Domestic Violence

This information was provided by the AWAKE (Advocacy for Women and Kids in Emergencies) Program at Children’s Hospital Boston.

Child abuse and spousal abuse is often concomitant. It is therefore imperative that healthcare providers screen for partner abuse in cases of suspected child abuse or neglect and vice versa. Witnessing the abuse of a parent or other caretaker may be just as harmful to a child as direct abuse. Domestic violence can be defined as intentional violent or controlling behavior by a person who is or has been intimate with the victim(s) and may or may not reside in the same household. It encompasses a syndrome of coercive behaviors that may include, but are not limited to, the following:

• Actual or threatened physical injury
• Sexual assault
• Psychological abuse (intimidation, threats, privilege)
• Economic control
• Progressive social isolation(1)

The following information is intended to help pediatric providers screen for domestic violence in the lives of their patients’ caregivers. It is important to understand the perspective of the abused partner - she/he often views the abuse as only one aspect of a relationship that may still have some positive elements. She/we wants the abuse to end, but wants to keep the good aspects of the relationship. These two goals may be incompatible, but it may take time for the victim to realize this.

Learn
Recognize
Screen
Safety Plan
Hotlines and Services

Learn:

• The Process of Abuse:

1. Honeymoon Phase - the relationship is new and loving.

2. Rule Reversal Phase - the abused partner makes efforts to make the relationship work using logical and creative strategies of appeasing. S/he begins to question her worth as a partner because no matter how hard s/he, the rules change as soon as s/he things s/he understands them.

3. Capture - the victim tolerates the relationship because of its positive aspects and because s/he feels at least partly responsible for the abuse. This understanding may come from a realization that s/he is in danger, and in some instances in fear of death based on threats made by the abuser if s/he ever attempted to leave the relationship.

3. Empowerment - via connection to a community resource or individual who understands the complexities and dynamics of dating and domestic partner violence. This connection helps a victim to look back and then carefully access the services and support s/he may need in order to increase her/his level of safety.

4. Freedom - the battered person has been able to safely escape the relationship and continues to access intervention services.

• Unique Aspects of Violence in Teen Dating Relationships:

- The power differential between younger boys and girls may not be as strong as when they are older (14+), when physical and social power imbalances between men and women become more pronounced. In early adolescence, neither may possess the capability to physically dominate the other. Therefore, incidents of girls using physical violence against boys probably occur in more equal numbers at earlier ages. Although some girls do continue to use violence, more often they learn that they are at an increasing disadvantage if they continue to use this response.

- Simultaneously, of course, socialization influences on girls tend to reinforce submission to males in other aspects of life as well.

- Due to lack of experience, teens may be especially susceptible to the sex-roles presented in society which are overwhelmingly stereotypical and not egalitarian models. Indeed, teens may feel more confusion than adults about all kinds of appropriate behavior in intimate relationships due to lack of experience and confused messages from society regarding sexual behavior, decision-making, birth control, etc. This may contribute to a girl’s inability to judge if her boyfriend’s abusive behavior is the norm or out of line. The isolation which results from abuse makes it even more difficult for her to compare her experience with others.

- Relationships which are perceived as significant by teens may be much shorter (sometimes lasting only a few months) than adult relationships. However, at this developmental stage, teen relationships are typically experienced as intensely as adult relationships.

- The victim is often unable to avoid her abuser because they may attend the same school, live in the same neighborhood, etc. These factors increase her fear and sense of entrapment.

- Many teens resist seeking help from their parents and other adults, especially authority figures like the police, courts, medical providers, etc. At this developmental stage, teens are typically struggling for independence and want to solve their problems by themselves or with their peers. They fear, rightly or wrongly, that if told of the abuse their parents or guardians would curtail their newly-gained independence and control future decisions about their relationships and other social aspects of their lives.

- In some situations, the relationship is ended after an abusive intervention by peers. For instance, friends or brothers of the girl may beat up the abusive boyfriend or warn him to leave her alone. This kind of intervention may protect the immediate victim, but probably does little to change the abuser’s behavior in future relationships.(1)

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Recognize:

The following are red flags which may signal domestic violence:

• A woman who seeks medical attention for herself or her children often, with vague complaints (headache, stomach pains, nausea, fatigue or low energy) or a history of psychiatric hospitalizations for anxiety or depression.

• A woman who frequently misses scheduled appointments for herself or her children but always calls to reschedule.

• A woman who is non-compliant with medical care although she understands both the need and the appropriate use of prescriptions. This woman may be having her medications (especially birth control pills or devices) destroyed or withheld. She may also be using symptoms that occur as a result of this noncompliance as a means to seek protection for herself and her children.

• A woman who is silent or reluctant to speak when her partner is present; whose partner does all the talking or makes it difficult or impossible for the provider to speak with the woman alone.

• Suspected or documented physical or sexual abuse of a child.

• Repeated injuries or injuries that are difficult to account for as accidental.

• Strokes in young women, often caused by blows to the head or damage to the arteries of the neck due to strangulation.

• A woman who frequently refers to her partner’s anger or temper.

• Frequent moves, changes in address or phone number, phone disconnected, etc.

• Suicide attempts.

• A woman whose partner attempts or threatens to psychiatrically hospitalize her or tries to convince her that she is insane.

• A child who is too compliant.

• A child who does not listen to mother and/or women clinicians but listens and behaves in the male partner’s presence and in the presence of male clinicians; particularly a child whose behavior is notably modified in the presence of the mother’s partner.

• Any sudden changes in a child’s historical behavior patterns.

• A child who is depressed and/or suicidal.(2)

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Screen:

• Sample screening questions:
- How are things at home?
- Does your partner ever do or say things that make you feel bad about yourself; that you can’t do anything right; that you are worthless?
- Does your partner monitor or limit your time on the phone or in-person with your family or friends?
- Has your partner ever threatened to harm you, your possessions, or other people or things that are important to you?
- Are you now, or have you ever been, afraid of your partner?
- Has your partner ever hurt you physically (thrown objects, pulled the phone from the wall, pushed, slapped, kicked, punched, bitten, choked, or forced you to have sexual contact which was uncomfortable or against your will)?(3)

• Screening Do’s and Don’ts:

Do:
Don’t:
Screen privately. DON’T screen in the presence of the partner, children, or anyone else who my have accompanied the patient/caregiver.
Use professional interpreters when screening patients whose primary language is not English. DON’T use family members as interpreters when screening patients whose primary language is not English.
Use simple and descriptive questions. DON’T use profession-specific jargon or vague questions.
Listen. Validate. Offer in-house or community resources.

DON’T use the following words when screening for domestic/partner violence: “abuse,” “battered woman,” “domestic violence.”

Follow up during each subsequent contact. DON’T assume you know what is best or what will keep the person the most safe.
Document screening and disclosure of domestic/partner violence. If you are documenting in a pediatric medical record, please document only in the Social Work Progress Notes, as this section of the medical record is more protected. DON’T use language which may be perceived as equivocal in a court of law (i.e. “alleges,” “claims,” etc.) when documenting.(3)

• Screening Tools:

The Domestic Abuse Intervention Project has developed sets of wheels to help patients and/or caregivers think about ways they are being treated and/or treating others. Asking the patient or caregiver to talk about her/his relationship or experiences using the appropriate set of complementary wheels can help you and the patient/caregiver work together to recognize abusive behaviors. There is also a set of wheels designed for teenagers in abusive relationships and a set designed to help parents/caregivers recognize the effects of their actions on their children. Click here to download printable versions of these wheels in .pdf format. (Note: this is a large file and may take time to download. You need Adobe Acrobat to view this file.)

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Safety Plan:

Click here to download a printable version of the Safety Planning checklists in .pdf format or view them below. You need Adobe Acrobat to view this file. (Or skip the text and go directly to Hotlines and Services.)

Assessing Risk
Victim Safety
Provider Safety

Assessing Risk:

When Filing a Report of Suspected Child Abuse

Have a conversation with Mom (or another safe caregiver) prior to filing to discern:

- How will the batterer react?

- Have there been any reports previously?

- If yes, how did the batterer react?

- Have there been threats towards the partner or children if abuse is disclosed?

- How should the batterer be informed?

- What immediate safety planning is needed for the partner and children?

- Is there a need for provider safety planning as well?

- Should you consult with DSS to enlist their assistance in formulating a plan which will best protect the children and the non-abusing partner prior to following?

Things to Consider when Assessing Risk

Batterer’s behavior:
- Suicide threats or attempts
- Homicidal threats or fantasies
- Possession of or access to weapons
- Substance use
- Stalking behaviors
- Sexual assault
- Violence out of the home
- Terrorizing or sadistic behavior
- Abuse of the children
- Any recent escalation in the violence

Context:
- Any recent loss (job, family member, divorce)
- Recent separation
- Recent purchase of a weapon
- Victim’s exposure to his secret or illegal activities
- Pregnancy
- Woman’s use of substances
- Woman’s suicidal/homicidal feelings
- Failed attempts at safety

Risk to Children:
- Ever hit or touched them in a way that made them uncomfortable
- Ever threatened to harm or kill them
- Ever driven recklessly or under the influence with them in the car
- Ever threatened Mom would never see them again
- Ever been caught in the middle or intervened to protect Mom
- Have any behavior problems or behaviors that remind Mom of the batterer
- Physical punishment by Mom to get them to do what she wants them to do

Back to Safety Plan

Victim Safety:

When Living with the Batterer

- Is it safe for you to call her?
- At what number?
- Best days or times of day/evening?

- Who else knows about the abuse?
- Is there someone else she feels it is safe to tell?

- Who is available to her if she decides to leave?

- How is that person accessed in an emergency?
- Is there a plan for transport?

- Does she have/has she packed important papers (birth certificates, social security cards, health insurance cards, immigration papers, bank books, driver’s license, etc.)?
- Other things of importance which should be packed include: prescribed medications, favorite toy/blanket, etc. for children, copies of house and car keys, and money.
- An “emergency bag” should be packed and placed in a safe and easily-accessible location (with friends, relatives, neighbors, or in a hidden location within the home).

Plan for emergencies:
- Avoid bathroom and kitchen areas.
- Have a code word for children when escalation is apparent.
- Have an emergency plan to get out.

After Separation with No Change in Address

- Change all door locks.

- Install window locks.

- P.O. Box rather than home mail delivery.

- Change phone number and make it unlisted.

- Alter daily routing.

- Have an emergency safety plan.

- Inform school officials.

- If working, alert workplace.

- Keep a copy of the protective order with you, at the children’s school, and at work.

- Keep emergency numbers (police, battered women’s hotlines, etc.) readily accessible.

- Locate and involve yourself and children with supportive intervention services.

Back to Safety Plan

Provider Safety:

For Providers or Helping Individuals

If you have worked with or assisted a battered woman, your careful assessment of her risk will help you to determine if you may also incur some level of jeopardy. Generally, the primary victims of a batterer’s violence are their partners and often their children. However, it is best for providers to consider possible safety issues and take steps which offer maximum protection based on information gathered when talking with the victim. If there is a perceived potential risk to the provider, the following should be considered:

- Don’t walk to your car alone.

- Take a different route home.

- Alter your arrival/departure time.

- Have someone pick you up/drop you off.

- Take your ID badge/nametag off.

- Take your name off your door.

- Have an unlisted telephone number.

- Don’t meet alone with potentially dangerous clients or partners of clients; or leave your door open when meeting when them and inform someone of your meeting, the potential danger, and when you expect to finish.

- Inform colleagues.

- Use security when available.

- Take time away if warranted and possible.

For Providers in the Home Care Field

- Assess for possible abuse issues privately.

- Know and make available to women the numbers of local resources.

- Set a standard of practice which includes ongoing “private” time with every woman during each visit.

- Never drive directly to your own home after home care visits when you suspect abuse.

- Have an unlisted home phone number.

- Inform others in your agency of the abuse, the day/time of each of your visits, and your expected return time.

- When entering the home, never assume you are alone with the patient.

- Develop code words/signals, etc. with women prior to initiating home visits when the presence of domestic violence is known.

- Don’t confront the batterer regarding the violent behavior without careful planning and additional staff present.

- Don’t attempt to discuss or intervene regarding the domestic violence using a “couples” model approach.

- Never disclose what the woman has told you without her permission.

- State your concern and follow-up at each subsequent contact.

- Don’t attempt to rescue.

- Don’t form expectations regarding the woman’s actions following disclosure.(2)

Back to Safety Plan
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Hotlines and Services

The following 24-hour domestic violence hotline numbers are toll-free:
Screen:

• In Massachusetts, victims of domestic violence or sexual assault can call the SafeLink Hotline at 1-877-785-2020. Spanish-speaking rape crisis counselors are available at 1-800-223-5001.
• In other States, victims of domestic violence can call the National Domestic Violence Hotline at 1-800-799-SAFE (1-800-799-7233).

The AWAKE (Advocacy for Women and Kids in Emergencies) Program at Children’s Hospital Boston provides extensive individual and group domestic violence advocacy and intervention services for battered adult and adolescent women (patients, parents/caretakers of patients, and employees), as well as case consultation, education, and training. For in-hospital providers at Children’s, you can page the on-call AWAKE advocate Monday through Friday, 8:30 AM - 5:00 PM by calling the page operator. At all other times, you can page the CPT person on call. For more information about the AWAKE program or to schedule a training session, please call 617-355-4760. For more information about AWAKE in English and Spanish, click here.

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References:
(1) The Curriculum Project: Minnesota Coalition Against Domestic Violence. 500 Ashbury Park Street, St. Paul, MN 55104, 612-646-6177.
(2) AWAKE Project. Children’s Hospital Boston, 1995.
(3) AWAKE Project. Children’s Hospital Boston, 1997.

 


Last Updated: December 30, 2003
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