In addition to the role of the pediatrician, the report addresses other ways that health care systems can better support IPV survivors and their children. A number of strategies, such as use of pediatric IPV advocates across a variety of health care settings and collaborations with community-based organizations, are presented. There is also a robust discussion about leveraging the electronic health record as a resource for patient care, quality improvement, training and research, and doing so in a way that is both safe and compliant with new federal legislation, specifically the 21st Century CURES Act.

Healio: Are there any issues that have gone unexamined?
Thackeray: We have so much yet to learn about IPV and how to best support children and families experiencing violence in the home. For example, there are direct connections between IPV and child maltreatment, but the degree to which interventions on behalf of a caregiver experiencing IPV may reduce the risk of child maltreatment remains unclear.

As mentioned earlier, implicit and explicit biases impact the services and supports IPV survivors receive in health care settings, but more research is needed to help us understand how to better promote trust of the health care system and enhance the ability of a caregiver to feel safe and secure.

References:

Thackeray J, et al. Pediatrics. 2023;doi: 10.1542/peds.2023-062509.