Cincinnati--Should children be in the room when mom's physician asks questions about partner violence? Therese Zink, MD, MPH, assistant clinical professor of Family Medicine at the University of Cincinnati College of Medicine, researched this question and published her findings in the February issue of The Journal of Family Practice.

After meeting with 29 different family physicians, pediatricians, child psychologists, social workers, and domestic violence agency directors for interviews and focus group discussions about family violence, Zink concludes that routine screening for intimate partner violence by physicians may give a child a better chance at maturing into a healthy adult by interrupting the cycle of violence. "The benefits of screening are two-fold," says Zink. "If domestic violence is recognized and addressed by the physician, the mother is given the opportunity to alert a professional about the violence and, if action is taken, the children are less likely to be in abusive relationships down the road." Zink also suggests that physicians need further research to understand appropriate questions and methods of screening for intimate partner violence in front of children.

In Zink's study, experts agreed that researchers need to help physicians identify the method of screening that best preserves the safety of both the victim-parent and the children. "Health care providers should receive domestic violence intervention training to ensure that both the mother and children are protected during the screening process," says Zink.

While the American Academy of Pediatrics recommends screening for domestic violence and abuse at the child's well visit, and advises that if the child is old enough to talk, screening of patients is to be done when the mother is away from both the suspected abuser and the children, some of the experts Zink interviewed disagreed with this recommendation. "Most thought that general questions in the child's presence were appropriate with in-depth questioning of the victim in private," says Zink. The experts who advocate general screening in front of children believe the children already know what is taking place within their family. These experts explain it is important for the kids to know there are other ways to live and help is available. All study participants agreed that women should not be interviewed in the abusive husband's presence.

According to Zink, the experts also addressed the issue of physicians documenting the suspicion of domestic violence in the child's medical chart. "This raises questions about confidentiality since the perpetrator, if a legal guardian, has access to those medical records. Screening and documentation must be done in a confidential manner that ensures the mother's safety," says Zink. For example, one must consider the possibility of the child telling the abuser about the conversation mom had with the doctor. She adds, "Failure to consider this may have life-threatening consequences for her and the children."

"Physicians need more education and training on how to recognize the symptoms of children who are exposed to violence between adults and how to document it," continues Zink. "Children who hear and see violence between their parents display a variety of behavioral, physical, cognitive, and emotional problems and symptoms," she adds.

Since children who witness violence are at greater risk for becoming perpetrators or victims, routine screening by physicians is important. "Failure to screen means the family continues to live with violence and abuse without intervention," adds Zink. "Once health care professionals have confirmed the domestic abuse the health care giver needs to give the patient information about local crisis centers, hotline phone numbers, and begin the development of a safety plan," says Zink. Future research could examine the advantages and disadvantages of face-to-face interviewing compared to questionnaires, the development of screening questions to be used with the children present, and legal guidelines to clarify what type of notation about the mother's victimization is appropriate in a child's chart.

While acknowledging the need for future research, Zink gives the following recommendations for current domestic violence screening practice:

• The AMA-formatted questions should be used in the presence of children younger than two or three years old.
  
  
• Physicians should educate patients about intimate partner violence and distribute resource materials and crisis phone numbers.
  
  
• Physicians should ask the mother's permission before screening questions are asked in front of children older than two or three.
  
  
• Because of an established link between spousal abuse and child abuse, whenever one is present, the other should be considered.