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Institutional and Statewide Policies on
IPV Screening
Healthcare SummitOctober 24, 2014
Kathy Franchek-Roa MDUniversity of Utah
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Objectives Discuss the association
between childhood adversity and lifelong health
Summarize national recommendations for screening patients for IPV victimization
Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting
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Objectives Discuss the association
between childhood adversity and lifelong health
Summarize national recommendations for screening patients for IPV victimizationUtilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting
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Adverse Childhood Experiences
Obesity is not the problem–
it is the solution
Vincent J Felitti MD
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Felitti 2001
How does this happen, this reverse alchemy, turning the gold of a
newborn into the lead of a depressed, diseased adult?
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Multiple
ACE•Child Abuse•Caregiver -IPV -Mental Illness -Substance Abuse -Incarceration
High Risk Health
Behaviors•Smoking•Alcoholism•Illicit Drug Use•Sexual Promiscuity•Unhealthy Diet•Physical Inactivity•Suicidality
1 Heart Disease
2 Cancer
3 CLRD
4 Stroke
6 HIV/AIDS
7 Diabetes
10 Suicide
12 Liver Disease
Adverse Childhood Experiences
Felitti 1998
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Disease, Disability, and Social Problems
Adoption of Health Risk Behaviors
Social, Emotional, Cognitive Impairment
Disrupted Neurodevelopment
Adverse Childhood Experiences
Felitti 2001; www.cdc.gov/ACE
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HTNCADDiabetes
Physical InactivityUnhealthy Diet
Chronic Depression
Disrupted Neurodevelopment leading to physical deregulation
Childhood Sexual Abuse
Felitti 2001; www.cdc.gov/ACE
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What’s Your ACE Score?
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Childhood Adversity Adversity and on-
going toxic stress exposure during childhood is of critical concern because it can negatively affect brain development resulting in permanent changes to brain anatomy and function
McEwen 2007; 2010
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Childhood Adversity A child’s response
to stress may have originated as a biologically based adaptation to the child’s abnormal world
Hibel 2011; McEwen 2007; 2010; Stirling 2008; www.developingchild.harvard.edu
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Up to 30% of Childrenare exposed to IPV
McDonald 2006; Moore 2007
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Child Exposure to IPV“Domestic violence…seems to be the most toxic form of violence for children…
“For many children, the first lessons they learn about violence are not from television or from the streets, but from their parents.”
Groves 2002
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Objectives Discuss the association
between childhood adversity and lifelong health
“Patients see doctors because of anxiety, while
doctors see patients because of disease. Therein lies the problem between the two.”
Michael Balint
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Objectives Discuss the association
between childhood adversity and lifelong health
Summarize national recommendations for screening patients for IPV victimization
Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting
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Maine opens first DV shelter“We will not be beaten”Most US States allow wives to bring criminal action against husband for physical abuse
First marital rape law
National Coalition Against Sexual Assault is formed
HHS establishes objectives for violence1994 VAWA
Violence as a Public Health Issue
1967
1970
1975
1976
1978
1980
1994
SG report listing violence as a priorityCDC Violence Epidemiology Branch2020 Healthy People addresses violence
AMA recommends screening women for DV
Violence seen as a public health issueNational Violence Against Women Survey
USPSTF recommendations for screening women for IPV
1979
1983
1990
1992
1993
1994
SG report listing violence as a priorityCDC Violence Epidemiology Branch2000 Healthy People addresses violenceAMA recommends screening women for DV
Violence seen as a public health issueNational Violence Against Women SurveyUSPSTF recommendation for screening women for IPV
1979
1983
1990
1992
1993
1994
2013
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Screening Recommendations AMA AAP ACOG USPSTF recommends that
o Clinicians screen women of childbearing age for IPV and provide or refer women who screen positive to intervention services
o This recommendation applies to women who do not have signs or symptoms of abuse
ACOG 2012; AMA 2008; Moyer 2013; Thackeray 2010; USPSTF 2013
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Abuse, Neglect and Exploitation
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Purpose of Policy Policy on Abuse,
Neglect and Exploitation is to ensure appropriate guidelines for physicians and staff caring for patients they suspect may be victims of abuse, neglect or exploitation
CHIIP Model Domestic Violence Hospital Policy; Futures Without Violence
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Types of Abuse Covered in the Policy
Intimate Partner Violence Vulnerable Adult Abuse Trafficking in Persons Child Abuse and Neglect Any patient who presents
with concerns of abuse, neglect and exploitation
Further additions: chapter specific to sexual assault
CHIIP Model Domestic Violence Hospital Policy; Futures Without Violence
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Chapter Organization Definitions Public Health Impact Standards Health Consequences Risk Factors/Presenting Signs
and Symptoms Procedure for Identifying
Victims Procedure Once Victim
Identified Resource and Referral
Information Additional Considerations
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Intimate Partner Violence
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“Are you here today to be treated for injuries caused by
another person?”
“I am concerned that you may not be in a safe relationship. This can
affect your health and the health of your children. Here are some
resources. I strongly urge you to call the crisis hotline number (800-897-LINK) or speak to a
DV advocate. They can help you.”
Document what patient stated in her own words and what resources were given to the patient.Perform a thorough exam, documenting/photographing injuries
Contact DCFS 855-323-3237 if acts of DV were committed in the presence of a child.
NO
Physical findingsconsistent withassault/abuse?
“I am glad youare in a saferelationship.
Would you likesome
resources in case you or
someone youknow ever
needs help?”
NO YES
YES
NO
Physical findingsconsistent withassault/abuse? NO
YES
Call Law Enforcement
Recommend contactingDV AdvocateSocial Worker/Crisis Worker
YESYES
YESYES
I ask all my patients if they are in a relationship or in a home with someone who may be hurting or controlling them because this can affect people’s health (and the health of their children).
In addition, you should know that in some instances what you tell me may need to be reported. Are you in a relationship with someone who physically hurts, threatens or emotionally abuses you?
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Vulnerable Adult Abuse
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Vulnerable Adult Abuse Algorithm Presentation Concerning for Vulnerable Adult Abuse
If you suspect Elder/Disabled Adult Abuse and patient has no
cognitive dysfunction*separate patient from
accompanying adults and ask:
YES Is patient medically stable? NOStabilize patient as
appropriate--then proceed with
algorithm
“Are you here today to be treated for injuries caused by
another person?”
NO
1) Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?2) Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides, other assisted devices or medical care, or from being with people you wanted to be with?3) Have you been upset because someone talked to you in a way that made you feel shamed or threatened?4) Has anyone tried to force you to sign papers or to use your money against your will?5) Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
YES
If YES to question 2,3,4,OR 5
If NO to questions
2,3,4,AND 5
YES
Physical findings consistent with assault/abuse
AND/OR HCP notices: poor eye contact, withdrawn nature,
malnourishment, hygiene issues, inappropriate clothing, or medication compliance issues and elder/disabled adult abuse suspected
NO
Document What patient stated in her/hisown words;
What resources were given to the patient; and
Reports made to authorities
Refer to Social Worker as needed
Reiterate to patient that your hospital is a resource if needed
Ensure follow-up with PCP Consider referral to Geriatrician
CALL LAW ENFORCEMENT ORAPS 800-371-7897
*If patient has cognitive dysfunction consult:PsychiatryNeurologyConsider Geriatrician
CALL LAW ENFORCEMENT ORAPS 800-371-7897
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Trafficking In Persons
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Trafficking in Persons (TIP) Algorithm Presentation Concerning for Human Trafficking
Is patient medically stable? NO Stabilize patient as appropriate--
then proceed with algorithm
YES< 18 years of age > 18 years of age
CONSIDER OTHER RESOURCES:Notify hospital security if needed Call Social Worker or Crisis Worker if availableUtah Human Trafficking Task Force 801-200-3443Trafficking Hotline for additional info 888-373-7888SANE Nurse Sexual Assault Crisis Hotline 888-421-1100
If you suspect TIP ask:
If you suspect TIP ask questions alone with the patient: “Have you ever been forced to do work when you didn’t want to do?”“Does anyone hold your identity
documents?”“Has your employer threatened you if you
leave?”“Have you ever exchanged sex for food,
shelter, drugs, or money?”
“Are you here today to be treated for injuries caused by another
person?”
IfYES
Assessment of Potential DangerAsk Hotline (888-373-7888) to assist in assessing level of danger. Be vigilant of immediate environmentQuestions to consider: Is the trafficker present? What will happen if the patient does not return to the trafficker? Does the patient believe he/she or a family member is in danger? Is the patient a minor?
Document what patient stated in her/his own words and what resources were given to the patient.
IfYES
Important Dynamics for Assessment Keep in mind that the victim may not self-identify as a human trafficking victim Victims have been conditioned not to trust others Victims have been conditioned not to tell the truth Speak to the patient alone without accompanying
adults (adults may portray themselves as relatives) Prioritize the patient’s medical needs and safety as
the primary reason for the assessment
Refer to Social Worker as needed Reiterate to patient that your hospital is a resource if needed Give the patient the Human
Trafficking Hotline Number if safe to do so (888-373-7888; 801-200-3443)
IfNO
CALL LAW ENFORCEMENT ANDCALL DCFS (IF < 18 YO) 855-323-3237
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Child Abuse and Neglect
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Child Abuse and Neglect Algorithm Presentation Concerning for Child Abuse/Neglect
YES NOIs patient medically stable?Stabilize patient as
appropriate--then proceed with
algorithm
Physical Injuries NeglectWitness to IPVSexual AbuseEmotional Abuse
Assess for Risk Factors Ask about IPV in the home
Carefully document history using quotes when possiblePerform a careful, thorough physical exam Use body maps and photography to document visible injuriesLabs and Imaging as indicated
CONSIDER OTHER RESOURCESAbuse PediatricianLaw EnforcementChildren’s Justice Center
Assess for Risk Factors Ask about IPV in the home
Assess for Risk Factors See IPV Algorithm
Assess for Risk Factors Ask about IPV in the home
Assess for Risk Factors Ask about IPV in the home
Carefully document history using quotes when possible
Perform a careful, thorough physical exam
For children <14 years: call child abuse pediatrician on call
For children >14 years: call SANE nurse
Contact Social Worker: If available
Carefully document history using quotes when possible
Perform a careful, thorough physical exam
CONSIDER OTHER RESOURCESContact Crisis Worker/Social Worker to help families with homelessness, socio-economic factors, educational needs,drug use, food insecurity and health insurance needsChild Abuse Pediatricianto help with evaluation if neededChildren’s Justice CenterHospital Security Law Enforcement
CONSIDER OTHER RESOURCESHospital Security Call DV Advocate if parent so desires DV Crisis Hotline: 800-897-5465
CALL DCFS 855-323-3237
CALL DCFS 855-323-3237
CALL DCFS 855-323-3237
CALL DCFS 855-323-3237
CALL DCFS 855-323-3237
CONSIDER OTHER RESOURCESAbuse PediatricianLaw EnforcementChildren’s Justice Center
CONSIDER OTHER RESOURCESAbuse PediatricianLaw EnforcementChildren’s Justice Center
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Reminders Activate your
policyo Make it a useful
documento Make it relevant
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Objectives Discuss the association
between childhood adversity and lifelong health
Summarize national recommendations for screening patients for IPV victimization
If you don’t ask—they
won’t tell health care setting
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Objectives Discuss the association
between childhood adversity and lifelong health
Summarize national recommendations for screening patients for IPV victimization
Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting
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Trauma-informed Care Realization that many
patients seeking behavior services and many other public health services have a history of physical and sexual abuse and other forms of trauma
Trauma-informed care approach to patients provides a more therapeutic interaction and avoids re-traumatization
“What is wrong with you?”“What has happened to you?”
http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf
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Trauma-informed Care Realization that many
patients seeking behavior services and many other public health services have a history of physical and sexual abuse and other forms of trauma
Trauma-informed care approach to patients provides a more therapeutic interaction and avoids re-traumatization
“What is wrong with you?” “What has happened to
you?”
http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf
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Trauma-informed Care What happened is not
nearly as important as what the trauma means to the individual
Screening to identify patients who have histories of trauma and experience trauma-related symptoms is a
prevention strategy With a history of trauma
so common it has been suggested that we should use ‘universal precautions’ when interacting with patients
SAMHSA TIP Series 57, 2014; Harris 2001
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10 Principles of TICRecognize the impact of violence and victimization on
development and coping strategiesIdentify recovery from trauma as the primary goalEmploy an empowerment modelStrive to maximize a patient’s choices and control over
her recoveryAre based in a relational collaborationCreate an atmosphere that is respectful of survivors’
need for safety, respect, and acceptanceEmphasize patient’s strengths, highlighting adaptations
over symptoms and resilience over pathologyGoal is to minimize the possibilities of retraumatization Strive to be culturally competent Solicit consumer input and involve patients in designing
and evaluating servicesElliott 2005
1
23456
789
10
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Objectives Discuss the association
between childhood adversity and lifelong health
Summarize national recommendations for screening patients for IPV victimization
Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare setting
Trauma-informed care embraces a perspective that highlights
adaptation over symptoms and resilience over pathology.
Elliott et al. 2005
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In Conclusion
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In Conclusion
Discuss the association between childhood adversity and lifelong healtho “…the need is clear, the opportunities are major…what happens in
childhood…commonly lasts throughout life…Time does not heal, time conceals… The impact of a successful approach here might be as great as that of a major vaccine.” Felitti 2009
Summarize the national recommendations for screening patients for IPV victimizationo “I will remember that there is an art to medicine as well as a science,
and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” Louis Lasagna MD
Utilize best practice guidelines in developing a coordinated response to victims of IPV in the healthcare settingo “I wonder how different my life would have been if someone in a
white lab jacket had sat down, listened to my story, and seen the health issues lurking in my tomorrows.” Survivor
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Thank You!
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American College of Obstetricians and Gynecologists. Committee Opinion. Intimate Partner Violence. February 2012, Number 518. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-onHealth-Care-for-Underserved-Women/Intimate-Partner-Violence
American Medical Association. Opinion 2.02 – Physicians’ Obligations in Preventing, Identifying, and Treating Violence and Abuse. Available http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion202.page
Balint M. The Doctor, His Patient and the Illness. 2nd Ed. The Bath Press Avon. 1964.
Centers for Disease Control and Prevention. Intimate Partner Violence Consequences. Available http://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html
References
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CHIIP—Connecticut Health Initiative for Identification and Prevention. Model—Domestic Violence Hospital Policy. Available http://www.vdh.virginia.gov/ofhs/prevention/dsvp/projectradarva/documents/older/pdf/CHIIP_PROGRAM_Domestic_Violence_Hospital_Policy.pdf
Dahlberg LL, Mercy JA. History of violence as a public health issue. AMA Virtual Mentor, February 2009. Volume 11, No. 2: 167-172. Available on-line at http://virtualmentor.ama-assn.org/2009/02/mhst1-0902.html. 1976
Delphi Instrument. Available http://archive.ahrq.gov/research/domesticviol/dvtool.pdf
Elliott, DE et al. Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology. 2005:33;461–477
References
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Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. Family Violence Prevention Fund, 1999. Updated 2004. San Francisco, CA. Available at http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf
Felitti VJ et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults—the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245-258
Felitti VJ. Reverse alchemy in childhood: Turning gold into lead. Health Alert. Vol 8 No 1. 2001
Felitti VJ. Commentary—Adverse Childhood Experiences and adult health. Acad Ped. 2009;9:131-132
Groves BM. Children Who See Too Much: Lessons from the Child. Boston, MA: Beacon Press; 2002
References
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Harris M, Fallot RD (Eds.) Using trauma theory to design service systems. New Directions for Mental Health Services, 89. San Francisco, CA, 2001
Hibel LC, et al. Maternal sensitivity buffers the adrenocortical implications of intimate partner violence exposure during early childhood. Develop Psychopath. 2011;23:689-701
McDonald R, et al. Estimating the number of American children living in partner-violent families. J Fam Psych. 2006;20:137-142
McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007;87:873–904.
McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health and disease. Ann NY Acad Sci 2010;1186:190-222.
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Moore CG et al. The prevalence of violent disagreements in US families: Effects of residence, race/ethnicity, and parental stress. Pediatrics. 2007:119(S1), S68-S76
Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;158:478-486
Shonkoff JP et al. Technical Report—The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012:129:e232-e246
Stirling J et al. Understanding the behavioral and emotional consequences of child abuse. Pediatrics. 2008;122:667-673
Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014
References
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Thackeray JD et al. Intimate partner violence: The role of the pediatrician. Pediatrics 2010;125:1094-1100
U.S. Preventive Services Task Force Recommendations on Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Available http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatmentFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults screening
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