A baby girl presented to the emergency department after she stopped breathing. She was lethargic and had bruises on her back. Upon further evaluation, it was discovered that she had suffered a skull fracture, a brain bleed, spinal injuries, and had multiple healing broken bones.
This child lived with her mother and her mother’s boyfriend, who was not the infant’s biological father. The patient’s mother had moved to the United States just months prior, without social supports.
Initially, the mother did not provide any history of trauma to the infant. However, after the medical team worked to establish rapport and trust with her, the mother shared that she was a victim of intimate partner violence (IPV) and that her boyfriend had repeatedly choked, punched and kicked her. When she tried to call for help, he would take away her cell phone. She successfully called the police several times prior to this event, but due to fear, had declined further help. A pediatrician had not evaluated the infant after these incidents. The mother revealed that her boyfriend may have hit the patient’s head on a door and would swing the infant around by the legs.
The infant was ultimately diagnosed with severe and life-threatening physical abuse. Over time, the child’s condition improved, and she was discharged to a rehabilitation facility to manage chronic healthcare needs.
As pediatricians, we often intervene on behalf of children who suffer from abuse and neglect. Increasingly, we understand that any violence in a child’s life, and especially IPV, poses a serious risk to children. The impacts of IPV are complex. Adults who cope with stress by using violence may not only assault their partners, they may also assault children, causing both significant physical injuries and emotional trauma. Exposure to IPV is by itself a potent adverse childhood experience. Although the prevalence and deleterious downstream health consequences of children exposed to domestic violence are well researched, this public health problem is infrequently emphasized. More than 15 million children in the United States live in a home in which IPV occurs, and approximately 7 million of them witness severe violence, such as a parent using a weapon. Research has shown that child abuse co-occurs with IPV, as often as 30 to 60% of the time.
Children’s experience of IPV can occur in different ways. They can be directly exposed by being present in the room where the violence is happening. Children may be accidentally injured or physically abused. Indirectly, children can experience IPV through a parent’s emotional trauma, poor coping skills, and an unstable home environment. These experiences can lead to feelings of fear, anxiety, depression and behavioral challenges. As pediatricians, we have an incredible opportunity to identify a child’s exposure to IPV in the home and intervene to prevent some of these long-term health issues. While many national organizations recommend universal screening for IPV, a cost-effective and evidence-based strategy includes case finding and providing support to families when IPV is disclosed. When children present with emotional or behavioral problems, school-related issues or non-specific somatic problems, screening a caregiver for IPV in the home may lead to a positive disclosure (or at least knowledge that a safe place exists to make a future disclosure). Validation, education, referral to community resources (e.g., by offering to call an IPV advocate utilizing the office phone to improve the safety of the caregiver) and mental health services and early follow-up with families who disclose IPV has the potential to improve the safety and well-being of children and caregivers experiencing IPV.
As emergency medicine and child abuse pediatricians, we work to improve the recognition of child abuse in acute care settings, such as emergency departments throughout the state of CT. Through our work, we have witnessed many children who have been abused, neglected, or suffered emotional trauma due to ongoing IPV. These cases have highlighted for us how victims of family violence are often sorted into systems that fail to address the family as an integrated unit, leading to missed opportunities to mitigate ongoing and prevent future family violence. In response, we started a new integrated care IPV clinic to better understand the risk of abusive injuries in young children exposed to IPV. When a young child exposed to IPV is reported to the Department of Children and Families (DCF), we arrange for a medical exam for the child to identify any physical injuries. Further, in collaboration with the community organization, Umbrella Center for Domestic Violence Services in New Haven, we provide support and advocacy services for affected caregivers. We assure that caregivers and their children have access to trauma-focused mental health follow-up.
Since starting our work with victims of family violence, we have come to realize just how much more work there is to do, but also that none of this work can be done alone. We have come to appreciate how IPV, child abuse, and family violence need and deserve a family-centered response from us all.
Our New Haven Family Violence Community Advisory Board which consists of members from organizations such as Umbrella, Hope, Connecticut Coalition Against Domestic Violence, DCF, the Yale child abuse team, Yale emergency medicine department, New Haven police department, Yale Child Study Center, and community members such as IPV survivors provides regular input on our work in order to ensure we are equally considering the children and their caregivers, who are both victims of IPV and family violence. The community advisory board has had a powerful impact on our work. Board members continuously teach each other so much about the impact of IPV on families, especially on the abused caregivers. Community board members have ensured a trauma-focused environment for the abused caregivers and proposed the powerful idea to link a child’s medical evaluation with an opportunity to engage and connect the child’s caregiver to a community-based IPV advocate. Some survivors of IPV may find it challenging to seek help for themselves, however they are often able to do so for their children. The chance to appeal to the protective instincts of caregivers for their children provides a powerful opportunity to link caregivers to additional resources.
Since starting our work with victims of family violence, we have come to realize just how much more work there is to do, but also that none of this work can be done alone. We have come to appreciate how IPV, child abuse, and family violence need and deserve a family-centered response from us all.
Gunjan Tiyyagura, MD, MHS, is Associate Professor of Pediatrics and of Emergency Medicine at the Yale University School of Medicine. She is the associate program director of the Pediatric emergency medicine fellowship and a clinical researcher interested in improving detection of child abuse and developing and evaluating interventions to improve family violence. She is most grateful to work in New Haven with people who inspire her to be better every day.
Andrea Asnes, MD, MSW is an Associate Professor of Pediatrics and board-certified child abuse pediatrician who directs the Yale Programs for Safety, Advocacy and Healing. Dr. Asnes also is the Graduate Medical Education Director of Resident and Fellow Wellbeing for Yale-New Haven Hospital.