Elsevier

Child Abuse & Neglect

Volume 34, Issue 4, April 2010, Pages 275-283
Child Abuse & Neglect

Results of a multifaceted Intimate Partner Violence training program for pediatric residents

https://doi.org/10.1016/j.chiabu.2009.07.008Get rights and content

Abstract

Objective

To evaluate the efficacy of a multifaceted Intimate Partner Violence (IPV) intervention on knowledge, attitudes, and screening practices of pediatric residents.

Methods

The intervention included: an on-site IPV counselor, IPV training for attending physicians, residents and social workers, and screening prompts. Evaluation included baseline and post-training surveys of residents, assessing their knowledge, attitudes, and comfort with IPV screening, patient chart reviews at baseline, 3 months, and 8 months for documentation of IPV screening, and review of the IPV counselor's client charts.

Results

Baseline chart review showed screening rates of less than 1%. Screening rates were 36.2% at 3 months and 33.1% at 8 months. After training, residents were more likely to know: IPV screening questions (47.1% vs. 100%); referral sources (34.3% vs. 82.9%); and the relationship between child abuse and IPV (52.9% vs. 97.1%). At baseline, barriers to IPV screening included time (50%), lack of knowledge of how to screen (26.5%) and where to refer (23.5%). Post-training, barriers were time (44%), presence of children (25.9%) or other adults (18.5%) in the room, and inappropriate location (18.5%). Post-training, none of the residents listed “lack of knowledge” or “lack of referral sources” as barriers to IPV screening. After 12 months, 107 victims of IPV were identified; most referred from inpatient units and subspecialty clinics.

Conclusion

A multifaceted IPV intervention increased identification of IPV victims and markedly improved attitudes, comfort, and IPV screening practices of pediatric residents. IPV screening rates were sustainable with minimal ongoing training.

Practice implications

Consideration should be given to the training and practice supports necessary to encourage IPV screening in the pediatric setting. Educational efforts that familiarize pediatricians with the content surrounding the risk and potential impact of IPV to children and families along with practice supports that make incorporating screening for IPV as easy as possible have the potential to increase the identification of this problem and promote referrals to IPV agencies for follow-up and intervention where needed.

Introduction

Exposure to Intimate Partner Violence (IPV) has many adverse effects on children (AAP, 1998). Each year as many as 15 million children are exposed to IPV (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006). Of these IPV exposed children, the co-occurrence of child maltreatment is between 33% and 77% (Christian et al., 1997, Garbarino et al., 1991, Wright, 2000, Zuckerman et al., 1995). Long-standing, adverse effects of IPV exposure include post-traumatic stress disorder, behavior and school problems, risk-taking behaviors, and violence perpetration (Anda et al., 2001, Bair-Merritt et al., 2006, Kernic et al., 2002, Lapidus et al., 2002). Additionally, living in a household where the “mother is treated violently” is one of the adverse childhood experiences (ACE) defined by Felitti et al. (1998) in the now classic ACE studies which is correlated with the child, so exposed, developing poor health related behaviors and actual medical conditions as they later grow into adulthood. Even if the child or children living with IPV are not physically harmed, a growing body of work makes clear that exposure and witnessing violence or its aftermath can have significant consequences for a child's emotional and cognitive development and wellbeing (Feerick and Silverman, 2006, Groves, 2002). As a result, the American Academy of Pediatrics (AAP) recommended that pediatricians routinely screen female caregivers for IPV and that pediatric residency programs incorporate IPV training into their curricula (AAP, 1998). The AAP (1998) frames the screening for IPV in the pediatric setting as a child abuse prevention activity and states: “intervening on behalf of battered women is an active form of child abuse prevention” (p. 1091). Despite these recommendations, only 5–21% of pediatricians routinely screen for IPV (Bair-Merritt et al., 2004, Erickson et al., 2001, Lapidus et al., 2002, Parkinson et al., 2001, Siegel et al., 1999, Sugg and Inui, 1992), and up to 30% of pediatricians never screen for IPV (Lapidus et al., 2002). Nearly 74% of practicing pediatricians report they have never received IPV training during residency (Bair-Merritt et al., 2004, Erickson et al., 2001). The most commonly cited barriers to screening for IPV include: lack of time, training, experience, no office protocol, and a fear of opening up “Pandora's box” (Bair-Merritt et al., 2004, Erickson et al., 2001, Lapidus et al., 2002, Parkinson et al., 2001, Siegel et al., 1999, Sugg and Inui, 1992). Other barriers to guideline compliance include: lack of familiarity with the guidelines, lack of self-efficacy, and feelings of futility (Cabana et al., 1999, Scalzi et al., 2006).

Few published studies have addressed IPV education in pediatric training programs. Berger and colleagues used a 30-minute didactic session followed 3 months later by a 90-minute multimodal teaching session (didactic, video, role play) (Berger, Bogen, Dulani, & Broussard, 2002). Response to positive IPV screens was provided by the medical social work staff and a 6-month follow-up demonstrated self-reported improvements in IPV screening rates, but no change in attitudes towards IPV screening in the pediatric setting.

We utilized the successful aspects of this intervention and combined them with general principles of changing physician attitudes and practices (Cabana et al., 1999, Scalzi et al., 2006) to develop a multifaceted, longitudinal IPV intervention called the Children and Mom's Project (CAMP). CAMP is a multicomponent, collaborative program designed to increase IPV screening rates by health care providers, identify families experiencing IPV, and minimize the adverse effects of childhood IPV exposure. Innovative features of the program include the presence of an onsite IPV counselor, IPV screening support from attending physicians and pediatric resident “champions,” and IPV screening prompts in the patient charts. In this paper we report on the impact of CAMP on the attitudes and IPV screening practices of pediatric residents, as well as the IPV referrals generated from these screening efforts.

Section snippets

Setting and participants

St. Christopher's Hospital for Children (SCHC) is an urban tertiary care pediatric hospital. In 2006, the 4 zip codes surrounding SCHC accounted for over 13,000 incidents of IPV, which comprises 20% all IPV-related crime in Philadelphia (Philadelphia Neighborhood Information System, 2008). SCHC has an onsite Ambulatory Pediatrics Clinic (APC) with approximately 25,000 patient visits yearly, 85% of whom receive medical assistance. The ethnic breakdown for patients served in the Clinic is as

Resident survey

Fifty-nine of 72 (82%) residents completed the baseline survey. Thirteen (22.1%) were third year residents, 16 (27.1%) were second year residents, 28 (47.5%) were first year residents, and 2 (3.4%) were fourth year chief residents. Forty-one (69.5%) residents were female, and 52 (88.1%) were less than 30 years old. Thirty-nine (66.1%) residents stated that they had received previous training on IPV in their professional education. Of the 59 residents who completed the baseline survey, 52 had

Discussion

This multifaceted IPV intervention improved resident attitudes, comfort, and IPV screening practices. As a result, 107 cases of IPV were identified over a 1-year period. The success of our intervention stems from its multilayered approach that addressed specific, well-established barriers to IPV screening. These barriers included a general lack of awareness of IPV and its effects on children, the role of the pediatrician in addressing IPV, comfort asking about IPV, lack of an office protocol

Acknowledgements

The authors thank Cynthia Delago, Corinne Lagermasini, Kavitha Antonyraj, Colleen Fitzpatrick, and Monique Sapute for their contributions to the design and data analysis of this work. We also acknowledge Matilde Irigoyen for her contributions to the editing of a previous version of this manuscript. Finally we wish to acknowledge Robert Bonner and the Ambulatory Pediatrics attending staff for their continued support in making IPV screening a routine aspect of patient care.

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    This work was supported by the Children's Trust Fund of Pennsylvania.

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