by Tia Will
Recent regional and national events have once again focused attention on a difficult subject, that of domestic violence. Within the last year we have been faced with the conviction of William Gardner for the stalking and murder of Leslie Pinkston, a former intimate partner. Regionally we have also seen the episode of domestic violence in the Jo case and the accusation of child abuse resulting in death of a local infant. Nationally we have seen multiple sports stars provide us with the spectacle of physically abusing their partners and children in public as well as in the privacy of their own homes with Ray Rice and Adrian Peterson as the most prominent examples.
One succinct description of domestic violence as found on Wikipedia is:
“Domestic violence can take a number of forms including physical, emotional, verbal, economic and sexual abuse, which can range from subtle, coercive forms to marital rape and to violent physical abuse that results in disfigurement or death.”
“Domestic violence often occurs because the abuser believes that abuse is justified and acceptable, and may produce inter generational cycles of abuse that condone violence. “
Key to the role of domestic violence in the generation and maintenance of a violent society is the normalization of the use of power of one individual over another in order to achieve the goals of the stronger individual. While the power differential in our society is more commonly that of the male over the female and children, this is not universally the case and anyone can be either the aggressor or the victim in these unhealthy relationships. Domestic violence and abuse does not discriminate. It happens among heterosexual couples and in same-sex partnerships. It occurs within all age ranges, ethnic backgrounds, and economic levels however, it does show patterns of prevalence.
Intimate partner violence (IPV), a subset of domestic violence, is characterized by episodic unpredictable outbursts by the abuser that often begin as verbal and emotional abuse but, over time, tend to become physical. Many cases have a component of isolation and dependency in which the victim has been deliberately undermined and convinced of his or her incompetency by the perpetrator.
Intimate partner violence is estimated to result in 2 million injuries to women and 600,000 injuries to men annually. In 2005, there were 1,510 IPV homicides in the United States, 78% of which were women. Women ages 20-34 are at the greatest risk thereby exposing millions of children to IPV. An estimated 15.5 million children live in homes where IPV occurs.
According to Adverse Childhood Experience studies the effects of these exposures may have profound and long lasting effects on brain development and may ultimately affect the adult mental and physical health and functioning of the exposed children.
Toxic stressors including domestic or community violence, maternal depression, parental substance abuse, food scarcity and poor social connectedness can lead to adverse changes in learning, behavior and physiology including chronic stress related illnesses throughout childhood and into adulthood.
As noted in the online medical reference Up to Date, a meta-analysis published in 2008 concluded that exposure to IPV is associated with poor emotional and behavioral outcomes in children. With regard to mental health, exposure to IPV leads to an increase in externalizing behaviors such as aggression, conduct disorders, and impulsivity such as drug use, sexually irresponsible behaviors, and petty crime. For others, it may lead to internalizing behaviors such as anxiety, sleep disturbances and depression.
Exposure to IPV has age dependent effects.
- Infants may show disrupted feeding and sleep routines, excessive crying, and developmental delay
- Toddlers may use comforting, acting out or other distracting behaviors to attempt to avert the fear producing interactions of their parents
- Preschoolers may recreate the violent act in play, through aggressive acts or may demonstrate regressive behaviors such as bed wetting or thumb sucking and may have nightmares, onset of stuttering or clinging behaviors.
- School aged children may blame themselves for the violence. The may exhibit somatic complaints such as headaches or stomach aches increasing school absenteeism and may display either aggression or depression.
- Adolescents may demonstrate depression, substance abuse, and various forms of acting out
Results of exposure to IPV have also been shown to vary by gender. One study of 6 to 11-year-olds found that girls exposed to IPV demonstrated more internalizing behaviors such as anxiety and depression while boys tended to demonstrate more externalizing behaviors such as conduct disorders, impulsiveness and poor temper control.
Exposure to IPV also affects cognitive development. Multiple factors contribute to adverse affects on school performance. Sleep deprivation, depression, PTSD, absenteeism, disruption of attendance by need for safe house placement all can contribute to disruption of cognitive development and school performance. One study showed that 40% of preschool children of IPV mothers had developmental delays. Almost 50% of school-aged children from affected homes had academic problems such as grade repetition.
IPV has a complicated relationship to parent-child relations. In one study, 20% of affected women reported that the presence of the child or children was the source of parental conflict. The mother’s attitude about the source of conflict can lead to self-blame on the part of the child. IPV may also have direct effects on parenting consistency and style. In another study, some mothers reported being harsher with their children when their abuser was present hoping to spare the children from worse treatment from the abuser, while others reported being more lenient hoping to compensate for harsh treatment from the abuser. Both strategies lead to inconsistency and uncertainty regarding expectations and consequences on the part of the child.
There is a consistent finding of a relationship between IPV and child abuse. Although the degree varies, multiple studies have shown that 30-60% of homes where either child abuse or IPV is present, the other form of abuse is also found.
Many of the adverse effects of IPV persist into adulthood. These include higher incidences of depression, Post-Traumatic Stress Disorder, poor social adjustment, conduct disorders, antisocial behaviors, self injurious behaviors, increased risks of becoming a perpetrator of IPV or child abuse, or becoming either a perpetrator or victim of violent behavior oneself. Finally children from IPV families are at increased risk of substance abuse, high-risk sexual behaviors, and other high-risk behaviors.
As with any multifactorial problem there are many possible approaches and interventions. I believe there is room for intervention at many different levels of society including extended families, neighbors, churches, schools, social services and the medical field. Since the latter is my area of expertise, I am going to focus the rest of this piece on what I see as the potential contribution of health care providers.
- Screening: Many major medical associations encourage routine screening for IPV and domestic violence. Among them are the American Academy of Family Physicians, the American Academy of Neurology, the American Academy of Pediatrics, the American College of Emergency physicians and the American College of Obstetrician Gynecologists, as well as the American Medical Association. The 2013 the U.S. Preventive Services Task Force recommended routine screening for all females ages 14-46 for IPV with referral for all those who screen positive. This recommendation is based on studies showing that interventions can improve both the safety of these women and their children both in terms of short-term physical safety and long term improved outcomes.
- Use of a specific screening and intervention designed by the Massachusetts Medical Society: Routinely screen, Ask direct questions, Document in chart or as restricted access documentation as needed, Assess safety, and Real time referral (RADAR).
Safety assessment questions include: Are you afraid to go home? Are there guns in your home? Is there a threat of homicide or suicide? Have you ever been choked? Has the violence increased? Do you have a safe place to stay?
- Real time referral is critical when there is an imminent threat. This includes the provision of numbers for local shelters and/or the National Domestic Violence Hotline number 1-800-799-SAFE, mental health referrals as needed, and reporting to police and or social service agencies as indicated.
- Home prevention can also be taught and reinforced in the medical setting at the time of appointments and should be a routine part of adult and pediatric care. Simple suggestions will sometimes make a huge difference in the life of a child. Children should be kept separated from heated discussions between parents. Parents should enforce consistent, agreed upon rules for behavior. Each parent should maintain good communication with each child. Negative impacts of domestic conflicts on children should be reviewed with parents when identified and more productive alternative behaviors suggested.
It is my belief that for too long the issue of domestic and intimate partner violence has been kept in the closet as a dirty little secret that families and our society wish to avoid. We continue this belief that it is the exclusive purview of the family to our own harm and expense as a society on many levels, both economic and social. I believe that this is a subject that should be openly discussed and addressed with a view not towards demonization and finger pointing, but rather with an attempt to understand how each of us can contribute to lessening this widespread and pernicious problem that affects us all.