Practical Tools for Supporting IPV Survivors in Pediatric Health Care Settings

Scenario

Scripts

 Verbal universal screening

"Because violence at home is very common, it has negative impacts on kids’ health and education, and resources are available, I’ve started asking all families about violence at home. Is this something you or your child have experienced?"

"I noticed your injury. Sometimes injuries like this happen when a parent has been hurt by someone else. We have resources to offer when this happens, so I always ask. How did your injury occur?"

"Sometimes when children are having trouble sleeping, it’s because they’ve seen or been part of something scary, like violence at home or other forms of trauma. Has anything like this happened to your child?"

Verbal screening with indicators of IPV are present

"When children have symptoms such as abdominal pain or headaches, they can be related to stress. Is there anything stressful happening to you or your child?"

"Many families find it hard to make to all their child’s medical appointments. We ask about this because we want to help your child get the medical care they need. What things make it tough for you to make it to your child’s appointments?"

"Sometimes when we don’t see the expected response to a treatment, it’s because there are other things going on in a child’s life, like violence or other stressors at home. We ask because we can offer resources for things like this. Is there anything at home that you think might be impacting your child’s response to treatment?"

 Validation after IPV disclosure

"Thank you for sharing this with me. It’s not an easy thing to talk about. No one deserves to be treated that way."

 Warm handoff to IPV resources

"I’d like to connect you to someone who can let you know about the many resources available for families experiencing this."

 Mandatory reporting for IPV

"I’d like to ask you about violence at home, because we know that it’s common, it negatively impacts kids’ health, and resources are available. Before I do, though, I want to let you know that our state law requires me to make a hotline report when I learn about this, so I can’t keep this just between us if you tell me it’s occurring"

Sample Script

Confidentiality and privacy

Assessing privacy when scheduling the visit: “During the pandemic, we are recommending virtual visits whenever they can be done safely. We know virtual visits are new to many families. We share with all families that a virtual visit will mean that the healthcare provider will talk with you and see your child through a video. Other people in your home may be able to see and hear the visit. We know virtual visits work for some parents, but others prefer an in-person visit for many reasons, such as wanting an in-person examination, not feeling safe speaking in their home, not having access to the Internet or a data plan, or for other reasons. All parents may choose an in-person visit for their child.”

Assessing privacy when starting the visit: “Are you in a private place right now?” If not: “If you would like, you can move to a private place, we can schedule an in-person visit, or I can schedule the visit at a later time.”

Universal education and empowerment

Broad script offering education and support for multiple stressors, including IPV: “Being a parent is so hard now and parents don’t always get to hear how important they are, so I am thanking you for all you do for your children and family. Because people are more stressed than ever, we are sharing ideas about helping yourself and people you care about. Some types of stress that parents are feeling are not having enough food to eat, not having a stable place to live or getting behind on the rent, worries about having enough hot water or heat, not having childcare, feeling lonely or sad, or experiencing stress in a relationship. We want to you to know that we are here for you. We send over a resource sheet to all families, such as fresh food, who to call for help with utilities, numbers to call if you are stressed, lonely, or experiencing violence, and childcare. Before we end our visit, I want to take a pause and see if there is anything that this conversation has brought up for you that you would like to discuss. It is your choice if you want to share, and we provide resources to all families.”

IPV-specific script: “One of the things on the resource list we talk to everyone about is how more stress in our relationships may come with fighting or harm, and that can affect our health. There is free, confidential help available if you know someone who is being hurt in their relationship. Before we end our visit, I want to take a pause and see if there is anything that this conversation has brought up for you that you would like to discuss. It is your choice if you want to share, and we provide resources to all families.”

Support if a parent discloses IPV, with a focus on validation

Validation: “Thank you for sharing that, I am so sorry that this is happening. What you are telling me makes me worry about your safety and health. A lot of parents experience things like this.”

Dynamic assessment of privacy: “Are you in a private place where we can talk more about this? At any point while we are talking, if you are no longer in a private location, you can say, ‘I am breaking up, I cannot hear you’ and then call me back.”

Connection to resources: “I can connect you today with people who can help if that interests you. I can send you a list of resources, connect with someone right now if you like, or we can talk more about different resources, whatever you prefer.”

Converting to an in-person visit: “Based on what you are telling me, how would you feel about coming to the clinic to talk about this in safe, private location.”

Mandated reporting: “I am so sorry for all you are going through. Because your child is being injured, I will need to file a report to Child Protective Services. I will support you through this process [if in a private location]. Can we call Child Protective Services together, right now, to talk about what you told me? If you would like, I can also connect you with a local organization who can help you come up with a safety plan.”

Patient vignette

Potential response with resource provision

Gabby^a is a 16-year-old girl with symptoms of discharge, abdominal pain, and spotting. She missed her last Depo-Provera injection at the school-based health center six weeks ago. The health center staff sent her several reminder messages; and then school closed abruptly, including the health center. The school-based health center was a safe space for her to receive contraception. Her partner, who goes to a different school, does not want her to use hormonal contraception.

Responding to a post on social media about AYA telemedicine services, Gabby calls to schedule an appointment. She is asked if she has a private place to have the visit through telehealth. During the visit, the clinician shares information with her about the national dating abuse helpline (loveisrespect.org), saying, “In case you or your friends could use this information, we make sure to share this with all our patients.” Arrangement is made for Gabby to be seen at the AYA medicine clinic closest to her home for a nurse visit to receive a pregnancy test, Depo-Provera, and antibiotics for presumed pelvic inflammatory disease. She receives daily check-in calls from the clinic to ensure her symptoms are resolving; during each call she also receives adolescent-relevant resources.

Aarav^a is a 17-year-old boy with a history of anxiety and ADHD. He was about to start therapy when the pandemic started and behavioral health visits were switched to telehealth. His primary care provider called and spoke with him about virtual visits. He said he does not feel safe doing visits in his home because his father is emotionally abusive to his mother and also to him if he tries to stop the abuse. He says the walls are thin and it would be impossible to start therapy now.

His pediatric clinician called and asked for a safe time to schedule a telehealth call. Aarav provided his and his sister's cellphone number, both which he felt safe using. They decided on a time when his father was out of the house. Aarav spoke with the clinician first and then asked his sister to join. They decided to start therapy, using behavioral health resources provided by the clinician, but would need to limit it to times when their father was not at home. The clinician also provided resources to a local victim services agency for youth exposed to parental IPV.

Daneesha,^a a 9th grader, was an active participant in a support group on healthy relationships in an after-school program. In group, she had shared her fears about her stepfather's anger. One of the facilitators saw bruises on her wrist. With the support of the group facilitators, child protective services got involved. Several weeks later, she shared how grateful she was to have the support of the adult facilitators who cared about her safety as well as the counselor whom she sees in school. Owing to COVID-19, the schools and after-school programs closed. The facilitator has not been able to reach her by phone; no one from the school district has responded to messages from the facilitator. The facilitator wonders what more she can do.

The facilitator reached out to the clinician who was overseeing the group, who then reached out to the school principal. The principal was grateful to hear that community partners were also seeking to support students during this difficult time and connected the facilitator to the school social worker. The school social worker was able to reach the home to check in and speak with Daneesha, and to let her know the facilitator was worried about her and offered the facilitator's phone number so that Daneesha could call her.

Since school closed, Daniel^a (age 17) has had fights almost daily with his mother. A housekeeper in a large hotel downtown, his mother is now without work. He cut his electronic ankle monitor and left his house to go stay with his boyfriend. This boyfriend was working in construction; three weeks ago, he was laid off as all nonessential building has stopped. He threatens to call Daniel's probation officer if Daniel seems reluctant to do what his boyfriend wants to do sexually.

Daniel sees a post on social media about the drop-in clinic for youth run by a local community health agency. While the clinic is closed due to the pandemic, he receives a call from a youth coach who offers a phone or video visit with a clinician. The youth coach also offers information about confidential services provided by a local intimate partner violence agency. The clinician speaks with Daniel by phone and offers to help make a call to this victim service agency together. While Daniel declines, he also knows that he can reach out to the youth coach or clinician any time.

Nate^a (age 16 years) sustained a gunshot wound after a dispute in his neighborhood. Nate is admitted to the hospital trauma service for medical stabilization. His physical wounds begin to heal and he is discharged home to continue his recovery. Sitting in the passenger seat on his way home, his heart begins to race as his mother's car nears the block where the shooting took place. Nate is worried about his safety and the safety of his siblings amidst an escalating turf war.

Following consent from Nate's mother and a referral from a nurse, a violence intervention specialist reaches out to Nate after discharge to discuss safety planning. Nate is skeptical about speaking with the interventionist by phone. The interventionist offers to send take-out to Nate's home and they enjoy a virtual meal together to build their relationship.

Withholding insurance

“He didn’t put the family on [his] health insurance even though he was the only one who had access to health insurance. And then she [IPV survivor] was blamed and at fault for them not having health insurance.” (IPV advocate)

Limiting access to transportation

“So, it’s more a manipulation-type deal versus blatant “You can’t go.” It’s ‘You don’t have access to go. If you don’t have the car you can’t take him [the child].” (IPV advocate)

Controlling appointment scheduling

“Like scheduling, canceling appointments, I think that in instances where the abusive partner is responsible for getting people to appointments and things like that, there might be some, you know, power plays happening.” (IPV advocate)

Not allowing the IPV survivor to speak with the healthcare team

“I’ll often have social workers or other providers who consult me and say, you know – there were two parents who came in for this child’s outpatient visit and dad took over the entire conversation. He wouldn’t let mom get a word in and I’m really concerne

Controlling visits by using language

“With limited English proficiency survivors, sometimes, I’ve heard about [the abusive partner] not allowing an interpreter. It creates either information not being shared or inaccuracies or just limitations in what accurate accounts related to the child’s health are provided.” (IPV advocate)

Controlling medical decision making

“I see it with ADHD a lot. The primary caregiver wants the child on medication for behavior, but the abusing partner will not allow it. And so, they’ll make the victim feel bad about their inability to parent effectively.” (Pediatrician)

“I’ll hear oftentimes from a parent – ‘They told me that this surgery needs to happen, but now my partner’s saying, ‘We’re not going to do it.’”. (IPV advocate)

Stalking and harassing in the healthcare system

“They will call and try to get health information. We’ve had them call nursing staff, threatening nursing staff, trying to get any kind of information that they can.” (Security)

“Every time [the IPV survivor] moved, [the abuser] would try to at least isolate the area he thought she was, and he’d start calling all the [durable medical equipment] companies and say “Oh, I just moved…I can’t remember which DME I was supposed to get for my kid”. And then he would find her.” (Social worker)

“I’ve had survivors who would come in for their children’s visits and then when they’re leaving or going to the parking lot, the abuser would be in the parking lot, would harass them to their car, would show up.” (IPV advocate)

Abusive partner becoming angry or agitated

“This child was on one of the cardiology floors…and this abusive partner will just keep showing up and disrupting the quiet milieu they’re trying to provide for their other sick patients.” (IPV advocate)

“If I had to think about quality of care, I would think about…getting frustrated as healthcare providers with all the noise that’s happening around maybe some of the power and control that’s going on in the medical setting. And so [they are] not attending as fully as one might to the child’s care because you just want to get him out. And so maybe missing some things or not being as thorough or not asking as many questions.” (Social worker)

Abusive partner aligning with the provider

“What the father was trying to do was align with me, as the provider, when we were talking about ways to improve the child’s behavior…he was sort of trying to prove to me that he was actually trying to improve the child’s behavior by making this threat that they would take the kids back to their country or they would get the mother deported if the child’s behavior didn’t improve.” (Pediatrician)

Abusive partner is charming

“I have found that most caregivers are respectful of the hospital. I can think of one where the mother had not wanted the father to come back…And I was like ‘Wow. You were really polite and really nice.’ And almost like ‘Wow, I couldn’t imagine you doing the things that I’ve been told you do.’” (Pediatrician)

“Abusers are often very, very, very charming to everyone else. Healthcare providers, social workers. They often succeed in getting them on their side. I think that’s really dangerous. I don’t think providers are very well trained in detecting that either.” (IPV advocate)

Abusive partner appears like a caring parent

“We did a consult for this mom who was breastfeeding her first baby and the dad was just so great – he was at the bedside, he really wanted to help [and] he was really supportive of the breastfeeding. And the next day I learned that they were in a chronically dangerous relationship for this mom and that there was a history of really severe violence.” (Pediatrician)

Acute care settings can be challenging due to brevity and lack of continuity

“These are not things I will say you most likely suss out with your emergency department cases. These are things you get a sense of in your ongoing primary care, your longer-term families, unless there’s a real red flag, like, something that – you know, someone is yelling at a partner, and behaving in a way that is more blatantly abusive.” (IPV advocate)

Inpatient setting offers more time to understand relationship dynamics

“You do not have an extended amount of time to determine if things are safe in this relationship or not. So that’s helpful. You don’t necessarily have to do it in this moment. Unlike, when you’re in the emergency department and everything’s stressful and crisis.” (Nurse)

Consider parental behaviors within a framework of power and control

“…watching dynamics between caregivers is important – if there’s someone whose world seems a lot smaller, if there’s someone who’s voice seems a lot larger. Obviously, that doesn’t necessarily have anything to do with IPV. Sometimes that’s just the roles that have been assigned in that family dynamic. I still think it’s always worth keeping an eye out and not being afraid to ask those really hard questions.” (IPV advocate)

“Those little subtleties – what’s the family system, classic rules in the family system? How are they aligning? How are things shifted? How does it change when certain people are in the room? All those things are stuff that we should try to notice.” (Social worker)

Engaging a multidisciplinary team

“Filing [a report] can make things really, really dangerous. If that is the case, it is really important to be transparent with the parent…and involve [child abuse pediatricians] on our [IPV] team, so that we can help come up with a plan to keep the survivor safe.” (IPV advocate)

“Our Medical Records Department is really good at identifying things that are more sensitive in nature and making sure the right person has the right access. .But it is possible for the information that’s disclosed in a visit to then be shared with an abusive partner.” (Social worker)

Normalizing policies and procedures

“That’s just a part of their clinic’s process, so that, particularly if their abusive partners become skeptical of the situation, [they can] frankly say, ‘That’s just how [they] do assessments here.’” (IPV advocate)

“Being very clear, succinct, and as direct as possible and as calm as possible…So really leaning on solid policies and procedures.” (IPV advocate)

Focus on the child

“I think that you could potentially diffuse a lot of things and then kind of get to the root of , ‘We need to move forward with the care of the child, and this is the best way to do that.’” (IPV advocate)

Trust and validation

“Making sure that you are open, express your concern for the children and mother’s safety…because she [the IPV survivor] is the expert on how best to keep herself alive and be safe.” (Social worker)

Providing safety options

“We have what’s called the patient protected status, and making sure that their visitors are limited, including family members.” (Security officer)

“‘…let’s come up with a safe plan where the [child protective services] can meet you and your partner won’t know about it’…Like have [child protective services] come to interview mom and the child, like at the hospital when the partner’s at work or something like that.” (Social worker)

“For instance, the abuser works from 1:00 – 10:00 every day. And so, we’ll only offer them afternoon appointments. And so, they have to come alone. And then to offer them transportation or to circumvent whatever control methods might be put in place to keep that victim from coming alone with the child.” (Pediatrician)