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Screening for Family and Intimate Partner Violence

Recommendation Statement


This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for family and intimate partner violence based on the USPSTF's examination of evidence specific to family and intimate partner violence. It updates the 1996 recommendations in the Guide to Clinical Preventive Services, Second Edition1.


Summary of Recommendation

  • The USPSTF found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse.

    Rating: I Recommendation.

    Rationale: The USPSTF found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death. The USPSTF found no existing studies that determine the accuracy of screening tools for identifying family and intimate partner violence among children, women, or older adults in the general population. The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed (see Clinical Considerations). The USPSTF found limited evidence as to whether interventions reduce harm to women, and no studies that examined the effectiveness of interventions in older adults. No studies have directly addressed the harms of screening and interventions for family and intimate partner violence. As a result, the USPSTF could not determine the balance between the benefits and harms of screening for family and intimate partner violence among children, women, or older adults.


Contents

Background
Clinical Considerations
Discussion
Recommendations of Others
References
Members of the Task Force
Contact the Task Force
Available Products

Task Force Ratings
Strength of Recommendations and Quality of Evidence

Background

In 1996, the USPSTF found insufficient evidence to recommend for or against the use of specific instruments to detect domestic violence (a "C" recommendation according to 1996 grade definitions). The Task Force now uses an explicit process in which the balance of benefits and harms is determined exclusively by the quality and magnitude of the evidence. As a result, current letter grades are based on different criteria than those in 1996.

Clinical Considerations

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Discussion

Approximately 1 million abused children are identified in the U.S. each year.5 In 1999, an estimated 1,100 children died of abuse and neglect.6 It is likely that reported abuse captures only a fraction of all cases. Estimates of the prevalence of intimate partner violence in the U.S. indicate that 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners each year,7,8 with 31 percent of all women reporting abuse at some point in their lifetimes.9 Although violence by women against men also occurs, women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner.10

The National Elder Abuse Incidence Study (NEAIS) estimates that approximately 551,000 older adults in domestic settings were abused and/or neglected during 1996.11 The abuse of older adults takes many forms, including physical, sexual, and psychological abuse; financial exploitation; and neglect.12 In 90 percent of cases, the perpetrator of such abuse is a family member, usually an adult child or spouse.11 Harmful outcomes of family violence may include not only repercussions of acute trauma, including death or unwanted pregnancy, but also long-term physical problems and psychiatric disorders, such as depression, post-traumatic stress disorder, somatization, suicide, and substance abuse.13-23 In addition, children who witness intimate partner violence are at risk for developmental delay, school failure, violent behavior, and a variety of psychiatric disorders, including depression and oppositional defiant disorder.24-26

The USPSTF focused this review on children, women, and older adults because they are the largest groups at risk for domestic violence in the general primary care setting and are most likely to have been the subjects of published studies. The USPSTF reviewed the evidence for the effectiveness of screening procedures and interventions in the primary care setting in reducing harmful outcomes of domestic violence against children, women, and older adults. Because no studies were found that directly addressed the impact of screening on reducing harmful outcomes, the USPSTF examined the accuracy of clinical screening instruments in identifying risk for current or future abuse and the efficacy of clinic-based interventions in reducing harmful outcomes.

Screening for child abuse in the primary care setting can involve a variety of techniques, including physical examination as well as screening questionnaires. Findings during a routine physical examination suggestive of abuse and/or neglect, such as burns, bruises, and repeated suspicious traumatic injury, have been described.27 All instruments designed to screen for child abuse and neglect were directed at parents, particularly pregnant mothers. Limited evidence suggests that these instruments had fairly high sensitivity but low specificity for identifying future child maltreatment when administered in the study populations, particularly when self-administered questionnaires were provided to pregnant mothers in a 2-step method such as the Hawaii Risk Indicators Screening Tool followed by the Kempe Family Stress Inventory.28,29 These questionnaires have not been widely tested in different populations. Newer brief instruments designed to identify women who are victims of intimate partner violence in primary care settings compare well with lengthier, previously validated instruments.4 Studies indicate that self-administered questionnaires elicit more positive responses than interviewer-administered questionnaires in emergency department settings,30 but the opposite was true in a Planned Parenthood clinic.31 No studies have evaluated the performance of screening instruments using verified outcomes of reported intimate partner abuse, although self-reported abuse may be a more accurately measured outcome than some verified outcomes (i.e., police or social services reports). The USPSTF found few screening instruments for the detection of older adults who are the potential victims of abuse or their caretakers. None of the instruments available have been widely validated.

The USPSTF reviewed the evidence for the efficacy of interventions with children, women, and older adults in reducing harmful outcomes of family and intimate partner violence. The intervention trials identified "high-risk" women and children based on various inclusion criteria that have not been validated, including sociodemographic characteristics, maternal substance use, low infant birth weight, and homelessness. A randomized controlled trial with 15 years of follow-up indicated that nurse home visit programs (i.e., the Nurse Family Partnership program) during the prenatal and 2-year postpartum periods for low-income, first-time mothers can improve the short-term and long-term outcomes of child abuse and neglect.32,33 When compared with the nonintervention group, the home visit group had improved outcomes, including decreased reports of child maltreatment, child injuries/toxic ingestions and emergency department visits, and maternal criminal activity and drug use.

Several trials utilizing nurse home visits for varying lengths of time and with various program components for pregnant and postpartum mothers support these findings, although the outcomes in these studies were short-term measures of child abuse and related factors.4 There were 2 studies of interventions to decrease intimate partner violence in women; both studies, which only recruited pregnant women, showed a trend (not statistically significant) in women reporting decreased violence after brief counseling or outreach interventions.34,35 There are no studies of interventions initiated in the primary care setting with health outcomes for older children, women who are not pregnant, or older adults. Further research is required to identify screening tools that are valid in the general population and effective programs that decrease abuse outcomes and the health-related consequences of family and intimate partner violence.

No studies have directly addressed the harms of screening and intervention for family and intimate partner violence. False-positive test results, most common in low-risk populations, may compromise the clinician-patient relationship.36 Additional possible harms of screening may include loss of contact with established support systems, psychological distress, and an escalation of abuse.37 However, none of these potential harms has been studied.

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Recommendations of Others

The American Academy of Pediatrics (AAP)38 and the American Medical Association (AMA)39,40 recommend that physicians remain alert for the signs and symptoms of child physical abuse and child sexual abuse in the routine examination. The Canadian Task Force on Preventive Health Care (CTFPHC) recommends that screening procedures aimed at identifying individuals at risk for experiencing or committing child maltreatment should be excluded from the periodic health examination.41 However, the CTFPHC recommends a program of home visitation for disadvantaged families during the perinatal period through infancy to prevent child abuse and neglect.

The Centers for Disease Control and Prevention Task Force on Community Preventive Services found that home visitation programs aimed at children with high risk for maltreatment (e.g., single or young mothers, low-income households, families with low birth-weight infants) were effective in decreasing maltreatment episodes.42

The American College of Obstetricians and Gynecologists (ACOG)43 guidelines on domestic violence recommend that physicians routinely ask women direct, specific questions about abuse. The AMA encourages physicians to inquire routinely about their patients' domestic violence histories and refer those patients with violence-related problems for medical and/or community-based services.44

The CTFPHC concluded that there was insufficient evidence to recommend for or against routine screening for violence against women. ACOG and AMA45 recommend that physicians routinely ask elderly patients direct, specific questions about abuse. The CTFPHC determined that there was insufficient evidence to include or exclude case-finding for elder abuse as part of the periodic health examination, but recommended that physicians be alert for indicators of abuse and institute measures to prevent further abuse.46

The American Academy of Family Physicians (AAFP) notes that family physicians can provide early intervention in family violence through routine screening and the identification of abuse, and recommends that physicians be alert for the presence of family violence in virtually every patient encounter.47

Reporting child and elder abuse to protective services is mandatory in most states, and several states have laws requiring mandatory reporting of intimate partner violence.48,49

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References

1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion, 1996.

2. Nelson H, Nygren P, McInerney Y, Klein J. Screening Women and Elderly Adults for Family and Intimate Partner Violence: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004; 140(5):387-96.

3. Nelson H, Nygren P, Klein J. Screening children for family violence: a review of the evidence for the U.S. preventive services task force. Ann Fam Med.

4. Nelson HD, Nygren P, Qazi Y. Screening for Family and Intimate Partner Violence. Systematic Evidence Review No. 28. (Prepared by the Oregon Health & Science Evidence-based Practice Center under Contract No. 290-97-0018). Rockville, MD: Agency for Healthcare Research and Quality. February 2004. (Available at: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=es28).

5. Sedlak AJ, Broadhurst DD. Third National Incidence Study of Child Abuse and Neglect: Final Report. 1996, U.S. Dept of Health and Human Services, National Center on Child Abuse and Neglect: Washington, DC.

6. Child Maltreatment 1999: Reports from the States to the National Child Abuse and Neglect Data System. 2001, U.S. Department of Health and Human Services: Washington, DC.

7. Violence by Intimates: Analysis of Data on Crimes by Current or Former Spouses, Boyfriends, and Girlfriends. 1998, U.S. Department of Justice: Washington, DC.

8. The Commonwealth Fund, First Comprehensive National Health Survey of American Women. New York: The Commonwealth Fund; 1993.

9. The Commonwealth Fund, Health Concerns Across A Woman's Lifespan: The Commonwealth Fund 1998 Survey of Women's Health. New York: The Commonwealth Fund; 1999.

10. Muelleman RL, Lenaghan PA, Pakieser RA. Battered women: injury locations and types. Ann Emerg Med 1996;28(5):486-92.

11. Tatara T, Kuzmeskus-Blumerman L, Duckhorn, E, et al. The National Elder Abuse Incidence Study (NEAIS); Final Report. 1998, by The National Center on Elder Abuse at the American Public Human Services Association in Collaboration with Westat, Inc., for the Administration for Children and Families and The Administration on Aging in the U.S. Department of Health and Human Services.

12. Elder abuse and neglect. Council on Scientific Affairs. JAMA 1987;257(7):966-71.

13. Felitti VJ, Anda RF, Nordenberg D, 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(4):245-58.

14. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA 2001;286(5):572-9.

15. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 2001;286(24):3089-96.

16. Anda RF, Chapman DP, Felitti VJ, et al. Adverse childhood experiences and risk of paternity in teen pregnancy. Obstet Gynecol 2002;100(1):37-45.

17. Diaz A, Simantov E, Rickert VI. Effect of abuse on health: results of a national survey. Arch Pediatr Adolesc Med 2002;156(8):811-7.

18. Osofsky JD, Wewers S, Hann DM, Fick AC. Chronic community violence: what is happening to our children? Psychiatry 1993;56:36-45.

19. Shakoor BH, Chalmers D. Co-victimization of African-American children who witness violence: effects on cognitive, emotional and behavioral development. J Natl Med Assoc 1991;83:233-8.

20. Lansford JE, Dodge KA, Pettit GS, Bates JE, Crozier J, Kaplow J. A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Arch Pediatr Adolesc Med 2002;156(8):824-30.

21. Campbell JC, Lewandowski LA. Mental and physical health effects of intimate partner violence on women and children. Psychiatr Clin North Am 1997;20(2):353-74.

22. Campbell DW, Sharps PW, Gary FA, Campbell JC, Lopez LM. Intimate partner violence in African American women. Online J Issues Nurs 2002;7(1):5.

23. Coker AL, Smith PH, Thompson MP, McKeown RE, Bethea L, Davis KE. Social support protects against the negative effects of partner violence on mental health. J Womens Health Gend Based Med 2002;11(5):465-76.

24. Maxfield M, Widom C. The cycle of violence. Revisited 6 years later. Arch Pediatr Adolesc Med 1996;50:390-5.

25. Garbarino J, Kostelny K, Dubrow N. What children can tell us about living in danger. Am Psychol 1991;46:376-83.

26. Durant RH, Pendergrast RA, Cadenhead C. Exposure to violence and victimization and fighting behavior by urban black adolescents. J Adolesc Health 1994;15:311-8.

27. Johnson CF. Inflicted injury versus accidental injury. Pediatr Clin North Am 1990;37(4):791-814.

28. Korfmacher J. The Kempe Family Stress Inventory: a review. Child Abuse Negl 2000;24(1):129-40.

29. Duggan A, Windham A, McFarlane E, et al. Hawaii's healthy start program of home visiting for at-risk families: evaluation of family identification, family engagement, and service delivery. Pediatrics 2000;105(1 Pt 3):250-9.

30. Glass N, Dearwater S, Campbell J. Intimate partner violence screening and intervention: data from eleven Pennsylvania and California community hospital emergency departments. J Emerg Nurs 2001;27(2):141-9.

31. McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessing for abuse: self-report versus nurse interview. Public Health Nurs 1991;8(4):245-50.

32. Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA 1997;278(8):637-43.

33. Eckenrode J, Ganzel B, Henderson CR Jr, et al. Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. JAMA 2000;284(11):1385-91.

34. McFarlane J, Soeken K, Wiist W. An evaluation of interventions to decrease intimate partner violence to pregnant women. Public Health Nurs 2000;17(6):443-51.

35. Parker B, McFarlane J, Soeken K, Silva C, Reel S. Testing an intervention to prevent further abuse to pregnant women. Res Nurs Health 1999;22(1):59-66.

36. Reid B, Long A. Suspected child abuse: communicating with a child and her mother. J Pediatr Nurs 2002;17(3):229-35.

37. Sachs CJ, Koziol-McLain J, Glass N, Webster D, Campbell J. A population-based survey assessing support for mandatory domestic violence reporting by health care personnel. Women Health 2002;35(2-3):121-33.

38. American Academy of Pediatrics Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse of children. Pediatrics 1991;87(2):254-60.

39. American Medical Association Diagnostic and Treatment Guidelines on Child Sexual Abuse. Arch Fam Med 1993;2(1):19-27.

40. American Medical Association Diagnostic and Treatment Guidelines on Child Physical Abuse and Neglect. Arch Fam Med 1992;1(2):187-97.

41. MacMillan HL; Canadian Task Force on Preventive Health Care. Preventive health care, 2000 update: prevention of child maltreatment. CMAJ 2000;163:1451-8.

42. Hahn RA, Bilukha OO, Crosby A, et al. First Reports Evaluating the Effectiveness of Strategies for Preventing Violence: Early Childhood Home Visitation. Findings from the Task Force on Community Preventive Services. MMWR Recomm Rep 2003;52:1-9.

43. Guidelines for Women's Health Care, 2nd Edition. American College of Obstetricians and Gynecologists: Washington, DC. 2002.

44. American Medical Association Policy Statement on Family and Intimate Partner Violence H-515.965. Available at: http://www.ama-assn.org/apps/pf_online/pf_online. Accessed November 28, 2003.

45. AMA Council on Scientific Affairs. Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago: American Medical Association; 1992.

46. Wathen CN, MacMillan HL, and the Canadian Task Force on Preventive Health Care. Prevention of violence against women: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2003;169(6):582-4.

47. American Academy of Family Physicians. Family Violence and Abuse. Available at: www.aafp.org/x16506.xml. Accessed December 11, 2003.

48. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. Do they promote patient well-being? JAMA 1995;273(22):1781-7.

49. Lachs MS, Pillemer K. Abuse and neglect of elderly persons. NEJM 1995; 332(7):437-43.

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Members of the Task Force

Members of the U.S. Preventive Services Task Force* are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland Baltimore, Baltimore, MD); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Professor of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); C. Tracy Orleans, Ph.D. (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H. (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N. (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor of Obstetrics and Gynecology and Professor of Public Health, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine and Director of Research Department of Family Practice, Virginia Commonwealth University, Fairfax, VA).

* Member of the USPSTF at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.uspreventiveservicestaskforce.org/about.htm.

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Contact the Task Force

Address correspondence to: Ned Calonge, M.D., M.P.H., Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850.

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Available Products

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for family and intimate partner violence based on the USPSTF's examination of evidence specific to family and intimate partner violence. It updates the 1996 recommendations in the Guide to Clinical Preventive Services, Second Edition1.

The complete information on which this statement is based, including evidence tables and references, is available in the summary article2,3 and in the systematic evidence review, "Screening for Family and Intimate Partner Violence: Systematic Evidence Review for the U.S. Preventive Services Task Force."4 The USPSTF recommendations, the accompanying summary article, and complete systematic evidence review are available through the USPSTF Web site at http://www.uspreventiveservicestaskforce.org.

Source: U.S. Preventive Services Task Force. Screening for Family and Intimate Partner Violence: Recommendation Statement. Ann Intern Med 2004;140(5):382-6.

Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.

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Current as of March 2004


Internet Citation:

U.S. Preventive Services Task Force. Screening for Family and Intimate Partner Violence: Recommendation Statement. March 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/famviolence/famviolrs.htm


 


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