To screen or not to screen…

     Domestic violence, also known as intimate partner violence, is serious medical, social, and public health concern (Koziol-McLain, Coates, & Lowenstein, 2001). Women who have experienced physical, psychological or sexual violence can suffer many physical and mental health problems (Taft, et al., 2013). Taking this into consideration, many victims of domestic violence seek medical attention in various healthcare settings. Victims of domestic violence customarily seek medical attention in emergency departments, hospital clinics, medical offices, prenatal clinics, family planning facilities, and other clinical settings (Koziol-McLain, Coates, & Lowenstein, 2001). The argument ensues that victims of domestic violence tend to seek help in these various healthcare settings therefore, healthcare professionals should routinely ask all women if they have experienced violence while in the healthcare facility (Taft, et al., 2013). However, some debate that there is not sufficient evidence proving that domestic violence screening helps prevent future abuse. Without hard evidence, doctors question whether screening their patients for domestic violence will help to end the abuse (Singh, 2014).

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     According to the U.S. Department of Health and Human Services (HHS), screening for domestic violence can help identify current or past abusive and traumatic experiences, can help to prevent abuse in the future, minimize disability, and can also lead to a better health status. The World Health Organization (WHO) provide many tools, guidelines, and recommendations for screening victims of domestic violence (WHO, 2013).

    Health care providers are in a distinctive position to become involved and connect with victims of domestic violence while providing support (Office on Women’s Health, U.S. Department of Health and Human Services, 2013). Over a decade ago domestic violence was declared a national epidemic and now many health professionals are required to screen for domestic violence in accordance with national health policies (O’Doherty, et al., 2014).

     The Department of Health and Human Services have implemented certain guidelines for women’s preventive health services which will help to make sure that women can receive, without cost-sharing, a complete set of suggested preventive health services. With the implementation of the Affordable Care Act, many insurance plans are required to offer preventive health services which include screening and counseling for domestic violence (HHS, 2013).  

     A study by Koziol-McLain, Coates, and Lowenstein (2001) found that a short violence screen could identify in a subset of women who are at high risk for the different forms of domestic violence (i.e., verbal, physical, and sexual partner abuse) the likelihood they would experience abuse four months after their study. In similar research conducted by Houry et al. (2004), they examined the predictive validity of a three-question domestic violence screen used in an emergency department population. Their research found that women who screened positive for domestic violence were 11 times more likely to encounter violence from a current or past partner over a four month period after they had been screened.

     The article (Singh, 2014) published on npr.org highlights the analysis written by O’Doherty et al. (2014) which states that screening victims for domestic violence doesn’t appear to cause them any harm in the short term and also increases identification of domestic violence it doesn’t however, appear that in the long term, screening provides increases in effective referral to agencies that support victims. This study provides us with a direction for future studies and trials that should be conducted in order to take a step in the right direction. Mainly, to provide healthcare professionals and policy makers with evidence that by screening for domestic violence, violence will decrease and women’s wellbeing will increase (O’Doherty, et al., 2014).

 

Sara Greenfield

Temple University

 

Sources:

Davila, Y. R. (2005). Teaching nursing students to assess and intervene for domestic violence. International Journal of Nursing Education Scholarship, 2, 1-11.

Houry, D., Feldhaus, K., Peery, B., Abbott, J., Lowenstein, S. R., al-Bataa-de-Montero, S., & Levine, S. (2004). A positive domestic violence screen predicts future domestic violence. Journal of Interpersonal Violence, 19, 955-966.

Koziol-McLain, J., Coates, C. J., & Lowenstein, S. R. (2001). Predictive validity of a screen for partner violence against women. American Journal of Preventive Medicine, 21, 93-100.

O’Doherty, L. J., Taft, A., Hegarty, K., Ramsay, J., Davidson, L. L., & Feder, G. (2014). Screenign women for intimate partner violence in healthcare settings: Abridged Cochrane systematic review and meta-analysis. BMJ, 348. doi:http://dx.doi.org/10.1136/bmj.g2913

Office on Women’s Health, U.S. Department of Health and Human Services. (2013). Screening and counseling fact sheet. Retrieved from http://www.womenshealth.gov/publications/our-publications/fact-sheet/screening-counseling-fact-sheet.html?from=AtoZ

Singh, M. (2014, May 14). Doctors debate whether screening for domestic abuse helps stop it. Retrieved from NPR: http://www.npr.org/blogs/health/2014/05/14/312152420/doctors-debate-whether-screening-for-domestic-abuse-helps-stop-it

Taft, A., O’Doherty, L., Hegarty, K., Ramsay, J., Davidson, L., & Feder, G. (2013). Screening women for intimate partner violence in healthcare settings. Cochrane Database of Systematic Reviews(4). doi:10.1002/14651858.CD007007.pub2.

World Health Organization. (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidlines. WHO. Retrieved from http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf?ua=1

 

Addressing the Gaps: Mighty Fine from the American Public Health Association talks solutions with Speranza.

A meeting packed with tactful conversation took place between Mighty Fine, the American Public Health Association’s (APHA) violence expert, and the Speranza team July 17, 2014. Stemming from his background in public health, Mighty began work with the APHA developing partnerships with organizations that implement policy to better our world. He took interest in the violence department after learning that violence, a 100% preventable occurrence, was the top cause of death for people ages 1-44 years old.

 

Founder of Speranza, Christina Blackburn (left) and APHA member, Mighty Fine (right) posing in our office space down town.

Founder of Speranza, Christina Blackburn (left) and APHA member, Mighty Fine (right) posing in our office space down town.

Mighty said a solution to this problem that affects 1 in 3 includes integrating violence with other health environments and bringing in allied sectors. Sectors, such as employment and housing, may want to consider greater access to sidewalks and have more open spaces since it is harder to hide violence in a public setting.

Currently, domestic violence is a silent issue that goes severely under reported. Therefore, implementing a policy understood by everyone poses a challenge. Mighty said,

“Every case is different and you can’t look at different situations as a deterrent.”

To put an end to violence, we must look past shaming and victim blaming and look at abuse as a comprehensive situation. To explain how domestic violence is 100% preventable, Mighty puts the abuse cycle in to the perspective of a disease model as exemplified below:

Disease model of violence created by Mighty.

Disease model of violence created by Mighty.

So where can we break the cycle? Where do we fill in the gaps?

Our solution? Close the gap in services by training first responders to provide tools and instruction for those facing abuse. Put the human compassion back into caring for women and children in dangerous situations. Have answers prepared for those “what now?” thoughts that race through the heads of battered victims before it is too late.

Unfortunately, mortality rates are what catch the eye of the public. Think about it, how many times have you heard about a domestic violence situation on the news that does not end in death?

Death by an abusive partner is just the tip of the iceberg to a worldwide issue. Below the surface lies the 400 domestic violence calls 911 dispatchers receive every day in Philadelphia alone, not to mention the thousands of women and children that are turned away from shelters in Philadelphia on a yearly basis. Below the surface lies the complex issue of domestic violence faced by 1 in 4 women each year.

How can we dive deeper and see what lies beneath the tip of the iceberg?

In order to implement policy, we must un-silence the issue of violence. Rallying a political push takes a grassroots effort, according to Mighty. Victims must step forward and let their stories be heard. Advocates of this issue must speak out and show what is really going on behind closed doors. He also mentions the importance of exposing how domestic violence affects families, and comparing violence to other health issues.

Violence can be stopped, and together, we can make it happen.

Let’s advocate for action.

The Silent Witnesses to Domestic Violence

It is a staggering fact: according to a Princeton University study, anywhere from 3.3 to 10 million children are exposed to domestic violence every year (Carter, Wheithorn and Behrman 1999). Unfortunately, this number keeps growing. In households plagued with domestic violence, children become silent witnesses, especially children younger than 10 years old. Young children may not be able to accurately describe the situation at home to other adults in their lives and, therefore, decide not to disclose the violence to other people at all.

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In a study conducted about parents separating after having a history of domestic violence, children were asked if they had been the victims of violence in their homes. According to the study, 55% of the children had been physically abused, and 85% had suffered emotional abuse (Neckles 2000). It is important to note that much of the research focusing on domestic violence in the home, suggests that there is a strong connection between domestic violence and child abuse. This being said, exposure to both domestic violence and child abuse can cause devastating consequences in children of all ages.

 

Due to the continuous disruption commonly seen in homes with a history of domestic violence or child abuse, children fall victim to emotional, behavioral, cognitive, and attitudinal difficulties (LaLiberte, Bills, Shin, et al., 2010). It is common for children with exposure to these traumatic events to show behaviors normally viewed as symptoms of post-traumatic stress disorder, or PTSD. If a child “re-experiences the traumatic event”, then they are also experiencing the same emotions that they felt during the violence. (Nelms 1994). This can cause emotional overload, and lead to meltdowns, tantrums, or fear.

 

This also leads to avoidance of everyday situations and interactions, in fear that the child may experience a violent interaction with another person. Another PTSD symptom associated with children who have been exposed to domestic violence or child abuse is the numbing of the child’s responses to what can be viewed as bad situations. This is due to repetitive exposure and involvement in horrifying circumstances—which, in turn, causes the child to numb themselves to any pain they may feel because of these situations, whether that be emotion or physical pain. (Nelms 1994).

 

There are several other lasting effects that prolonged or constant domestic violence exposure causes in children of all ages. According to a study conducted in 2003 by Kitzmann, Gaylord, Holt and Kenny, a child exposed to domestic violence may become unusually disruptive, perform poorly in school, and lack problem-solving skills. Children exposed to violence may also become depressed, overly anxious about everyday situations, and develop phobias or insomnia. A “lack of curiosity and exploration” may occur if the child is very young, and would stop a child from being inquisitive. If a child has a prolonged contact with domestic violence in their home, they may also develop a lack of empathy for others who may be involved in harmful situations elsewhere (Neckles 2000).

 

Since there is such a strong connection between domestic violence and child abuse, child welfare workers are now being trained on how to screen for domestic violence in their cases. The welfare workers use the Green Book, which is actually titled “Effective Interventions in Domestic Violence & Child Maltreatment: Guidelines for Policy & Practice”. This manual is famous for a scale called the Child Exposure to Domestic Violence scale, or CEDV. The CEDV measures a child’s exposure to domestic violence and maltreatment, and is used to gauge the effects that a child may experience after dealing with violent incidents in the home. The scale is broken up into 6 different sections: level of violence in the home, exposure to violence in the home, involvement in violent events at home, exposure to violence in the community, presence of other risk factors, and other forms of child victimization (LaLiberte, Bills, Shin, et al., 2010). The CEDV helps child welfare workers evaluate a child’s situation, and intervene when necessary.

 

The CEDV scale used by child welfare workers is HUGE step towards prevention when dealing with a combination of child abuse and domestic violence in a home. However, in order for prevention strategies to take off and become a global norm, changes need to happen on many levels. Not only do child welfare workers need training in order to screen for domestic violence, but pediatricians need this training as well. Pediatricians have direct contact with children during a regular office visit, and can easily screen for domestic violence in the home during regular checkups. Unfortunately, many pediatricians are not trained for this kind of screening, and do not take classes focusing on domestic violence in medical school. Therefore, a very large amount of pediatricians do not feel qualified or prepared to screen for domestic violence during office visits, and feel that they need extensive training to do. This can be fixed with extensive training for pediatricians and regular primary care doctors as well.

 

Although children are the silent witnesses to domestic violence, we do not have to be silent about the effects of domestic violence on children of all ages.

 

We need to SPEAK UP.

 

We need to TRAIN those who work with children, and help them be capable of screening for violence in the home.

 

We need to EDUCATE those around us about the dangers of exposing children to this kind of violence.

 

We need to PREVENT domestic violence, and use every resource we have to do just that.

 

 

 

 

 

 

 

 

 

Beth Cohen

Speranza Human Compassion Project

Champions for Safe Homes ~ Champions for Families ~ Champions for Women

http://www.speranzaproject.org/

 

 

LaLiberte, Traci, Jessie Bills, Narae Shin, and Jeffrey L. Edleson. “Child welfare professionals’ responses to domestic violence exposure among children.” Children and Youth Services Review 32.12 (2010): 1640-1647. Print.

Carter, Lucy Salcido , Lois A. Weithorn, and Richard E. Behrman. “Domestic Violence and Children: Analysis and Recommendations.” The Future of Children 9.3 (1999): 4-20. Print.

Kitzmann, Katherine M, Noni K Gaylord, Aimee Holt, and Erin D Kenny. “Child Witnesses to Domestic Violence: A Meta-Analytic Review.” Journal of Consulting and Clinical Psychology 71.2 (2003): 339-352. Print.

Neckles, Carmaen. “Child Contact and Domestic Violence.” Probation Journal 47.3 (2000): 212-213. Print.

Nelms, BC. “Domestic Violence: Children are Victims Too!.” Journal of pediatric health care: official publication of National Association of Pediatric Nurse Associates & Practitioners 8.5 (1994): 201-202. Print.

 

It Starts Young; Can it Stop Young?

A recent US study tracks the prevalence of violence among adolescent relationships.

 

Teen dating violence is alive and well according to a study published in the Journal of Adolescent Health May 2013. A national sample of 2,203 10th graders were asked to complete surveys regarding physical and verbal domestic violence. Assessments on perpetration, health issues, substance use, and depressive symptoms followed.

The survey revealed that nearly half of all participants suffered from some form of dating violence. Females outweighed males in the verbal abuse category, while males slightly outweighed females in the physical abuse category.

Females also ranked higher in all the health complaints and substance use categories. Health complaints included depressive symptoms, physical complaints and psychological complaints while substance use included tobacco, alcohol, and marijuana. Keep in mind; the average age of surveyors was 16 years old.

Dating violence among teens has become more prevalent, not to mention more lethal. In 2007, 1/3 of female murder victims aged 12 or older were killed by intimate partners. No one should have to face the threat of death condoned by his or her loved one, especially not our youth.

Death, depression, substance use, and physical/verbal abuse is unfortunately all too common in the lives of adolescents. When growing and developing is at it’s peak, teens need to learn what to expect in a healthy relationship. Practicing healthy habits at a young age could be the solution to solving the DV problems faced by children, teens, and adults today.

So can DV be stopped young? With the right tools and resources, teens can stop it young. Teens can develop the ability to recognize red flags. Teens can learn to create healthy relationships.

Adolescents should not suffer from physical agony, mental distraught, and fear of death brought on by people who are supposed to love and care for them. Education is power. Lets show them the way.

Sources:

http://www.jahonline.org/article/S1054-139X%2813%2900086-4/fulltext

http://opdv.state.ny.us/statistics/nationaldvdata/nationaldvdata.pdf

How survivors remain surviving

                A study conducted in Sewanee University of the South reveals the life goals, strengths and resources needed for Domestic Violence survivorship.

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         Abuse leads to a shattered confidence. Abusive partners may seem like the glue holding the pieces together when in actuality, going back to an abusive partner only enables the continuation of partner violence. Instead of falling back into unhealthy patterns, women can learn what helped other victims get through survivorship.

         Yooson Esther Chi and Sherry Hamby from the department of Psychology asked 100 different women open-ended questions that indicated what DV victims needed and wanted to achieve the most after surviving an unhealthy relationship:

 

  • In terms of psychological and personal needs, women that survived an abusive relationship relied on faith, personal strength and motivation to stay strong for the sake of their children. Having belief that every thing would work out played the largest role in psychological and personal needs. Self-esteem and self-worth came in a close second. Confidence can be empowering in itself. Knowing one’s strengths and believing in serving a purpose keeps victims focused on all the good they have to offer the world despite going through a time where self-worth was very little.

 

  • What women needed in a social environment/ community to remain on the path to survivorship included support groups, church, and family. Support groups came in number one for victims in a social environment. Support groups are a great source of empowerment for women facing abuse. Listening to others with similar stories and relating to their hardships makes it impossible to feel completely alone during a time of abuse. Sharing stories and encouraging others to achieve their goals proves to be one of the most helpful tools domestic violence victims could have.

 

  • The top three goals for the women in this study included employment, education and safe housing for them and their children. Employment and education go hand in hand when it comes to moving on from an abusive relationship. Being able to stand on one’s own two feet after relying on the safety of a shelter makes the women realize that she can provide for her family without the help of an abusive partner.

 

  • From a financial standpoint, victims are most reliant on employment, parents and child support. According to this study, financial struggles often lead to depression. This is why it is important to educate and prepare victims for post-shelter life.

 

         There is a need for education and opportunity for DV victims. Becoming financial independent and attending support groups empowers survivors to remain on the road to survivorship.

 

Source:

Chi, Yooson Esther. “The LIfe Goals, Strengths, and Resources of Domestic Violence Victims.” (2013).

 

Do Genetics Play a Role?

Do genetics play a role in violent behavior?

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     In research conducted by Miles and Carey (1997) suggest that up to 50% of the variance in aggression was influenced by genetic factors. This research implicates that, specific genes might identifiable and more specifically, the ones that contribute to aggressive phenotypes. One likely heavy hitter gene that has been linked to aggressive behavior is monoamine oxidase A (MAOA) or as it is also called “the warrior gene”. This mitochondrial enzyme, which is located on the X chromosome, has a pretty important role. It metabolizes on some key neurotransmitters such as: serotonin, dopamine, and norepinephrine. A variation of the “warrior gene” has been connected with aggression in primates, aggression in laboratory models, and impulsive aggressive behavior (Stuart, et al., 2014).

     MAOA is just one of the genes that is linked to aggressive behavior and many of the studies of genetics and violence have only focused on single genetic variants (Stuart, et al., 2014). In a study conducted by Stuart et al., (2014) an association between specific candidate genes and Interpersonal Violence was examined. With the use of a cumulative genetic score (CGS), which takes into consideration the collective impact of several variants. Among many benefits of using this type of tool is provides larger statistical strength than do studies of single genetic variants.

     This study was conducted with a sample of men who were harmful drinkers and were arrested for domestic violence. Genetic associations were examined in the sample. A CGS developed from empirically selected candidate polymorphisms were established to investigate if the combination of “the warrior gene” and another gene 5-HTTPLR were linked to three forms of interpersonal violence. The findings of the study were significant and having controlled for alcohol problems, drug problems, age, and duration of relationship, the CGS accounted for importance of biological links of interpersonal violence and the for further research to be conducted (Stuart, et al., 2014).

 

Miles, D. R., & Carey, G. (1997). Genetic and environmental architecture of human aggression. Journal of Personality and Social Psychology, 72, 207-217.

Stuart, G. L., McGeary, J. E., Shorey, R. C., Knopik, V. S., Beaucage, K., & Temple, J. R. (2014). Intimate partner violence in a sample of hazardous drinking men in batterer intervention programs. Violence Against Women, 20, 385-400.