How Can I Help One of My Moms Develop a Safety Plan?

Patient Presentation
An 8 month-old male came to clinic with upper respiratory tract infection symptoms for 2 days.
The physician had seen the mother, infant and 2 other siblings for health supervision visits and several acute care visits for this infant and 2 other siblings who also came along.
The children appeared well taken care of, but the mother seemed more disheveled in appearance than normal and withdrawn during the interview. When the physician asked her about how things were going at home, the mother burst into tears.
Once she was calmer, the mother said she wanted to talk but not with the children around.
While the children were watched by the nursing and office staff the mother revealed that her husband was becoming more and more angry with her especially since the birth of the third child.
The “explosions” as she called them, came after the children went to bed and he would start to scream at her. The reasons for the episodes were various including money, household cleanliness, children’s behavior, etc. The episodes were worse if he had been drinking and occurred several times per week.
He showed little remorse per the mother, and said that otherwise he spoke very little to her.
She said that he never touched or hit her physically, nor would force her to perform sexual acts but that he would not allow her to go out of the house without him unless it was to the doctor’s office, the grocery store or her part-time job as a cashier at a gas station.
She wasn’t allowed to have visitors over including her family that lived in the same town and she wasn’t allowed to talk with friends or family by the telephone.
She was given money by him for groceries and for the doctor’s visits but only at the time of those errands.
She gave him her paycheck as soon as she arrived home from work and he did not allow her any other money.
She said that she never felt like he was going to hurt her physically so that she had never called the police but that the explosions were occurring more and he was drinking more.
Overall she said he did help to take care of children physically, but that he preferred to work around the house or watch TV, and didn’t spend much time with the children.
She said he talked “roughly” to them and occasionally would yell at them, but that he never had “exploded” at them or hurt them physically.
The past medical history for the child was unremarkable.
The social history revealed that the father worked in a manufacturing plant. Both parents were high school graduates.
Both extended families lived in the area. The mother denied any domestic violence in the extended families or any problems with alcohol, drugs or law enforcement.
The pertinent physical exam showed an infant with normal growth parameters and development. He had no obvious bruising, scratches or other skin changes. He had clear rhinorrhea and the rest of his examination was negative.
The diagnosis of an infant with an upper respiratory infection and a mother who is being emotionally abused was made.
The mother was afraid and unwilling to talk with a social worker or a counselor.
She was very afraid of what her husband may do if he found out that she had told the physician about the episodes.
The physician tried to talk about developing a safety plan for her and the children if the problems became worse and she needed to leave the home quickly, but the mother did not want to discuss it. She was willing to come back to have the child re-checked later in the week though.
The patient’s clinical course showed that the infection was improving. There had been 1 explosive episode since the previous visit, and the mother said she had thought about the safety plan.
She said that she was willing to take a paper with the local domestic violence intervention program telephone number on it as she knew a safe place that she could hide the paper. However she was unwilling to try to gather other items such as clothing and documents because she was afraid of her husband.
Over the next few weeks, she brought the children to the clinic for rashes, upper respiratory infections and other minor illnesses. Each time she confided that she was slowly gathering items and had surreptitiously gotten some help from her family.
She said that she was going to call the domestic violence intervention program soon. Unfortunately, she did not come back to the clinic after this visit.

Discussion
According to the National Domestic Violence Hotline, “Domestic violence can be defined as a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner.
Abuse is physical, sexual, emotional, economic or psychological actions or threats of actions that influence another person. This includes any behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure or wound someone.”

It is a national and international problem mainly for women but men can also be abused. It affects the entire family including the children even if they are not directly abused as they may be a witness to the violence or suffer from neglect because of it.
About half of men who abuse their female partners abuse their children also.

Many professional organizations recommend screening for domestic violence. The American College of Obstetrics and Gynecology recommends asking all women the following 3 questions:

  • Within the past year — or since you have been pregnant — have you been hit, slapped, kicked or otherwise physically hurt by someone?

  • Are you in a relationship with a person who threatens or physically hurts you?
  • Has anyone forced you to have sexual activities that made you feel uncomfortable?

The National Domestic Violence Hotline has a more extensive but short list of self-asked questions (see To Learn More below).

Physical abuse that may trigger the healthcare provider to consider domestic violence as a cause. There are also behavioral and emotional symptoms can also represent domestic violence.

  • Anxiety
  • Aggression towards self or others
  • Apathy
  • Attention seeking, often for minor problems
  • Depression
  • Eating disorders
  • Emotional lability
  • Withdrawing from social interactions
  • Learning problems and declining school or work performance, especially in children
  • Malnutrition
  • Neglect of self or others
  • Sexual dysfunction including early initiation of sexual activity and compulsive sexual behaviors
  • Sleep disturbance
  • Somatization disorders
  • Substance abuse including alcohol, drugs and tobacco
  • Suicide attempt
  • Poor adherence to medical recommendations
  • Problems with authorities including lying, stealing, truancy and running away, particularly in children

Resources are available to healthcare providers to assist their patients and families.
The National Domestic Violence Hotline is available 24 hours per day at: 1-800-799-SAFE (7233), 1-800-787-3224 (TTY).

Guidelines are also available from the Victorian Government Department of Justice in Australia, which are applicable internationally (see To Learn More below).

Learning Point
Victims of domestic violence should be offered help to develop a safety plan to get out of a violent situation quickly, even if they are not willing or able to leave their current environment. The plan needs to be thought out with the idea that the victim and/or children may never be able to return to that location again.
The plan should include:

  • Try to avoid fighting in a kitchen or bathroom where the abuser may have access to weapons or where there is no escape.
  • Know exactly where you will go. Regardless of the time of day or night, know a friend’s or a relative’s home or a shelter for battered women where you can go. Also think of another alternative if for some reason you couldn’t go to this place. Remember that you may not be able to return ever!
  • Pack a suitcase and keep it in a safe place. Keep a change of clothing for you and your children, bathroom items, and an extra set of keys to the house and car with a friend or neighbor.
  • Keep special items in a safe place. Keep important items handy so you can take them with you on short notice, or pack duplicates. These may include prescription medicines, identification, extra cash, checkbook, credit cards, and address book and telephone numbers. Also include medical and financial records, such as mortgage or rent receipts. Consider taking a special toy or book for each child.
  • Talk to your children. Let them know that it is not their job to try to stop the fighting. Tell them to call the police or get help from a family member, friend, or neighbor if they need to.
  • If you are hurt call your doctor or go to the emergency room. Give your doctor complete information about how you were injured. Ask for a social worker or a domestic violence intervention worker to help you and the children with finding safe housing, medical treatment and filing charges with police officers if you wish
  • Call the police. Domestic violence is a crime. Give the police complete information about what happened. Be sure to get the officer’s badge number and a copy of the report in case you want to file charges later.

Questions for Further Discussion
1. What is PTSD and how does it relate to domestic violence?
2. What days of the week or year are especially high risk for domestic violence?
3. What is the telephone number to the local domestic violence intervention program?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Domestic Violence and Child Abuse
and at Pediatric Common Questions, Quick Answers for this topic: Child Abuse

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Committee on Child Abuse and Neglect.
The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women.
Pediatrics 1998 101: 1091-1092. Available from the Internet at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/6/1091 (rev. 10/2004, cited 5/23/07).

American College of Emergency Physicians. Policy Statement. Guidelines for the Role of EMS Personnel in Domestic Violence. Available from the Internet at http://www.acep.org/webportal/PracticeResources/issues/pubhlth/violence/GuidelinesRoleEMSPersonnelDomesticViolence.htm (rev. 2000, cited 5/23/07).

American College of Obstetrics and Gynecology. Domestic Violence. Available from the Internet at http://www.acog.org/publications/patient_education/bp083.cfm (rev. 2002, cited 5/23/07)

American Academy of Family Physicians. Policy Statement. Family and Intimate Partner Violence and Abuse. Available from the Internet at http://www.aafp.org/online/en/home/policy/policies/f/familyandintimatepartner-violenceandabuse.html (rev. 2004, cited 5/23/07).

Victorian Government Department of Justice. Management of the whole family when intimate partner violence is present: guidelines for primary care physicians. Melbourne, Australia, 2006. Available from the Internet at http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/
Familywomenviolence/Intimatepartnerabuse/20060507intimatepartnerviolence.pdf
(rev. 10/2006, cited 5/23/2007).

American Bar Association. Safety Tips for You and Your Family.Available from the Internet at http://www.abanet.org/domviol/safety_tips.html (cited 5/31/2007).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 16, 2007