Report 7 of the Council on Scientific Affairs (A-05)
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Diagnosis and Management of Family Violence

Resolution 438 (A-04), introduced by the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Academy of Pediatrics, and American Academy of Neurology and adopted as amended, asked the  American Medical Association (AMA) to study the best practices in diagnosis and management of family violence (including an analysis of studies not reviewed in the recent U.S. Preventive Services Task Force  [USPSTF] Recommendations on Screening for Family Violence) and present a report that identifies future research and practice recommendations.

Background

Family violence is a generic term that encompasses elder abuse, child abuse, and intimate partner violence. The clinical epidemiology and consequences of these various forms of family violence were reviewed in a 2000 Council on Scientific Affairs (CSA) report¹ and will not be addressed in this report.

Early identification of patients involved in an abusive relationship is important when assessing the general health and mental health status of the patient; the health impact of the abuse; and the need for support, information, and appropriate referral resources for persons victimized by family violence, including all family members affected by the events. Research results indicate, however, a high rate of missed opportunities for patient identification in clinical settings. Approximately half of physicians report screening for family violence, 10% to 30% report they never screen, and only 6% to 12% report they screen routinely. Furthermore, physicians screen for family violence less frequently than for other health risks.^2-7 These data fail to reflect  the concerns voiced by expert practitioners that even when screening is performed, it is not done in a manner that promotes patient trust and full disclosure. Regardless of the burden of suffering caused by family violence, and the strong advocacy among health professionals for identification and intervention, there is no consensus on the value of routine screening of patients in the clinical setting.

This report will (1) briefly review relevant AMA policy and activities; (2) review the current status of preventive service recommendations for routine screening for family violence; and (3) provide recommendations for the physician’s role in addressing family violence and for new directions in family violence research.

Methods

Literature searches were conducted in the MEDLINE database for English-language articles published between 2002 and January 2005 using the MeSH terms family violence and clinical screening (14 of 193 were relevant), and clinical management (1 of 32 were relevant) or treatment (28 of 39 were relevant). Additional references were identified from the bibliographies of these articles. Relevant reports issued by the USPSTF, the Canadian Task Force on Preventive Health Care, and the Cochrane Collaboration were consulted. Additionally, the Web sites of the Family Violence Prevention Fund, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention were searched for pertinent information.

Relevant AMA Policy and Activities

The AMA has developed guidelines for detecting and treating family violence, which are contained in Ethical Opinion E-2.02 (AMA Policy Database). These guidelines call on physicians to “…routinely inquire about physical, sexual, and psychological abuse as part of the medical history. Physicians must also consider abuse in the differential diagnosis for a number of medical complaints, particularly when treating women.”

More recently the AMA published a monograph on intimate partner violence as part of the AMA's Roadmaps for Clinical Practice series.⁸ This monograph:

• Familiarizes physicians with the magnitude of the problem;
• Describes how to identify abuse and violence through routine screening and recognition of clinical presentations;
• Helps physicians assess the impact of abuse and violence on the health and well-being of their patients;
• Provides examples of questions that can elicit meaningful responses and encourage patients to explore their options and to improve their health and safety;
• Provides information on appropriate resources and referral; and
• Addresses frequently encountered obstacles.

Clinical Preventive Service Recommendations for Screening for Family Violence

AMA support for routine screening for interpersonal violence needs to be clarified, given some uncertainty among medical professionals in the field resulting from the recent USPSTF Recommendations on Screening for Family Violence. Clinical guidelines on screening for family violence have been developed by a variety of organizations. In general, these guidelines either call for routine screening of all patients or for case finding (see below) among patients who are presumably at risk for family violence based on clinical signs or symptoms.

In 2004, the USPSTF released the following recommendation on routine screening of asymptomatic patients for family and intimate partner violence:

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.⁹ 

Similar conclusions regarding routine screening to prevent violence against women were reached by the Canadian Task Force on Preventive Health Care,¹⁰ and by Ramsay and associates¹¹ who conducted a systematic review of the scientific literature.

The USPSTF recommendation is based on the lack of sufficient evidence that “screening for family and intimate partner violence leads to decreased disability or premature death”⁹ among patients with no presenting symptoms. A lack of adequate research on objective outcomes (as opposed to self-report) of patients referred for treatment is the basis for this viewpoint. It is important to recognize that because the Task Force only included studies of asymptomatic patients in its reviews, studies involving  patients seen in emergency rooms, patients in high-risk social circumstances, or patients who had provider-elicited signs of violence were not evaluated. By only measuring the impact of screening on disability or premature death, no analysis of the other health benefits of assessment and intervention for abuse, such as improved safety or health behaviors as a result of the interventions, was included.

In a recent report, the Family Violence Prevention Fund (FVPF) addressed the limitations of the USPSTF recommendations on intimate partner violence.¹² In summary, the FVPF believes that screening for intimate partner violence should be considered a psychosocial assessment and counseling practice, rather than a medical procedure as reviewed by the USPSTF. This distinction is important because, according to the FVPF, the USPSTF uses a different analytic framework to assess the two types of interventions (medical screen versus psychosocial assessment). Intimate partner violence is viewed by experts, including the FVPF, as a chronic, recurrent, and usually escalating problem that is not easily divided into symptomatic and asymptomatic patients. Thus, screening for family violence would be a better fit in the behavioral and counseling services framework.

Additional concerns about the USPSTF review expressed by the FVPF include the limited consideration given to intimate partner violence screening during pregnancy, the emphasis on hypothetical adverse effects of screening, the exclusion of consideration of intimate partner violence within the context of other health risks and behaviors (i.e., unintended pregnancy, alcohol misuse), and the limited outcome measures included in the analysis.

Ultimately, the recommendation of the USPSTF depends on the strength of the evidence connecting routine, universal screening of asymptomatic patients with improved health outcomes. The USPSTF did not address the value of case finding—identifying victims of family violence among patients who express a constellation of signs or a recurring pattern of health care utilization or help-seeking that led the physician to suspect an underlying “hidden agenda.” 

A review of the scientific literature published since the completion of the USPSTF analysis (December 2002) and findings included in the FVPF analysis does not add substantial new evidence connecting routine screening and interventions with improved health outcomes, as operationalized by the USPSTF. It is evident from the debate described above that more data are urgently needed to better inform clinical decisions and health care policy. Research on the clinical impact of family violence, effectiveness of management strategies, and strategies for primary prevention would provide critical information to guide future directions in reducing the health effects of family violence.

Primary Prevention of Family Violence

A growing body of research is demonstrating the long-term consequences of childhood exposure to abuse. Thus, children who are victims of child abuse or sexual assault and children who witness family violence are at risk for future perpetration, victimization, and other health disorders.^13-14 A new concept, assessment for lifetime exposure to abuse, may be a critical primary prevention strategy.  Neither the USPSTF recommendations, nor most health care practice guidelines, adequately address primary prevention of abuse.

To develop primary prevention strategies, more data are needed on the value of assessing for lifetime exposure to family violence in specific health care settings including family practice, child and adolescent health, perinatal health settings, and home nursing programs. Evaluating the impact of these strategies on at-risk groups to see how they affect patient self-efficacy and health behaviors, and to test messages about healthy parenting and partnering, would significantly contribute to our understanding of how to prevent abuse in the future. Longitudinal studies that measure any impact on violence and abuse as a result of interventions would be extremely beneficial.

RECOMMENDATIONS

The following statements, recommended by Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy and directives at the 2005 AMA Annual Meeting:

The AMA:

1. Recommends that questions to assess risk for family violence should be included within the context of taking a routine social history, past medical history, history of present illness, and review of systems as part of emergency, diagnostic, preventive, and chronic care management. (Policy)
2. Urges the Agency for Healthcare Research and Quality and the National Institutes of Health to fund research on the following:
   • A national, multi-site interdisciplinary study of health care interventions that addresses the effectiveness of selected interventions for victims of family violence on improved lifetime health status, health care utilization, and a sense of safety and security.
   • Potential adverse effects of assessment for family violence on documentation and reporting to law enforcement and child-protective services.
   • Research on cost-effectiveness of health care responses to family violence.
   • Research on the primary prevention of interpersonal violence through identification and intervention of abuse across the life span. (Directive)
3. Will  inform physicians about educational tools to aid in assessment and management of family violence, such as the Consensus Guidelines developed by the Family Violence Prevention Fund and the AMA Roadmaps for Clinical Practice: Intimate Partner Violence monograph. (Directive)
4. Will ask the AMA National Advisory Council on Violence and Abuse to study strategies for the primary prevention of family violence and inform physicians of the findings. (Directive)

References

1. Council on Scientific Affairs. AMA Data on Violence Between Intimates. American Medical Association. Available at:  http://www.ama-assn.org/ama/pub/category/print/13577.html. Accessed 1/17/05.
2. Rodriquez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA. 1999;282:468-474.
3. Gerbert B, Gansky SA, Tang JW, McPhee SJ, et al. Domestic violence compared to other health risks: a survey of physicians’ beliefs and behaviors. Am J Prev Med. 2002;
 23:82-90.
4. Lapidus G, Cooke MB, Gelven E, Sherman K, et al. A statewide survey of domestic violence screening behaviors among pediatricians and family physicians. Arch Pediatr Adolesc Med. 2002;156:332-336.
5. Erickson MJ, Hill TD, Siegel RM. Barriers to domestic violence screening in the pediatric setting. Pediatrics. 2001;108:98-102.
6. Elliott L, Nerney M, Jones T, Friedmann PD. Barriers to screening for domestic violence. J Gen Intern Med. 2002;17:112-116.
7. Williamson KJ, Coonrod DV, Bay RC, Brady MJ, et al. South Med J. 2004;97:1049-1054.
8. Brown R. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion—Intimate Partner Violence. Chicago, IL: American Medical Association: 2002.
9. U.S. Preventive Services Task Force. Screening for family and intimate partner violence: Recommendation statement. March 2004. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/clinic/3rduspstf/famviolence/famviolrs.htm. Accessed 1/10/05.
10. Wathen CN, MacMillan HL. Prevention of violence against women: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ. 2003;169:582-584.
11. Ramsay J, Richardson J, Carter YH, Davidson LL, et al. Should health professionals screen women for domestic violence? systematic review. BMJ. 2002; 325:314-327.
12. Chamberlain L. The USPSTF recommendations on intimate partner violence: what we can learn from it and what can we do about it. Family Violence Prevention and Health Practice. 2005, vol 1.  Available at: http://endabuse.org/health/ejournal/.
13.  Felitti VJ, Anda RF, Nordenberg D, Williamson DF, 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.
14. Dube SR, Felitti VJ, Dong M, Giles WH, et al. The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med. 2003;37:268-277.

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