Intimate partner violence: Childhood exposure

INTRODUCTION — Intimate partner violence (IPV) is a common form of violence in intimate relationships. The epidemiology, effects, and treatment of children who are exposed to IPV and some aspects of diagnosing, screening, and counseling caregivers for IPV are reviewed here. A more thorough discussion of diagnosing, screening, and counseling for IPV is provided separately. (See "Intimate partner violence: Intervention and patient management" and "Intimate partner violence: Diagnosis and screening".)

BACKGROUND — Females between the ages of 18 and 34 are at the highest rate for intimate partner violence (IPV) victimization [1], and because many of these females are mothers, millions of children are exposed to IPV [2-4]. Exposure to such violence is a major threat to children's health and well-being [5-11]. IPV exposure during childhood can have deleterious effects on a child's developing brain resulting in long-term adverse consequences [10-13]. Data from the Adverse Childhood Experiences studies indicate that adverse childhood experiences, such as exposure to IPV, dramatically affect adult mental and physical health and mortality [14-16]. In addition, in an observational study, childhood exposure to IPV was associated with being a victim (for females) and perpetrator (for males) of IPV in adult relationships [17]. (See 'Effects' below.)

The American Academy of Pediatrics encourages health care professionals to use an ecobiodevelopmental framework to understand how exposure to toxic stress (eg, domestic or community violence, maternal depression, caregiver substance use, food scarcity, poor social connectedness) during childhood can lead to permanent changes in learning, behavior, and physiology [10,11,18]. Chronic toxic stress in childhood causes physiologic changes that lead to stress-related chronic illness and unhealthy lifestyles in adulthood.

Family violence has a significant impact on an individual's health, as well as community health and health care resources [19,20]. IPV frequently remains undiagnosed because victims may conceal that they are in abusive relationships and the clues pointing to abuse may be subtle or absent. Pediatricians are well-placed to identify maternal IPV because victims of IPV seek health care for their children, even if they do not for themselves [21-23].

TERMINOLOGY — The Centers for Disease Control and Prevention define intimate partner violence as a pattern of behaviors that may include physical violence, sexual violence, stalking, and psychological aggression that are used by a current or former partner in an intimate relationship [24]. These behaviors are used to establish power and control over the victim [25-27]. Abusive relationships are characterized by episodic, unpredictable outbursts by the abuser that often begin as verbal and emotional abuse but, over time, tend to become physical. As the abusive relationship continues, the victim begins to live in a state of constant fear, terrified about when the next episode of abuse will occur.

"Witnessed violence" is verbal or physical violence that is heard or seen by a child [28]. However, the definition of child witness to violence is expanded to include not only the actual observation of the violence or abuse, but also the observation of the effects of the violence suffered by the victim, such as visible injuries, bruises, intimidation, and fear [27,28]. The abusive behavior that may be witnessed by children in the home ranges from loud arguments to hitting, shoving, slapping, punching, and potentially lethal assaults (eg, strangulation or the use of a weapon) [29].

Toxic stress is defined as, "The biological response to frequent, prolonged, or severe adversities in the absence of at least one safe stable and nurturing relationship; these biological responses might be beneficial or adaptive initially, but they often become health harming or maladaptive or 'toxic' over time or in different contexts" [11].

EPIDEMIOLOGY — Intimate partner violence (IPV) is a common form of violence, with approximately one in three adults experiencing sexual violence, physical violence, psychological aggression, and/or stalking by an intimate partner at some point in their lives [30]. Each year in the United States, IPV is estimated to result in an estimated 1200 deaths, 2 million injuries to females, and nearly 600,000 injuries to males [31]. Large proportions of adults report having experienced various types of IPV during their lifetime (table 1) [32]. Partner violence often begins in adolescence (figure 1).

Female victims of IPV are more likely than male victims to experience injury, severe physical violence, and sexual violence [25,32]. They are also more likely to be killed [33,34]. Data from the Centers for Disease Control and Prevention indicate that among homicides where the relationship between the perpetrator and victim was known, the most common perpetrator for female homicide victims was a current or former intimate partner (approximately 50 percent) and the most common perpetrator for male homicide victims was an acquaintance or friend (approximately 35 percent) [35]. Approximately 7 percent of male homicide victims were killed by a current or former intimate partner.

It is estimated that up to 15.5 million children (30 percent of the United States population of children) live in homes where IPV occurs [3,4]. In the 2014 National Survey of Children's Exposure to Violence, approximately 6 percent of children reported witnessing an assault between parents [36]. These estimates probably underrepresent the true incidence because many cases of IPV go unreported. Children living in such homes become involved in the violence in a variety of ways, eg, they can sustain injuries either intentionally or unintentionally [37], try to stop the violence [38], affect the caregiver's decision-making process [39,40], and are at high risk to becoming victims of child abuse or homicide [5,41]. Review of narrative descriptions and coroner/medical examiner or law enforcement reports from the National Violent Death Reporting system from 2005 to 2014 suggests that approximately 20 percent of 1386 homicides of children age 2 through 14 years were related to IPV (ie, the perpetrator also killed or tried to kill the intimate partner or the homicide was preceded by intimate partner conflict [eg, separation, divorce, custody]) [42].

Risk factors for maternal IPV victimization identified in observational studies include [1,41,43-54]:

●Age 18 to 34 years

●Maternal disability

●History of physical injury during pregnancy

●Mother directly or indirectly refers to IPV

●Alcohol or substance abuse in the home

●Maternal history of depression, anxiety, suicidality

●Having a child with alleged or confirmed child maltreatment

Risk factors for paternal IPV victimization have not been systematically assessed.

Findings that may be associated with IPV include:

●Not following through with recommended treatments for self or child(ren)

●Chronically missing appointments for self or child(ren)

EFFECTS — Isolating the quantitative contribution of repeated exposure to violence, family dysfunction, and social stressors from the effects of witnessing intimate partner violence (IPV) is difficult because these variables usually occur in combination [55,56]. However, IPV in the home is a strong adverse experience and independently affects child mental and emotional health in addition to being associated with exposure to other adversities [57-59].

Exposure to IPV has short- and long-term effects on a child's emotional, social, and cognitive development [5-9,60-63]. The effects for an individual child are dependent upon several variables [11,64-68]:

●The proximity and severity of the violence

●The number of violent disruptions

●The age of the child

●The sex of the child

●The relationship of the child to the abuser and victim

●The loss perceived by the child

●The relationship of the violent act to the child's daily routine

●The availability of a support system

A meta-analysis concluded that "mere exposure" to IPV is associated with poor emotional and behavioral outcomes in children [69]. Positive relationships in the family; safe, stable, nurturing caregiving; a supportive environment outside the home; fewer social stressors (eg, poverty, low educational level of caregivers, caregiver substance use); fewer maternal health problems; and less severe violence exposure are protective factors for children who are exposed to IPV [11,70-73]. Additional information about creating safe, stable, nurturing relationships and environments is available from the National Center for Injury Prevention and Control and the Centers for Disease Control and Prevention.

●Mental health – Many children who are exposed to IPV exhibit an increase in externalizing behaviors such as aggression, conduct disorders, and impulsivity [6,7,74]. They also may suffer from internalizing behaviors such as anxiety, intrusive thoughts of violent events, disrupted sleep pattern, and depression [6,7,75]. Internalizing behaviors may improve if the IPV resolves. In a retrospective study of 320 children with caregiver-reported IPV, resolution of IPV after child protective services investigation was associated with improvement in child behavior problems [76].

Children who witness life-threatening acts toward their caregivers may exhibit symptoms of posttraumatic stress disorder [77-81]. Repeated exposure to violence may cause the child to have a fatalistic world view, which in turn may lead to risky behaviors (eg, drug abuse, noncompliance with medications, sexual promiscuity, careless operation of vehicles) [82].

•Age-related – The child's immediate reaction to the violent act is varied and significant. Age, sex, and developmental stage play a role in how children react to violence exposure. Common responses include crying, attempting a physical intervention, trying to protect the caregiver, creating a distraction, or becoming involved in the conflict [5,61]. Children who attempt to physically intervene in parental conflict are at risk for incurring physical injury [37].

From a developmental perspective, the health impact of witnessing violence is influenced by many factors, including the age of the child [5,61,83-86]:

-Infants may have disrupted feeding and sleep routines, excessive crying, and developmental delay.

-Toddlers may display comforting, acting out, or distracting behaviors. Acting out or distracting behaviors may defuse interparental aggression by redirecting the attention of the adults.

-Preschool children may recreate the violent act during play [82,87]. In addition, they may be withdrawn, have regressive behavior (eg, bedwetting or thumb sucking), have nightmares, stutter, or exhibit anxiety and clinging behavior.

-School-age children may blame themselves for the violence in their homes. They may have somatic complaints of headache or abdominal pain and varying degrees of anxiety. They also may have increased aggression and depression [75]. School absenteeism increases and school performance decreases [75,83,88,89]. In observational studies, exposure to adverse childhood experiences (which includes witnessing IPV) has been associated with attention deficit hyperactivity disorder [90,91].

-Adolescents may adopt inappropriate behaviors (eg, dressing older or younger than their age). They may become depressed [43], abuse substances to escape the pain, or act out in an aggressive manner.

•Sex-related – Studies that have looked at sex differences with respect to the mental and physical impact of witnessing IPV provide mixed results [92,93]. A meta-analytic review found that there was little to no difference in outcomes based on sex [84].

●Cognitive – Children who live in homes where IPV occurs may have problems in school for a variety of reasons, including increased school absenteeism, comorbid mental health issues, or concurrent child maltreatment.

In an observational study, children exposed to IPV were more likely to be suspended from school, visit a school nurse for social and emotional complaints, and more likely to be sent home after seeing a school nurse than children who had not been exposed to IPV [94]. School absenteeism for whatever reason results in less time in the classroom for learning.

In cross-sectional and cohort studies, exposure to community/neighborhood violence and child maltreatment have been associated with lower intelligence quotient (IQ), decreased reading achievement, and impaired cognition and academic functioning [88,95-97]. As an example, a longitudinal study found that exposure to interpersonal trauma (ie, child maltreatment and witnessing IPV) was associated with decreased cognition at 24, 64, and 96 months of age and that the effect on cognition was especially detrimental if IPV exposure occurred in the first two years of life [96]. This finding is consistent with that of other studies demonstrating that early exposure to toxic stress profoundly affects the health and well-being of children [11,13,98-100].

●Coping – A review of the literature reveals different strategies that children use to cope with living in a violent and disruptive home. A child's ability to navigate a violent household and develop coping strategies is dependent on multiple factors, including the age and developmental stage of the child.

Some of the adopted coping strategies are adaptive (eg, seeking safe environments and supportive friends, focusing on extracurricular activities at school) and some are nonadaptive (eg, emotional numbing, dissociation, self-blame) [101]. Younger children may become disengaged from the chaos around them, which professionals and family members may view as a sign that the child is not affected. As children get older, coping strategies may include using alcohol and drugs to escape the mental anguish of experiencing the abuse; taking on different family roles (eg, becoming the caregiver of younger siblings, being a confidant to a caregiver, trying to mediate peace between the adults); actively seeking to understand and prevent triggers wrongly perceived as the cause of the violence; and taking on the overwhelming burden of the false assumption that they are the cause of the violence [101].

●Caregiver-child interaction – Children who live in homes with IPV may be blamed as the cause of the conflict. One in five females in the Spousal Assault Replication Program database reported that the children were the cause of the domestic upheaval [102,103]. The caregiver-child relationship may be affected if the caregiver views the child as responsible for the domestic conflict; this, in turn, may affect the way in which the child responds to witnessing a traumatic event.

●Parenting style – The occurrence of IPV can affect the parenting style for both the victim and the perpetrator. Victims of IPV are often overwhelmed with issues of safety and survival, which can interfere with effective parenting [87,104]. Partner aggression and young maternal age combined with paternal harsh parenting is associated with maternal harsh parenting [105,106]. Mutual partner aggression doubles the odds that a caregiver will use corporal punishment as a means of discipline [107]. In addition, the mental health consequences of IPV impact a victim's ability to parent effectively [108]. Parental depressive symptoms are associated with negative parenting behaviors and negative views of the child's development and health [109,110].

●Related to separation – Children from violent homes may experience effects related to separation if their caregivers choose to seek refuge from the abuser. It may be necessary for these children to leave their home, school, friends, and other support systems. The feelings that they have may range from sadness and protectiveness to relief and pleasure [111]. Preschool children have the most difficulty in adjustment. They express their feelings through behavior problems, sleep disturbances, enuresis, and regressive behaviors [70,111]. Conversely, behavior problems associated with exposure to violence may improve after separation. While 42 percent of the three- to six-year-old children whose mothers left a violent relationship had behavior problems warranting clinical intervention at the time of interview, the mothers reported that the behavior of most of the children improved after the separation [55].

●Child abuse – Childhood exposure to IPV is associated with child abuse in multiple observational studies [60,61,112-115]. As an example, in a survey about adverse childhood experiences, more than one-half of adults who reported exposure to IPV as children also reported being physically abused, compared with one-fifth of adults who had not been exposed to IPV [112]. (See "Child neglect: Evaluation and management".)

●Long-term effects – The long-term effects of exposure to IPV are described in retrospective studies and archival records. They include [61,75,116-124]:

•Depression

•Low self-esteem

•Trauma-related symptoms

•Poor social adjustment

•Conduct disorders

•Antisocial behavior

•Self-injurious behavior

•Perpetrator of child abuse as an adult

•Potential to become a victim or perpetrator of violence toward others

•Substance use and high-risk sexual behavior during adolescence

THE PROCESS OF ASKING ABOUT CAREGIVER INTIMATE PARTNER VIOLENCE

Why ask — Intimate partner violence (IPV) can affect the health and well-being of victims and their children and may not be identified unless the provider asks about it (algorithm 1) [125-128]. Children exposed to IPV present with nonspecific and variable complaints (table 2).

Asking about the safety of all family members lets caregivers know that they can come to the clinician for help if and when the need arises. The process of asking about intimate violence is as important as the answers to the questions, particularly if the caregiver is not yet ready to disclose IPV.

Asking caregivers about exposure to IPV when a pediatric patient presents with signs or symptoms of exposure (table 2) may help to identify children at risk for other adverse effects and those who may benefit from intervention [62]. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to surveillance'.)

Identifying IPV may be an important means of preventing child abuse because IPV is a leading precursor to child maltreatment [60]. However, definitive evidence that primary care interventions, including identifying and responding to IPV, prevent child maltreatment is lacking [129,130].

Many victims will disclose IPV victimization when asked in a pediatric setting [125-128]. Targeted or universal screening for IPV victimization in the health care setting is recommended by the United States Preventive Services Task Force (USPSTF) and many advocacy groups and medical organizations [26,60,131-139]. The USPSTF recommends universal screening for IPV among females of reproductive age [139]. There is moderate certainty of a net benefit to identifying IPV in this population and providing or referring females who screen positive for ongoing support, particularly for pregnant and postpartum people [140]. The benefits and harms of screening males and older females are uncertain. The benefits and harms of screening and recommendations of other groups regarding screening for IPV are discussed separately. (See "Intimate partner violence: Diagnosis and screening", section on 'Benefits and harms'.)

Whom to ask — We ask caregivers about IPV victimization if the pediatric patient has signs or symptoms suggestive of exposure (table 2). Diagnosis and screening for IPV in other health care settings is discussed separately. (See "Intimate partner violence: Diagnosis and screening".)

We screen adolescents about violence in their own relationships and provide anticipatory guidance about healthy relationships.

How to ask — When clinicians have concerns about violence in the home and ask about IPV, it is important to recognize that the process of disclosing IPV can be frightening and traumatizing to the victim. The victim and/or children may have been threatened with death for revealing the abuse or trying to leave [60]. Victims may only be willing to reveal IPV if they believe that they can improve their situation.

When asking about IPV, health care providers should ask questions about IPV in the patient or caregiver's primary language. Children or family members should not be used as interpreters.

In the pediatric setting, the IPV victim often is the patient's parent or caregiver rather than the patient. We have modified the USPSTF screening guidelines to allow some flexibility when discussing IPV with patients' caregivers. The conversation may vary depending upon whether there are signs or symptoms of child exposure to IPV (algorithm 1 and table 2).

For caregivers whose children are without signs or symptoms of IPV exposure and in whom we have no concerns about IPV, we use the "indirect" approach to let families know that our clinic is a safe place to get help:

"Violence is so common in many people's lives and being a victim of violence or abuse can affect your health and the health of your children. We want to make sure that all our families are safe. So if you are afraid that someone is going to harm you or your children or if someone has harmed you or your children, you can come to us for help. Please be aware that in some instances what you tell us may have to be reported to the police."

For patients with risk factors, we ask about IPV directly. Advocates in the field of IPV suggest that direct questions are more likely to identify victims than open-ended questions statements [27].

The subject can be introduced to female caregivers as follows:

"I ask all my families if they are in a relationship or in a home with someone who may be hurting or controlling them because this can affect a person's health (and the health of children). Please be aware that in some instances what you tell me may have to be reported to the police."

The subject can be introduced to adolescents as follows:

"I don't know if this is a concern for you, but many teens I see are dealing with violence or bullying issues, so I've started asking questions about violence routinely. Sometimes if someone is being hurt in their own relationship, they may have seen it happen in their own family."

Dating violence in adolescents is discussed in detail separately. (See "Adolescent relationship abuse including physical and sexual teen dating violence".)

Concerns about safety and confidentiality — The safety of the patient and caregiver are important considerations when asking about IPV.

The clinician or other health care provider should not ask about IPV if the partner or other adults are present. Caution should be used when verbally asking about IPV in the presence of children who are older than two or three years of age. The clinician may ask these questions when the child is having hearing and vision screening or at another time when the caregiver and the child are separated.

Adolescents should be asked about IPV without caregivers or partners present. (See "Adolescent relationship abuse including physical and sexual teen dating violence".)

The adolescent or caregiver should be informed about the limits of practitioner/patient confidentiality before they are asked about IPV. (See 'Reporting' below and "Confidentiality in adolescent health care".)

What to ask — Several tools are available to screen for IPV in the primary care setting. (See "Intimate partner violence: Diagnosis and screening", section on 'Short surveys for clinicians'.)

As an example, the HARK is a validated IPV screening tool [141] that consists of four questions. The original screen asks only about victimization in the past year; however, because children can be affected months to even years later from the exposure, we expand our questioning to caregivers to include current and past victimization.

Are you now or have you ever been:

●Humiliated or emotionally abused by a partner?

●Afraid of a partner?

●Raped or forced to have sexual activity by a partner?

●Kicked, hit, slapped, or otherwise hurt by a partner?

Additional questions for adolescents may include:

●Have you seen anyone get hurt in your home?

●Do you ever feel afraid of or controlled by someone you're dating or a friend?

●Has anyone hit you at home in the last year?

HOW TO RESPOND

Advance preparation — Primary care clinicians who ask about intimate partner violence (IPV) must be prepared to address crisis situations. Steps that clinicians can take in advance of a crisis situation include:

●Discuss the plan of action with the local law enforcement agency or institutional security and estimate how long it will take for law enforcement to arrive.

●Know how to contact local domestic violence shelters and domestic violence advocates (available through the National Domestic Violence Hotline [800-799-7233] in the United States).

●Know how to contact additional local resources (eg, state domestic hotline number, state rape crisis number, legal aid, child protective services, suicide hotline, mobile mental health unit).

●Outside the United States, the HotPeachPages provides an international directory of domestic violence resources in more than 110 languages.

Caregiver discloses intimate partner violence

●Ongoing intimate partner violence – If the caregiver discloses ongoing IPV, the safety of the victim and children should be assessed. Assessment of safety and devising a "safety plan" are discussed separately. (See "Intimate partner violence: Intervention and patient management", section on 'Initial approach to the patient'.)

If there is an immediate threat to safety (eg, perpetrator has threatened to kill the caregiver and has a weapon; the caregiver has injuries and the perpetrator is on site; the clinician is concerned for the safety of the patient, patient's caregiver, clinic staff, or self), contact security (if available) and/or the police.

In addition to assessing safety and lethality, it is important to assess the caregiver/patient's mental health status (eg, suicidality, depression); whether it is safe for the patient/caregiver to return home; and the patient/caregiver's readiness to leave. Referrals to mental health providers, domestic violence hotlines, and local shelters should be provided as indicated, with the most pressing issue taking precedence (eg, a mental health crisis). (See 'Referrals and resources' below.)

IPV should be documented and reported as mandated to local authorities. (See 'Documentation' below and 'Reporting' below.)

●Past intimate partner violence – If the caregiver discloses IPV in the past and the caregiver feels that they and their children are safe, we provide a supportive message: "Thank you for telling me. I believe you and I can help you." If applicable, the clinician can say, "This may be why we are having difficulty in managing your child's symptoms." We also let the caregiver know that children can be affected by IPV months and even years later.

Past IPV should be documented and reported as indicated to local authorities; referrals should be provided as necessary (See 'Documentation' below and 'Reporting' below and 'Referrals and resources' below.)

Caregiver does not disclose intimate partner violence

●Clinician concerned about intimate partner violence – If the caregiver does not disclose IPV, but the clinician is concerned, the clinician can redirect questions to concerns about the child, by saying something like:

"Other children I see with symptoms like your child's have them because they have seen or experienced something traumatic or stressful in their life. Has anything like this happened to your child?"

If the caregiver does not disclose IPV upon redirected questioning, evaluate other causes of toxic stress. The American Academy of Pediatrics recommends that pediatric medical homes screen for precipitants of toxic stress that are common in their practice [18]. In addition to witnessing IPV, other causes of toxic stress include:

•Physical abuse

•Bullying/severe teasing

•Sexual abuse

•Medical care trauma

•Animal attack

•Motor vehicle accident

•Removal from the home by Child Protective Services

•Witness to violence in the home

•Witness to violence in the community/neighborhood

•Incarceration of a caregiver

•Loss of a caregiver due to death, divorce, deportation, or deployment

•Racism, sexism, discrimination

Provide information and resources about toxic stress as indicated. (See 'Referrals and resources' below.)

●Clinician not concerned about child exposure to intimate partner violence – Provide an opening for future disclosure, by saying something like: "I am glad you are in a healthy relationship. However, if you are ever in an unsafe or unhealthy relationship, you can come to us for help."

DOCUMENTATION — Intimate partner violence (IPV), whether ongoing or in the past, should be documented at the time of disclosure. Accurate documentation of IPV provides the correct diagnosis, helps the family through the legal process, and helps the family to obtain services.

However, there is no consensus about how pediatric care providers should document IPV of their patients' caregivers. IPV should be documented according to local policies (eg, hospital, clinic) for documenting sensitive information.

Suggested strategies include:

●Asking the caregiver if it is safe to document in the child's medical record.

●Placing an abbreviation (eg, IPV+) in the social history portion of the child's medical record and using an electronic medical records process for blocking access to certain aspects of the chart that may be concerning for safety issues can provide a level of safety.

The caregiver or patient's statements regarding IPV should be placed in quotation marks. Additional information about documentation of caregiver or patient disclosure of IPV is provided separately. (See "Intimate partner violence: Intervention and patient management", section on 'Documentation'.)

Be cautious about providing written material. It may jeopardize the safety of the victim if it is found by the abuser.

REFERRALS AND RESOURCES — When providing referrals and resources (table 3), clinicians should counsel patients that their computer use and phone records may be monitored. Written information can be provided if the victim feels that it is safe to do so. Providing a general resource list that not only provides crisis hotlines, but also resources for social determinants of health (eg, food banks, mental health services, transportation services, etc) is safer than providing specific IPV information.

●Referrals for the caregiver – Refer the caregiver or adolescent victim of intimate partner violence (IPV) to specialists trained to help victims cope with all aspects of IPV (available from the National Domestic Violence Hotline). (See "Intimate partner violence: Intervention and patient management", section on 'Intervention, counseling, and referral'.)

Additional indications for caregiver referral include:

•Caregiver is afraid to go home or ready to leave and needs safe shelter – Call local domestic violence shelter and/or domestic violence advocate (additional information is available through the National Domestic Violence Hotline [800-799-7233 (800-799-SAFE)]). Offer to allow the caregiver to make the call from a phone in the office so that the phone number is not stored on their phone.

•Caregiver is having a mental health crisis or is suicidal – Call the local mobile crisis team or suicide hotline.

●Referrals for children – Referral of the child to mental health services for support and counseling is warranted if the referral can be made without endangering the child or caregiver. The child who has been separated from the abuser may need grief therapy. They will experience the loss of the family unit, the possible loss of contact with the abuser, and the loss of their former daily life.

Children who are exposed to IPV have unique emotional needs [66]. The caregivers may be unavailable for emotional support, either because they are unsafe (the perpetrator) or addressing their own trauma (the victim). In addition, caregiver conflict, family dysfunction, maternal depression, decreased support and nurturance, isolation, relocation, economic, and social disadvantage may be ongoing [68,142].

The emotional response of children to witnessing IPV may include terror, fear of death, fear of loss of a caregiver, rage, guilt, and a sense of responsibility [66]. They may feel helpless and view the world as unpredictable, hostile, and threatening. Mental health counseling by a trauma-trained therapist is imperative to enhance the long-term health and well-being of children who have been exposed to IPV. If available, mental health interventions that target maternal risk factors as well as child risk factors may be more successful in decreasing the child's externalizing of mental health problems [143].

REPORTING

●Intimate partner violence – The definition of intimate partner violence (IPV) and types of assaultive injuries that require reporting to law enforcement agencies and the information that needs to be included in the report vary from state to state. The clinician should refer to their local and state laws regarding IPV reporting [144]. Contacting the local domestic violence advocates or the attorney general of the state may be helpful in understanding the mandatory reporting requirements of the state. The relevant state statute numbers are available through Futures Without Violence and should be checked for updated state laws.

●Child abuse or neglect – All 50 states mandate reporting suspected child abuse or neglect to the appropriate agency. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

●Child witness to intimate partner violence – Whether child witnessing of violence is considered child abuse and must be reported differs from state to state.

Information regarding an individual state's statutes regarding documentation and reporting of child witness to IPV can be obtained from the local district attorney's office or the state's attorney general's office. The relevant state statute(s) numbers are available through the Child Welfare Information Gateway.

Regardless of the reporting requirements, in all cases of IPV where child exposure is possible, the practitioner must assess the safety of the home situation and determine whether it is safe for the child(ren) to return home. If the home situation is not deemed to be safe, or the child has been abused or neglected, then a report must be made to the appropriate authority in that state.

PREVENTION — The health care provider is an important resource in helping families prevent or end the cycle of abuse. When individuals who were exposed to intimate partner violence (IPV) as children become parents, it is particularly important to provide guidance for appropriate styles of communication and discipline. Clinicians should discuss communication and discipline with caregivers during routine well-child visits.

During a child's health care visit, the clinician may provide education and suggest various types of prevention strategies for multiple members of the child's family in multiple generations. Improving the health and well-being of individuals who are experiencing mental and physical consequences of trauma can prevent exposure to trauma in the next generation [145].

●Strategies that decrease exposure (no exposure means no symptoms) and promote resilience are the most desirable. These strategies include:

•Encouraging caregivers to form and maintain safe, stable, nurturing relationships with their children and their partners [11].

•Encouraging caregivers to model the six core strengths of childhood, which teach children how to form healthy emotional bonds and relationships [146]:

-Forming healthy attachments

-Self-regulating and controlling impulses and feelings

-Being a part of and contributing to a group

-Being aware of others' needs, strengths, and values

-Understanding and accepting differences in others

-Respecting oneself and others

•Identifying families at risk for IPV (eg, pregnant people and mothers of young children), who can be referred to the Nurse-Family Partnership, or other home visitation programs, which have been associated with reducing IPV [147-149].

●Strategies that decrease the impact of trauma for those who have been exposed but remain without symptoms include:

•Asking about unhealthy relationships in families to provide referrals and resources. (See 'Referrals and resources' above.)

•Asking about other social determinants of health (eg, food insecurity, transportation barriers, depression and other mental health issues, substance use issues, financial strain) to identify families who may benefit from provision of resources. (See "Screening tests in children and adolescents", section on 'Screening for poverty' and 'Referrals and resources' above.)

●Strategies to improve the health and well-being of patients and families that have had exposure to trauma and are experiencing mental and physical consequences include:

•Helping families recognize their resilience factors.

•Letting families know that your health care setting is a safe place to obtain care.

•Becoming a trauma-informed health care setting, as described in the American Academy of Pediatrics clinical report on trauma informed care [150].

•Becoming familiar with and utilizing tools that are evidenced-based, such as trauma screening tools that identify trauma reaction symptoms and interventions geared towards those symptoms [151,152].

The Pediatric Integrated Post-Trauma Services at the University of Utah website section on the Child Traumatic Stress Care Process Model includes links to screening tools and suggests brief in-office interventions for specific symptoms.

“Essentials for Childhood—Creating Safe, Stable, Nurturing Relationships and Environments for All Children,” published by the Centers for Disease Control and Prevention, outlines strategies to promote nurturing relationships, which can mitigate the occurrence of toxic stress from an exposure and provide the foundational skills to enhance resilience and help children to face future adversity in a healthy and adaptive manner [11].

SUMMARY AND RECOMMENDATIONS

●Terminology – The Centers for Disease Control and Prevention define intimate partner violence (IPV) as a pattern of behaviors that may include physical violence, sexual violence, stalking, and psychological aggression that are used by a current or former partner in an intimate relationship. (See 'Terminology' above.)

●Effects and presentation – Exposure to IPV has short- and long-term effects on a child's emotional, social, and cognitive development. (See 'Effects' above.)

The presentation of children who are exposed to IPV is variable (table 2). (See 'The process of asking about caregiver intimate partner violence' above.)

●Whom to ask about IPV – Asking caregivers about IPV victimization should be performed if the pediatric patient has signs or symptoms suggestive of exposure (table 2 and algorithm 1). Adolescents should be provided anticipatory guidance about healthy relationships and asked about violence in their own relationships. (See 'Whom to ask' above.)

●How to respond – When IPV is suspected or disclosed, pediatric health care providers should send a supportive message, if appropriate link exposure to child's symptoms, and make referrals to local shelters or contact the National Domestic Violence Hotline number, 1-800-799-SAFE for more information (table 3). (See 'How to respond' above and "Intimate partner violence: Intervention and patient management".)

●Referrals and resources – Children who are exposed to IPV may benefit from mental health services if a referral can be made without endangering the child or victim. (See 'Referrals and resources' above.)

●Reporting – The clinician should refer to their local and state laws regarding IPV and child witness to IPV reporting. If the home situation is not deemed to be safe or the child has been abused or neglected, a report must be made to the appropriate authority in that state. (See 'Reporting' above.)