AAP Voices Blog

The Silent Epidemic of Discomfort

I received top notch training during my pediatrics residency, but even 80 hours a week for three years wasn’t enough time to cover the broad-reaching health impacts to children who witness intimate partner violence. I didn’t fully grasp the significance of that aspect of child maltreatment or its categorization as emotional abuse until I was about five years into my career. At that time, I worked as the medical director of a child abuse intervention center in rural Oregon. The geographic isolation of the role required me to bolster my familiarity with child abuse and neglect.

I became fluent in adverse childhood experiences (ACEs) and attuned to how they impact a child’s long-term health and well-being. These days ACEs are peppered throughout curricula far more liberally. However, short of a parent walking into an appointment with visibly patterned bruising, I’d wager intimate partner violence is seldom top of mind during most child well visits. It’s time to change that.

Growing up, I was taught asking about "trouble at home" was intrusive and rude so I get the discomfort general pediatricians may have about sticking their professional noses into what seems like private business. Nevertheless, as the updated AAP clinical report “Intimate Partner Violence: Role of the Pediatrician” outlines, it’s necessary. More than that, it’s good health care.

Have you ever had a patient with a tummy ache? Trouble sleeping? A behavioral concern? Almost sounds like your daily schedule, right? These are all symptoms of exposure to violence between partners.

“Talking about the unmentionable makes it mentionable. Just like anything, ease comes with practice.”

I recall a routine checkup where a caregiver mentioned their child, about 6 or 7 years old, had trouble sleeping. The child no longer wanted to sleep alone in their room, insisting instead on joining the caregiver in her “big bed.” The caregiver said she wasn’t in a relationship and typically slept alone, so it wasn’t too big an inconvenience. But even in the “big bed” the child tossed, turned, and woke up crying. The behavior was out of character and the caregiver was at a loss.

I took a moment and turned to the child. “Do you feel like you’ve had trouble sleeping?” She nodded.

“How come?”

She looked at her mom and then looked at the floor.

Ultimately, she disclosed she was scared the “bad man” was going to come back and hurt her mom.
 
Her mom looked flabbergasted. Evidently, she forgot about a date she had, roughly a month ago at the time, that ended poorly. She wasn’t aware the child heard any commotion outside the house that night.

Fortunately, this was a one-off situation. A circumstance the mother easily disclosed to me and addressed with her child. This incident underscores the sponge-like nature of children and how their understanding of safety is built on the world they witness. I took the opportunity to discuss with the mom what research shows about intimate partner violence and how it makes paths of sympathetic activation –fight, flight, freeze, or fawn– increasingly well-worn in the developing brain. She shared her experience witnessing violence between her parents growing up and how that has informed her choices of partners.

This was an instance where the caregiver was forthcoming and comfortable sharing information. But how do we address the stickier situations? The times when the violence may not be in the past and may not be an isolated incident. We confront the taboo. We’re pediatricians. It’s what we do. Snot, poop, first sexual experiences – things that make others uncomfortable are kind of our wheelhouse. Talking about the unmentionable makes it mentionable. Just like anything, ease comes with practice.

For me, part of what makes asking questions about psychosocial circumstances difficult is a feeling of being ill-equipped to provide answers. I went to medical school. I can talk to you about hemodynamics or the pharmacological mechanisms of x, y, or z medication, but I feel far less adept asking about relationships. That is why the recent AAP clinical report is so valuable, recommending universal education. This obviates the need to guess what people may be experiencing or appearing to pass judgment by making intimate partner violence and its effects a standard mention to all patients. We don’t need to imagine what’s going on behind closed doors, thereby allowing our implicit biases to run wild. That’s not what we’re trained to do.

Instead, the clinical report recommends we provide education on risk factors, including violence in relationships, that impact a child’s health and development.

Medical school may not have taught us how to artfully engage complex emotions. But it did teach us how to study. Homework is kind of our jam. I invite you to apply those skills and familiarize yourself with your community’s specific resources and services for caregivers experiencing intimate partner violence. Add a local domestic violence hotline to after-visit handouts. Include resources on your clinic’s website. If we don’t offer that information, who will? Individuals experiencing unsafe circumstances may not feel ready to act on behalf of themselves, but most parents will prioritize the health and safety of their child. Our training equips us to help with that.