ALECOMM

Domestic Violence, the number one public health problem in the United States, affects all aspects of society in staggering dimensions. It is the chief cause of injury to women, more than the next three causes combined: rape, auto accidents and muggings.⁽¹⁾

Health care professionals are the first line response to many domestic violence victims. In this capacity, they must be prepared to identify, assess, and assist victims with safety planning, and provide referrals to needed services. Health care providers must recognize that the emergency room is only one of many health care settings where victims are found. Almost every medical discipline is confronted at some point with the tragic results of domestic violence.

Nationwide, employers estimate that domestic violence costs them between three and five billion dollars each year in health care claims, plus another one hundred million dollars in absenteeism, high turnover and lost productivity.

The impact on America's children is devastating, both short and long term. Children are often present when law enforcement officers respond to domestic violence calls. Growing up in a violent home renders children vulnerable to truancy, delinquency, aggression and suicide, among other outcomes.

All who provide services to victims, both adults and children, must provide education as well as prevention and intervention strategies to offset the impact of the trauma of violent homes. Not only must safety, support and a wide array of services be available to victims, but offenders must receive prompt attention, assessment, education and treatment if society is to realize success in eliminating violence from America's homes.

Objectives of Domestic Violence Training

At the conclusion of this program, participants, will be able to:

1. Define domestic violence and the incidence of injury to women.

2. Discuss the common myths about domestic violence.

3. Identify the incidence and prevalence of domestic violence.

4. Explain the historical influences supporting abuse of women and children.

5. Describe the dynamics of a violent relationship and the relevance of factors like family history of violence, substance abuse and medical or mental health issues to determine the likelihood of continuing violence.

6. Explain the issues relating to children, who are at risk of exposure to domestic violence in the US each year.

7. Describe the healthcare provider's response to an incidence of domestic violence.

8. Explain healthcare provider's intervention strategies and reporting.

9. Utilize appropriate screening and assessment procedures and techniques.

Included in this report is a listing of additional national and state resources that are available to assist the victims of domestic violence.

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Section II: What Is Domestic Violence?

Behavioral Definition

Known by many names: wife abuse, marital assault, wife beating, battering, intimate violence, partner abuse, domestic violence is all of these and more. Rather than any single behavior, work with victims has taught us that domestic violence is a pattern of many assaultive and coersive behaviors that adults or adolescents use against their intimate partners or former partners.

The relationships include those currently intimate, dating, married, or cohabiting, heterosexual as well as gay men and lesbians, as well as those who may be divorced or separated. The relationships may be of long or short duration, and the participants may be elderly couples, teenagers and all ages in between.

Assaultive and coercive behaviors include physical and sexual violence, psychological and emotional attacks, threats against property, pets and even the children in the home, economic coercion and many more such acts. Some are injurious and criminal in nature while others are not.

All are designed to manipulate, control and dominate the partner and to achieve compliance and dependence. By isolating the partner from family, friends, neighbors or co-workers, the batterer ensures that his or hers are the only messages heard.

Over the course of a relationship, a pattern of multiple acts occurs, using a variety of the behaviors described here. Sometimes, the batterer does not have to utilize more than a few well-planned actions to maintain control. A certain look or a reminder of past actions may be enough to achieve the desired result.

Other individuals use a wide variety of actions with no particular pattern. The behavior can last a few minutes, hours, and sometimes even days. Success depends on a variety of factors; the batterer convinces the partner that his or her actions cause the batterer to respond. The victim is at fault, not the batterer, and therefore needs to be corrected. The batterer may minimize or even deny that anything harmful has occurred.

Within the relationship, perpetrators have access to their victims, know the daily routine and the special vulnerabilities the victim may have, such as a physical illness or disability. Victims must deal with the complexity of an intimate relationship with the batterer, and maintaining that relationship often makes those outside the home unaware of and insensitive to the nature of the abuse and violence.

The parts of the pattern of behavior interact with each other and victims respond to the pattern, rather than an individual act. Many cite the pain of emotional and psychological abuse (like name-calling, putdowns, using the children, constant criticisms, etc.) as being even more difficult to bear than physical assault.

Whatever the batterer feels: jealousy, anxiety or fear that she will leave him, he uses violence to get or keep power and control. While he may suffer from low self-esteem and a sense of powerlessness outside the home, he feels entitled to be empowered at home, and society has vested him with that entitlement until fairly recently.

Statutory Definition of Domestic Violence

The following selected state codes are used as examples of the statutory definition of domestic violence.

State of Florida

F.S.S.741.278: Domestic Violence means any assault, battery, aggravated assault, aggravated battery, sexual battery, stalking, aggravated stalking, false imprisonment, kidnapping, or any criminal offense resulting in physical injury or death of one family or household member by another, who is or was residing in the same single dwelling unit.⁽²⁾

Note: Aggravated assault, aggravated battery, aggravated stalking are felonies; assault on a victim who is pregnant, if the batterer knew or should have known she was pregnant, is a felony, as is assault or battery on a victim 65 years of age or older. Use of a weapon during an assault or battery can move that charge to a felony, also.

General Laws of Massachusetts

Section 20K. As used in this section the following words shall unless the context clearly requires otherwise have the following meanings:--"Abuse", causing or attempting to cause physical harm; placing another in fear of imminent physical harm; causing another to engage in sexual relations against his will by force, threat of force, or coercion.

"Victim", a person who has suffered abuse and who consults a domestic violence victims' counselor for the purpose of securing advice, counseling or assistance concerning a mental, physical or emotional condition caused by such abuse.

Family Code - Texas

Sec. 71.01. Definitions.

(2) "Family violence" means: (A) an act by a member of a family or household against another member of the family or household that is intended to result in physical harm, bodily injury, assault, or sexual assault or that is a threat that reasonably places the member in fear of imminent physical harm, bodily injury, assault, or sexual assault, but does not include defensive measures to protect oneself; or (B) abuse, as that term is defined by Sections 34.012(1)(C), (E), and (G) of this code, by a member of a family or household toward a child of the family or household.

(3) "Family" includes individuals related by consanguinity or affinity, as determined under Sections 573.022 and 573.024, Government Code, individuals who are former spouses of each other, individuals who are the biological parents of the same child, without regard to marriage, and a foster child and foster parent, whether or not those individuals reside together.

(4) "Household" means a unit composed of persons living together in the same dwelling, other or not they are related to each other.

(5) "Member of a household" includes a person who previously lived in a household.

For additional information on specific state laws and statutes, visit the web page for the Cornell Law School at: www.law.cornell.edu/statutes.html

In general, unwanted touching, shoving, pushing, and poking are batteries, as are slaps, kicks, bites, punches, etc. The key is "unwanted". Assault is a credible threat to do serious injury or harm to another person putting that person in fear for his/her life or safety.

Most of the 50 states do have at least a "probable cause" statute in place. This means a law enforcement officer can arrest without warrant if he/she has probable or reasonable cause to believe some violent act has taken place prior to the arrival of the law enforcement officers at the scene of a domestic violence call.

One important note is that if a parent beats a child, it is considered child abuse, not domestic violence. But, if a child beats a parent, it is domestic violence.

Who Qualifies Under "Domestic Violence"?

The following qualify under the term "domestic violence" as a Family or Household Member:

A spouse
Former spouse (no time limitation; the individuals could have been divorced many years earlier)
Persons related by marriage
Persons who are presently residing together as if a family unit
Persons who have a child in common, regardless of whether they have been married or have ever lived together at any time
Same sex partners are included, if they fit the statutory definition

Note: dating teens who do not have a child in common are not presently covered under domestic violence statutes.

Common Myths About Family Violence

Myth 1: Family Violence is Not Very Common

Almost all family violence experts seem to agree that domestic violence is much more common than ever realized. The National Committee to Prevent Child Abuse reported in 1994 that over three million children experienced some form of abuse (physical, sexual, neglect, or emotional abuse). Straus and Gelles reported in 1986 that 28% of American couples experience at least one act of violence during their marriages, 16% experience at least one act of violence per year, and 5% experience severe violence in any given year. Even these data are considered conservative.

Myth 2: Only Poor People Are Violent

While some studies do provide evidence that there appears to be a higher incidence of violence in families at or below the poverty line (Straus et al, 1980, cite a violence rate 5 times that of families above the line), and a later study indicated "blue-collar" husbands more violent (13.4%) than "white-collar" husbands (10.4%), this does not lead to the erroneous assumption often heard, that poor familes are always violent, or that only poor families are violent.⁽³⁾ This is not true. Poor people who lack other support or resources are much more likely to turn to police or social agencies more often than families who have money.

Myth 3: Children Who Witness Abuse or Are Abused Always Become Abusive Parents or Abusive Spouses

This is a dangerous generalization to make as it tends to make one accept the intergenerational pattern of abuse as the complete explanation, in and of itself, to predict behavior. Most of the research has been done on self reports and in retrospective research which relies on adult memories and perceptions. Also, there is not often a comparison group of nonviolent adults giving self reports. The data suggest that child witnesses to violence, or victims of abuse are more likely to be abusive, but not predetermined to be so.

Myth 4: Battered Women "Ask For It"

Criticisms of battered women, blaming the victims for not "just leaving", lead to conclusions such as they must really enjoy being beaten, are nags, or drunks, or are mentally ill, therefore they, and not the batterers are at fault. Attention needs to focus not on why they stay but why "he abuses".

Myth 5: Alcohol and Drugs Are the Real Cause of Family Violence

While alcohol or drug abuse does figure in a majority of violent incidents, it cannot be said to be the cause of the abuse. Many abusers batter their partners whether drunk or sober. Many batterers never use alcohol or drugs. Being drunk or stoned often serves as an excuse for the behavior and another way to deny personal responsibility for battering.

Myth 6: Violence and Love Cannot Coexist

The average battering relationship lasts about 6 years, the same length of time as the average marriage.⁽⁴⁾ Physical violence does not preclude the presence of love and intimacy, nor does it spell the end of the relationship. Many victims call police to make the violence stop, not to end the relationship. Children learn very young, that the people who love them, may also hit them.⁽⁵⁾

How Widespread Is Domestic Violence?

Between 30% and 35% of the visits made by women to hospital emergency departments are for treatment of injuries inflicted by a current or former intimate partner.⁽⁶⁾

Significantly, 92% of the women who were physically abused by partners did not discuss these incidents with their physicians and 57% did not discuss the violence with anyone.⁽⁷⁾

As many as 17% of adult pregnant women are battered by their partners. In pregnant teenagers, the figure may be as high as 21%.⁽⁸⁾

Emergency Room Physicians state that they do not identify more than 5% to 8% of the battering victims they see in their departments.⁽⁹⁾

Women of all races are equally vulnerable to attacks by intimate partners.⁽¹⁰⁾

Approximately 40% to 50% of the women murdered in the US are killed by current or former violent partners.⁽¹¹⁾

Up to 50% of the women and children who are homeless in the US are escaping violent homes.⁽¹²⁾

One of every four gay couples experiences domestic violence in their relationship.⁽¹³⁾

There are three times as many shelters for protecting animals in the US as there are shelters for battered victims and their children.⁽¹⁴⁾

For example, in Florida last year (1997), Domestic Violence Centers:

Answered 179,550 crisis calls,
Provided 243,870 days of emergency shelter to 14,833 women and children,
Provided outreach services to 75,321 women, a 42% increase over the previous year,
Assessed 7,479 children for abuse and neglect.

In 1996, more than 130,000 incidents of domestic violence were reported to Florida Department of Law Enforcement.⁽¹⁵⁾

Historical Influences Supporting Abuse of Women and Children

The regard of women and children as possessions (chattel), not persons, and the belief that what happens in the home is a "family matter" immune to outside interference, is deeply rooted in history. Old English common law held that a man had the right to beat his wife and children, so long as he used a stick no larger in circumference than his thumb. The expression, "Rule of Thumb" came from this practice, which was still on the statute books in America early in this century.

Husbands and fathers were entitled to compensation for "damage to their property" when wives or daughters were the victims of rape.

Until earlier in this century in America, women could not vote, own property in their own names, nor execute legal documents. A woman was considered to cease to exist in her own right when she married, taking her husband's name and his identity.

Late in the 1800s, at least two states, Alabama and Massachusetts, passed laws identifying spouse abuse as a wrongful act. Women campaigning for suffrage promoted their gender as equal to men, capable of being educated and functioning in other roles along with those of wife and mother.

Another century passed before equal rights for women and minorities became the rallying point for large numbers of Americans and lawmakers took note, passing laws to support and promote equal opportunities for jobs, housing and education. Feminists active in the movement to advance opportunities for women also examined closely what women experienced in their daily lives. As the abuse and battering by their intimate partners became known, women reached out to other women for help.

The first shelter, Haven House, in Pasadena, CA, was opened in 1964; Chiswick Women's Aid opened in England in 1971 and became the first widely publicized shelter for battered women.⁽¹⁶⁾ In 1974, the National Organization for Women (NOW) made battered women a major priority.

Around the world there are many cultures with very different perceptions of spouse abuse than in the US. In many countries, efforts to keep women and children in subordinate roles continue. Female genital mutilation, female infanticide and forced suicide of widows upon the deaths of their husbands are three of the issues raised at the World Conference for Women held in 1996, which attempted to raise world-wide awareness of inhumane practices against women and girls.

Research in the field is still new to many countries, and there is still no widespread recognition of domestic violence as a social problem. One study documented wife beating in 57 of 71 societies, revealing how common and ordinary the practice continues to be.

While America is recognized as one of the most violent nations in the world, it is also one of the most progressive and aggressive in recognizing and responding to family violence as a major segment of the violence in today's society.

Development of Domestic Violence Services

From the early 1970s, the shelter movement grew in a grassroots fashion, first offering women and their children a place to stay in safety and a chance to explore their options. Underfunded, staffed mostly by volunteers, these safe houses gave women an opportunity to support and help each other, and residents discovered a commonality in their experiences which cut across racial/cultural, educational and social/economic classes.

Pennsylvania formed the first state coalition against domestic violence, and also became the first state to enact a law providing orders of protection for victims. Another landmark event in 1976 was the first national conference on battered women, held in Milwaukee, WI.

In 1978, Florida became the first state to enact law mandating consideration of spouse abuse in child custody determinations.

Today there are some 1500 shelters for battered victims (many offer duplicate services to male victims) and their children. Services offered include emergency shelter, a 24-hour hotline, outreach counseling, safety planning, children's programming, legal advocacy, transportation and case management. Many also operate transitional housing programs for those who no longer need the security and structure of shelters, but are not yet ready to begin living on their own without the support services. Shelters network with local schools, colleges and vocational training programs to assist victims with educational activities designed to support their empowerment.

It should not be overlooked that a significant number of victims are men, although clinical reports of offender treatment for adolescents indicate that the percent of referrals for girls is increasing. Male and female adolescents self report initiating violent incidents.

As the awareness of domestic violence as a major societal problem increases, so must the awareness of the need for funds and other resources grow to maintain and expand programs, especially children's programs, in shelters and at outreach locations. All elements of the community must join together to support domestic violence organizations so the dream of a violence-free society can be realized.

Health care professionals play a vital role in the response to domestic violence. It is critical that they be informed of the size and scope of this problem, as well as the most effective techniques of identification and assessment of victims, wherever encountered, as well as the best ways to approach and offer referral services to them. It is also of primary importance that nurses, physicians, clinicians in any role understand the basic dynamics of violent relationships.

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Section III. Dynamics of Violent Relationships

Data Sources

The earliest data compiled about violence in relationships came from victims, who described their experiences to shelter advocates and clinicians. Later, batterers who were brought into the legal system and often ordered into the early treatment programs, gave accounts of their own behavior. Although some characteristics and beliefs emerge often enough to assume validity, it is important to remember that generalizations can be misleading and that batterers and their victims come from all walks of life, all races and cultures, rural and urban areas, and all economic and educational levels. There is no "typical" batterer, and no "typical" victim.

Characteristics and Beliefs: Batterers

Almost all research indicates that many individuals who use violence in their intimate relationships were exposed to violence as children. Some were themselves abused, physically as well as emotionally. Many grew up in homes where substance abuse by the adults in the home was frequent.

Some batterers have little experience with men and women dealing successfully with each other, showing respect for each other and resolving problems without violence. Some batterers grew up with very rigid ideas about the roles of men and women and maintained that rigidity in their own lives.

Batterers can be and often are jealous and possessive. They can be insecure about the intimate relationship and act in controlling ways to keep the partner in the relationship.

Batterers frequently blame others, often the partner, for their violence. They also frequently minimize the level of violence they have used against the partner and/or the children. Some use violence outside the home as well as inside it and when this occurs, they will often claim someone else "started it" and they had no other choice of action.

Others are not violent outside the intimate relationship and appear to deal successfully with social and work situations, handle stress well and solve problems effectively. These are individuals who usually have no criminal record prior to a domestic violence incident. Batterers perceive much approval for the use of violence in their daily lives, from media, entertainment, sports events and from their peers. They are amused by and often actively join in conversation that demeans and degrades women. Some are strongly influenced by cultural background and male relatives such as the Hispanic tradition of male as "Macho".

In summary, the most frequently encountered characteristics of battering males appear to be:

history of witnessing violence as children,
substance abusing parent(s),
personal substance abuse,
tendency to minimize violence, deny it or blame others,
jealousy, possessiveness, dependency on partner,
low self-esteem, insecurity,
poor problem-solving skills, inability to handle stress,
ineffective communication skills,
anger and hostility,
rigid ideas of male/female roles, rights, responsibilities.

Many batterers seem to believe that their partners are (or would be, if allowed) controlling, manipulative, equally violent as they themselves are, and secretly want to be dominated.

Characteristics and Beliefs: Victims

Much more data is available about victims from shelters and outreach domestic violence programs, from researchers able to use larger groups on which to base their conclusions and from victim-survivors who advocate for others in public speeches and in published accounts of their experiences. Again, it is necessary to point out the danger in generalization. There is no "typical" victim.

Like batterers, victims may minimize or even deny the effects of violent behavior: "it wasn't that bad", "I overreacted". They also may experience low self-esteem and it appears that the longer the battering relationship lasts, the lower the victim's self-esteem becomes. Sometimes, the victim forgets prior accomplishments, experiences difficulty making decisions beyond those necessary to survive the violent incidents and does not trust her own judgment. Spiritual and socialization experiences may have taught victims that divorce is failure, a sin, wrong. They hear they must "try harder to make the relationship work".

The batterer needs and depends upon the victim and the victim comes to feel the he/she can not leave the battering partner. The victim may be physically isolated from family, friends, neighbors, co-workers, anyone who could provide messages opposing those most often received.

Depending upon the extent of the isolation, the victim may lose touch with any reality outside her own daily existence. She often feels that hers is the only family enmeshed in the violent, turbulent behavior, and that she must just try harder, do better, be better, for the violence to stop.

She may experience love, affection and intimacy with the partner, and she loves and depends upon him in return. She may be overwhelmed trying to imagine any life without him.

Victims often suffer severe stress reactions: migraines, stomach disorders, psychophysiological complaints, depression. She may use and abuse prescriptive drugs and alcohol, to "numb the pain". (Unlike batterer substance abuse patterns, some victims, when removed from the violent relationship, stop using/abusing drugs and alcohol.)

Victims sometimes use extremely creative methods to manage their environment, protect their children and survive. Often they do not make the courageous decision to leave the relationship until confronted with the batterer's abuse of their children.

NOTE: While narrative identifies the majority situation of male batterer - female victim, it is important to state that similar tactics, characteristics and beliefs exist in situations of male victim - female batterer, and in same-sex relationships. Data given must be interpreted accordingly.

Contrary to some of the earliest research, the concept of "learned helplessness" does not appear to apply to more than the smallest (<5%) of the domestic violence victims.⁽¹⁷⁾ Later data, using a much larger sample (6,000 victims), done in 1990 by E. Gondolf, support a theory of survivorship and details the methods to which victims will resort to help themselves and their children.

Early advocates and clinicians in the domestic violence field realized fairly quickly that "doing it for the victim" is not nearly as successful as "giving the victim all her options" and letting her make her own choices. They also realized quickly that they needed to believe her accounting as few others did so.

Often the batterer the victim describes is unknown to anyone outside her own home. Family, friends, co-workers, neighbors may never have seen him practice the behaviors she cites. This disbelief helps reinforce her own feelings of shame, self-blame and responsibility for the batterer's behavior.

Effects on Batterer, Victim and Children

On the batterer:

There is support for the use of violence to gain one's desired result, which may lead to an increase in the level of violent activity. This results in increased contact with law enforcement, the courts, probation officers, victim advocates, group leaders, and clinicians. Financial burdens increase as costs include those levied in court, probation/supervision costs, treatment/education fees, lost time from work.

Individuals in the batterer's work, church or social settings may be made aware of the domestic violence incident, resulting in increased anxiety, loss or decrease in self-esteem, and even depression. In some employment situations, (law enforcement officers, for instance), continuing employment could be jeopardized by the domestic violence arrest/conviction/probation.

The resulting increase in stress, financial hardship, loss of status and embarassment may in turn trigger more violence against the victim. Finally, recent studies have indicated that some batterers may experience increased feelings of displeasure with themselves after a violent incident because they inwardly disapprove of the behavior.

On the victim:

After a violent incident, victims feel - in addition to the pain of physical injury - fear of a loss of stamina, energy, ability to manage their situation or protect the children. They also often experience a feeling of helplessness, desperation, isolation, feelings of being "off balance", particularly when an incident occurs without any prior warning.

Often there is an immediate need to hide the signs, cover the bruises, make up stories to explain the injuries, minimize or even deny the occurrence. There is sometimes an intense level of shame and embarassment, particularly when others, (neighbors, teachers, doctors, nurses, police, etc.) become involved.

There are intense feelings of fear and anxiety. "What do I do now?" "How will the kids and I survive?" "He has threatened to kill me - will it happen now?"

Many victims have never called the police before, nor seen the courts, or the judicial process. They are ignorant of and terrified by the procedures and find the entire experience frightening and overwhelming. The batterer at this time may be stepping up the frequency and severity of threats to take punitive action against her for involving "outsiders" in family matters.

All of these effects heighten her feelings of helplessness, her lack of self worth, and may even help to convince her that she is at fault, she is "crazy", and no one will help her.

On children who witness violence in their homes:

Children are terrorized by the sights and sounds of violence in their homes. Many suffer from nightmares, shaking, stuttering, nail-biting, anxiety, depression, digestive upsets, and other physiological, emotional and behavioral responses.

Cognitively, their development is delayed by their experiences. They suffer learning disabilities, delays in speech and other developmental measures. Some display behaviors similar to children with attention-deficit disorder and hyperactivity disorder.

Some act out aggressively, mirroring the behaviors they see in the home, while others withdraw and stop communicating. Some are injured attempting to intervene and stop the violence. They may be hit with objects thrown at the victim. Infants and toddlers may be injured by being dropped or hit while the victim is holding them and is the target of a violent act.

Often, children are unable to concentrate at school or when away from parents, for fear they will never see them again. Some suffer from extreme separation anxiety long after it is an age-appropriate behavior.

Other possible responses to domestic violence include eating disorders, early sexual activity and pregnancy, and in some cases, suicidal or homicidal ideation.

Children who come to the attention of juvenile court authorities for an arrest for violent behavior (with siblings, parents, schoolmates, friends, others) very often relate histories of violence in their families of origin.

Power and Control Tactics

Like much of the information cited above, the sets of behaviors most commonly called Power and Control Activities attributed to batterers, came from early research conducted with victims and batterers, and still form the basis for much of the educational work done with both batterers and victims.

The Domestic Abuse Intervention Program in Duluth, MN, adopted the model of a wagon wheel with spokes radiating out from its hub. Between the spokes of this wheel, behaviors are listed in eight major divisions, all designed to create a dependency on the part of the victim partner on the controlling individual, who utilizes these behaviors. (see Figure 1)

Figure 1. Duluth Wheel Model: Power and Control

Using the theory that violence is a learned behavior, the Duluth Model offers non-controlling behaviors in each of the eight areas and urges batterers to exercise the non-controlling options instead of violence and abuse. (see Figure 2)

Figure 2. Duluth Wheel Model: Equality

All the behaviors listed inside the wheel are non-physical and not criminal acts though they are abusive in nature. It appears that individuals who don't feel they truly have control over their partners with these actions, then move out to the rim of the wheel, where physical and sexual assaults are listed.

Some batterers achieve their desired results by using only a few of the behaviors, and may rarely if ever use physical violence. Others increase the frequency and severity of the violence after the first incidents and may run the gamut from verbal abuse to frequent sexual assaults.

It appears that the batterer must use some key tactics to maintain the control of his partner at the desired level. When refusing to accept responsibility for his own actions, he must convince the victim that he is really reacting to her actions. She "pushes his buttons" or "gets in his face" and must be punished for doing so. By blaming her, minimizing the violence and denying accountability for it, she becomes the guilty party and must try harder to please and satisfy him.

The eight areas of controlling behavior, and their opposite non-controlling options are:

1. Intimidation versus Non-threatening Behavior;

Looks, actions, gestures to frighten, breaking things, displaying weapons, abusing pets,

Talking and acting so that all in the family feel safe to express themselves.

2. Emotional Abuse versus Respect;

Putting her down, name calling, mind games, humiliating her, making her feel guilty,

Listening to her non-judgmentally, affirming her, valuing her opinions;

3. Isolation versus Trust and Support;

Controlling what she does, where she goes, whom she sees, being jealous, possessive,

Supporting her goals, respecting her feelings, her rights, friends, activities;

4. Minimizing, Denying, Blaming versus Honesty, Accountability

Making light of the abuse, shifting responsibility for abusive acts, saying she caused it;

Accepting responsibility, acknowledging past use of violence, admitting wrong, communicating truthfully;

5. Using Children versus Responsible Parenting;

Having them relay hostile messages, manipulating them, threatening to take them away, or hurt them;

Sharing decisions about the children, being a non-violent, positive role model for them;

6. Using Male Privilege versus Shared Responsibility;

Treating her like a servant, making all decisions, being the boss, defining everyone's roles;

Mutually agreeing on fair distribution of work, making decisions together, supporting each other;

7. Using Economic Abuse versus Economic Partnership;

Preventing her from work or forcing her to work, making her ask for money, taking her money,

Making money decisions together, sharing information, allowing both partners to benefit equally;

8. Coercion and Threats versus Negotiation and Fairness;

Threatening to hurt her, leave, commit suicide, report her to social services, making her drop charges,

Resolving conflict fairly, accepting change, being willing to compromise.

NOTE: Remember, the personal pronouns are interchangeable; males are victims, too.

Cycle of Violence

Dr. Lenore Walker, in her book The Battered Woman describes a cyclical theory for domestic violence. She states that violent behavior increases in severity as the relationship matures. She identifies three separate stages in violent relationships. (see Figure 3)

Figure 3. Cycle of Violence

Phase I - Tension Building; This phase is made up of many minor incidents of abuse that, over time, increase in severity. Tension builds in the home and everyone present is affected by it. The time frame varies from situation to situation. There is much arguing, blaming and anger, which accelerates to the second, more violent stage.

Phase II - Acute Battering Incidents; This phase is made up of explosive, uncontrollable rage and the batterer may hit, slap, kick, choke, or use an object or weapon against the partner. The incident can last minutes, hours, sometimes even days. Severe physical injury, even death, may occur. The batterer will often minimize, rationalize or deny the behavior even when faced with the results. After the attack is over, there is shock, denial and disbelief, felt by the batterer and sometimes, the victim, also.

Phase III - Remorseful, Contrite Stage; Sometimes called the "Honeymoon" period, the batterer will exhibit kind, loving behavior, and even beg forgiveness. He may bring her flowers, or gifts or take her places (when the injuries heal!) and promise that "it will never happen again". The batterer will go to any lengths to restore the status quo, sometimes promising to go to a counselor, although that does not often happen. Some abusers will actually attend a few sessions, but usually do not stay with the process. The batterer may believe he will not repeat the violence, because she has "learned her lesson" and he will remain in control.

This calm respite does not last. Tension again begins to build and the cycle repeats itself. Over time, there is less and less of the calm period, and more turbulence in the home. Some survivors disclose that the honeymoon phase stopped occurring at all. Other victims describe only the first two phases and have never experienced the calm period. Recent research shows that one or more of the phases may occur at any time, and that there is little or no predictability in violent relationships.

Assessment, Treatment and Education of Batterers

In communities where preferred arrest (or mandatory arrest) is the procedure, many judges order the batterer to be assessed for his (or her) potential to continue the violent behavior, and based on the results of that assessment, order the individual to enroll in a program to learn how to change the behavior.

The assessment process is fairly complex, and may include psychological scales, (Beck Depression Index and the Conflict Tactics Scale are examples of scales used), substance abuse evaluations, and where indicated, up-to-date information from a mental health practitioner on the individual's current status. The accompanying assessment interview covers the history in the family of origin, information about the individual's childhood, school experiences, use of weapons, employment and military history, past use of violence and arrest record.

Current family structure is described: ages, gender of children, any other relatives or individuals in the home. The batterer is required to describe his interaction with all others discussed.

Information is also gathered about the physiological history of the batterer: head injuries, chronic illness, current medications taken, hospital stays, etc. As substance abuse is encountered fairly frequently, the assessment process includes a section about past and current use, rehabilitation or detoxification stays, driving under the influence of alcohol (DUI) or other drug-related criminal activity.

Then the individual's current relationship, as well as previous relationships are explored, with special attention to violent incidents, use or display of weapons, and other key items. In one assessment process widely used, all eight areas of the Duluth Power and Control Model are explored, to determine the batterer's attitudes and expectations, as well as his behavior with the intimate partner.

The batterer is asked to recount his or her memory of the incident which resulted in the arrest. These data are compared to police reports, protective order narratives or other documents available. Discrepancies are questioned and explored.

Programs are instructed whenever possible to contact the victim(s) named in the incident to determine their safety and offer services, as well as to verify some of the information given in the assessment. After all the data are gathered, a recommended level of education and/or treatment is agreed upon, and communicated to the referring agent (Court Clerk, Probation Officer, etc).

Many individuals who assess batterers agree that there are widely varying levels of abusive behavior and referrals should be made according to these variants. Some research supports the recommendation that substance abuse issues and mental health conditions should be dealt with separately from treatment and education about battering and programs may refer according to the various issues to be addressed.

Florida State Batterers' Program Standards now require a 26-week intervention program although it may be that some abusers could be served in a shorter program and additional services might not be necessary.

An individual with no prior criminal violence record, little evidence of power and control in intimate relationships, no witnessing of violence in childhood, little evidence of drug or alcohol use, who presents shock and remorse over his/her involvement in violence, but who may disclose issues with anger or impulsivity might be served in the shorter program.

The largest group of batterers referred for assessment falls in the middle range, and may have a prior arrest record, violent family history, substance abuse issues, significant use of power and control in the intimate relationship, and may disclose use of abuse and violence in prior relationships. Many communities require these individuals to go to a psychoeducational program lasting six months, and using The Duluth (or similar) curriculum.

At the other end of the behavior spectrum, the individual who has an arrest record including other violent charges, who appears to use violence outside the home as well as inside it, who has used weapons, injured someone severely, discloses mental or emotional health issues, severe substance abuse, perhaps a learning disability, hearing impairment, language barrier or any combination of these variants is referred to special programming, and may be thought inappropriate for a classroom setting/program.

There is little formal research available on recidivism or other factors which might indicate how successful these programs are in assisting batterers to change behavior. National data indicate a recidivism/re-assault rate of about 50% Some workers in domestic violence feel that battering, similar to drug and alcohol use, can never be "cured", but will require continuing commitment to refrain from its use.

While it has been noted that physical violence lessens during attendance at a mandated program, there is some evidence from victims showing an increase of other forms of abuse: verbal, psychological, etc. with a marked increase in the victim's fear and anxiety that the violence will reoccur.⁽¹⁸⁾

Victims Needs and Services

Programs which deal with batterers and their use of violent behavior must also be concerned with the safety of the victim. Many work closely with the nearest domestic violence center to offer victims support, safety planning, programs for their children, and other needed assistance.

Attempts to reach the victim are often difficult and often unsuccessful. Mail is returned "moved - no forwarding address", or later contact with victims reveals they never received the letter. (Batterers often intercept their partners' mail; some go so far as to enter a change of address for the partner without her knowledge, routing her mail to a post office box.) Some destroy anything with a return address they don't recognize (or, if it's a domestic violence center, and they do recognize the name).

Victims are often threatened if they respond to anyone -e.g. attorneys, police, and advocates. Because there is financial strain on the family, paying the program fees, court costs, victims are made to feel guilty and further abuse often takes place. Children are denied things they want or need and are told "it's all your mother's fault!" creating further dissension in the family.

If the arrest and subsequent actions have interfered with the batterer's employment, other family members (his and hers) may vocally blame and abuse the victim for causing this distress.

Advocates attempting to serve the victim must be aware of these factors, and couch their offers to help and provide information in ways that reduce the distress the victim is already experiencing.

Often, in offering information about a program, such as what will be covered, how the program works, what things to look for as positive or negative signs, will open avenues of communication, and the victim advocate can pursue other goals as well.

Assuring the victim that all discussion is confidential and no one will know what she has said, helps, as does listening to her non-judgmentally. Believing her often goes a long way to reassure her of the advocate's genuine concern for her and her children.

Letting her know that she is not the only person with these experiences, and that others have sought and received assistance in many areas is a good tactic.

Reassuring her that she is not responsible for his choice of behavior, and that the behavior is criminal and harmful to her and her children can often lead to the victim reaching out for more information and more contact.

All who work with victims must recognize that denial by victims is normal, and will abate as the victim gains more information and validation. Also recognizing that victims want the violence to stop, but may not want the relationship to end is vital.

Emphasizing the things she can do to make her safety plan, and keep herself and the children from being hurt again is important. Listing some of the referrals for practical assistance: financial, shelter, medical care, child care, employment, legal advocacy, and emotional support may also help her reach out.

Many women who will not initially consider a shelter might readily agree to attend a victims' support group at a church or outreach center. Often hearing other women describe their experiences is the single most effective factor in a victim's decision to take control of her own situation.

Why Victims Stay in Abusive Relationships

Leaving a violent relationship is an act of courage that few understand, particularly in the justice system. The reality is that leaving is a process involving many factors rather than a simple physical act. There is an overriding terror that worse will happen when she tries to leave, and it is a valid fear: the risk of severe injury and death increases dramatically when a victim leaves the batterer.

The children's security, the financial cost, the issue of where to go, when and how to go, all enter in to the process. Many victims have no access to transportation or family finances and assets and must plan very carefully to surmount these obstacles.

Often, if the batterer senses any loss of control from any sign the victim gives him, he may accelerate the control and violence and make it even more difficult for her. The timing of such an action is critical. Should she get a protective order? When will it be served? Where can she and the children go for safety? Will he carry out threats he has made against her family members? How can she protect them?

Sensing his loss of control, he may successfully manipulate her with romantic actions, gifts, promises to change, go to counseling (usually, with her) or say other things which may lull her into believing him. He has usually had much practice and success with the manipulative behavior and she will learn all too often that this is one more example of control and abuse.

Victims With Special Needs

1. Victims Living in Rural Areas or Small Towns:

While isolation is a common tactic batterers use to control their victims, the isolation of a victim living on a farm or in a small town miles away from any populous urban area often presents overwhelming barriers to a victim of domestic violence. Consider these issues:

limited access to family vehicles,
roads that are often impassable in rural areas,
phone service that may often be inadequate,
emergency response that is coming from a distance,
emergency response that is operated by volunteers who are often friends, neighbors, relatives,
seasonal work which places batterer in the home for long periods of time,
limited contact with anyone outside the home, including medical care providers,
bruises and gashes will heal before anyone else sees them,
nature of farmwork provides ready excuses for any injury,
lack of, or at best, inadequate public transportation,
fear, distrust of, or lack of knowledge of, any of the services available in the nearest large city,
emotional ties to and responsibilities for the farm as a family business,
distance to be traveled even to reach basic services like protective orders, crisis shelter.

States with large rural areas must be made aware of the critical need to provide services to domestic violence victims residing on the farms and in the small towns within their borders. With the advances in communications technology, and the existing network of state agricultural cooperative extension services, better training and awareness could produce innovative methods of reaching out to these victims with effective safety planning and service.

2. Dating Violence Victims (Teens and Adults)

One study shows that one of every three girls will experience violence from a boyfriend before reaching adulthood. A resource center in Iowa working with less than five-hundred young females learned that 60% of them were involved in an ongoing abusive relationship.

Lawmakers have been slow to enact strong legislation responding to this issue in part because of the difficulty in defining a "dating relationship". Most advocates agree that a definition using the terms of unmarried, without children, but intimately involved in an ongoing relationship involving some degree of commitment between partners (courtship, engagement, etc.) should suffice.

Dating violence is similar to marital violence in the context of the utilization of power and control to dominate and control the partner, using violence to reinforce that control.

There are however, two significant differences:

Lack of financial, property and custody issues so there are no legal connections between the parties involved
An apparent lack of social stigma attached to violence between dating partners, and an apparent distance from the current level of increasing awareness of the criminality of battering behavior.

Young batterers disclose that physical violence is used against their partners to intimidate them into giving in to their demands, unlike older batterers who often blame their behavior on other things they have no "control" over, like alcohol, drugs, or stress.

Educators in many parts of the country have been hesitant to address the issues of violence in dating relationships with any formal curriculum. Both educators and lawmakers need to address the problem aggressively, effectively and responsibly.

3. Elderly Victims

Several key factors emerge when examining the population of elderly victims of domestic violence. Often, abuse of the elderly is compared to child abuse; victims in this age group are almost invisible in the movement to aid battering victims. Marketing and educational materials almost always feature photos and profiles of much younger people, with their needs and circumstances prominently displayed.

A larger number of men in this age group are battered in their own homes than men of any other age level. Many programs do not offer full services to male victims and community services that are present tend to be limited to medical and protective action, rather than empowerment. This philosophy ignores the fact that most elderly men and women are competent to make their own decisions.

The statutory remedies to violence against the elderly in their own homes need to be broad enough to include other family members (adult children and grandchildren, for instance) in addition to spouses as perpetrators. This requires a recognition by service providers that not all abuse is based on power and control over the victim, but may occur for other reasons: caregiver stress, limited capacity or medical condition which limits the abuser's capacity to understand the consequences of his/her abusive behavior.

Men and women who are battered by caregivers can and often do benefit from crisis hotlines, support groups, legal advocacy, safety planning and peer counseling, which are all traditional and effective remedies offered by most domestic violence programs. These programs need to review their materials and information packages so as to be sensitive and responsive to older victims, and they need to collaborate with other service providers in the community who offer services to seniors.

More training is needed for domestic violence professionals in ensuring that facilities are accessible and work for victims with health/medical needs and/or disabilities. Staff members need to know how to respond sensitively to the older victim's feelings and fears about aging, death and infirmity; they also need to recognize their own concerns with the issues of aging.

Domestic violence programs also need to share their knowledge and experience with others who serve the elderly but who do not understand the dynamics and issues involved.

4. Victims With Disabilities

Battering victims who are disabled often find themselves isolated not only by a violent partner but by their own peers who do not trust the able community to understand or intervene effectively. They are sometimes frustrated when reaching out for help, by programs whose facilities are not easily accessible and staff members who are insensitive to their needs.

Outreach efforts need to be strengthened and expanded for this victim group which is especially vulnerable to the batterer as that individual has even greater ability to cut off communication from outside the home and control physical movement.

Some programs are using specially trained volunteers from the ranks of letter carriers and utility workers who are able to approach the home without attracting undue attention from the batterer. If this approach proves to be effective without placing the victim in further danger, it offers possibilities for expansion.

5. Immigrant (and Undocumented) Victims

The impact of isolation is even more severe for immigrant victims of battering who may encounter language barriers, live under the constant threat of deportation and/or loss of children and who may be unable to reach out to anyone for help. Rarely are police, social agency workers, medical care providers, or the courts able to interact effectively with immigrants unless they are assisted individually by others in their own cultural group.

Most have no money of their own and depend solely on the batterer for everything. Without knowledge of the language, customs, or money of this country, they are unlikely to press charges against their sole means of support and communication.

Many victims come from cultures where spouse abuse is socially accepted and goes unchallenged, so they often do not understand they have rights and could be protected.

6. Gay and Lesbian Victims

Battered lesbians are thought to be the most under-served female victim population in the country. Few resources are available where victims would not also be victimized by homophobia. They are further hampered in reaching out for help by the Lesbian community which in many areas is still in denial about both the severity of the problem and the sincerity of anyone attempting to help outside the community itself.

Service providers must learn to discard two of the prevailing myths about lesbian abuse: that it is usually mutual, and that it is not as violent as male-to-female battering. Studies show that the battering is almost never mutual and can be as severe as when men batter women.

Within the gay community, domestic violence has been identified as the third leading health problem affecting gay men.⁽¹⁹⁾

It is believed by those who research this field, that the prevalence of violence in gay/lesbian relationships occurs at much the same rate as in heterosexual couples.

Profiled here are only some of those victim groups whose needs are not widely recognized and met. Others who present the same basic needs to be safe and accorded opportunities to explore their options and ways to become empowered are battered women in prison, battered women of color, pregnant battered women and prostitutes.

Domestic violence center staff and their colleagues in other agencies need to increase their awareness of and services to these individuals in support of their rights to live in peace and safety in their own homes.

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Section IV. Effects of Domestic Violence on Children

Who Will Talk For Us?

(From the Words of Crickett, a 10-year old)

She looked up at me with round dark eyes,

Her long hair neatly pulled into a french braid,

"Who will talk for us?"

"Somebody has to talk for the kids, 'cause we don't always know the words to tell our pain.

So...tell them...Watch for our signals...

Are we scared?

Are we shy?

Are we always acting bad?

Do we hurt inside and out?

Are our screams coming out in our dreams?

Can we pay attention to what you are saying?

Or are we spacing out?

Are we too active?

Or don't we play enough?

Are we always hanging around you?

Or do we push you away too much?

Ask us questions, let us know that we are not alone,

If you think we are lying just to cover up,

Then ask someone who will know.

We need your help.

We just need your understanding.

Just always remember, we are kids!

We are doing the best we can."

She paused, flung the braid over her shoulder and said, "Talk for us - just make sure they listen. Grownups have a hard time with that."

Woman Abuse-Child Abuse, Summary of Study Data

Over three million children (3.3 million) in the US, between the ages of 3 and 17 years are at risk of exposure to domestic violence each year. When children witness their mothers being abused by a male partner (father, stepfather, boyfriend), they are affected in many ways. According to one study, 40% suffer anxiety, 60% act out with siblings, 53% act out with parents, and 48% suffer from depression. These children also experience poor health, low self-esteem, poor impulse control, sleeping difficulties and feelings of powerlessness.⁽²⁰⁾ ("Figure 4. Children Coping with Family Violence" highlights the negative impact that domestic violence has upon children.)

Figure 4. Children Coping with Family Violence

They also become the victims of physical violence themselves. According to Straus & Gelles, in Physical Violence in American Families, 1990, these children experience a 300% increase in physical abuse by their mother's batterer.⁽²¹⁾

Maria Roy, writing in Children In The Crossfire, 1988, states that 62% of sons over age 14, were injured when trying to protect their mothers from physical violence. Roy also points out that children are injured by thrown objects (furniture, etc) during the violent episode, and the youngest children suffer the most severe injuries: concussions, broken bones, etc.

According to research conducted by Jean Giles-Sims, child abuse, whether done by father or mother, is likely to diminish once the battered woman is able to access services and separate from the violent male.⁽²²⁾

Most of the battered women who seek shelter, bring children. One study showed that 72% of the women residents in shelters brought children with them; 21% brought three or more children. Most shelter programs cite a census of 2/3 children under 17 years of age, and structure their services with this in mind.⁽²³⁾

It is imperative that domestic violence programs recognize these children and design programs to meet their very special needs.

Do The Children Know?

Both batterers and their victims often deny that their children are present during any of the violent incidents. Many insist the violence has never taken place where children could see it.

Interviews with children indicate most of them are aware of much of what has occurred. Even if not in the same room, they can reconstruct the sequence of events accurately from what was heard or seen later. One study shows that 90% of the children in homes where violence occurs can describe in detail what happens.

Loud voices, cursing, screaming, threats, the victim crying, and then the sounds of fists hitting flesh, glass breaking, wood splintering, pictures falling off the walls, do not have to be witnessed to be recognized.

When the incident is ended, children see the torn clothing, the bruises, cuts, blood, the holes in the wall, broken furniture, broken dishes, other graphic evidence that something bad has happened. They see mom's tension and preoccupation, and they fear what might come next.⁽²⁴⁾

Children often tell clinicians of being afraid to stay in the house during the violence, but being terrified to leave, for fear they will never see mom or dad again. Many have been interviewed by police officers after a violent incident. Some tell of having called the police themselves, and wanting the violence to stop; this does not always mean they want the batterer to be taken away.

Some children recount incidents where they kept younger siblings hidden away during the incident, or took them to a neighbor's or relative's home. Many children tell of things they did to try to prevent the incident, or stop it from escalating once it started. They also speak of being angry, frustrated and powerless as well as afraid, when nothing they do changes the situation or stops the violence.

The Empty Seat At School

Moving to escape domestic violence disrupts children's lives in many ways. They lose school time. Often, they are forced to leave home with little more than the clothes they are wearing, leaving books and other school materials behind. If shelter is not available, they may be living in the family car, without changes of clothing or money for food and other essentials.

Since school records are not protected by law, batterers use these records to find the victim and often, to kidnap the children. Many children are kept out of school for security reasons.

Children moving to a new school district may not be able to enroll in school without birth certificates, immunization records and other documents the victim had to leave behind when forced to flee the batterer. Sometimes, batterers destroy these documents as a further means to control the family.

Children, already frightened and confused at being in unfamiliar surroundings among strangers, may also be angry at the victim parent, for making them leave friends, playmates, and activities they enjoyed.

How Children Feel About The Violence At Home

Powerless because they can't stop the violence,
Guilty, believing they caused it,
Angry at the victim parent who is at fault, (the batterer says so),
Angry at the battering parent for hurting the victim,
Helpless, feeling they need to solve the problem, and getting hurt when they try to help,
Confused when the adults try to get them to take sides,
Afraid for themselves and everyone in the family,
Isolated and insecure, making excuses so they don't have to go home, unwilling to bring friends home,
Dishonest, embarrassed and guilty for making up excuses for victim parent's injuries and bruises,
Overwhelmed by a situation from which they see no escape.

Understanding Why The Victim Parent Stays

Even when there is violence, and there are bad, frightening experiences, there are also loving and good times.

Religious lessons teach that families should stay together; often other family members say this, too.

The victim needs to be a better person; the batterer is only punishing bad behavior and the victim needs to try harder.

The victim and the children are often isolated from family, friends and neighbors, because the batterer has told them they need no one else.

The victim is afraid; the batterer will find them if they try to leave. They won't have any money if they leave. The children may lose contact with the victim because the batterer has money to get a better attorney and may get custody.

It is dangerous to leave. Evan Stark and Anne Flitcraft pointed out in 1988 that as many as 75% of the visits to emergency rooms by battered women occur after they left a violent partner.⁽²⁵⁾

Children hear some of the same myths and untruths about battering that adult victims do. They also hear adults telling them "it's not so bad...everything is going to be all right". But everything they have experienced tells them it is bad and everything is not all right.⁽²⁶⁾

Battering victims are often penalized by child protective service professionals who cite them for "failure to protect", and remove the children from the victim's custody. In reality, many battered women try to be good parents despite their own terror, depression, and the injuries they receive. Many leave the violent relationship for the sake of their children.

At the same time, many often return for the sake of the children; homeless, they are no longer able to provide for their children and fear losing custody of them. It is always the responsibility of the batterer to stop the behavior; it endangers not only the adult victim but the children as well.

Children Caught In The Middle

Unfortunately, the impact of domestic violence on children does not end when the adult relationship ends. Often this is the start of a new reign of controlling, abusive and violent behavior. The battering parent may use the children as pawns in a custody dispute to force the victim to reconcile and discontinue any legal activity (divorce, protective orders, etc.).⁽²⁸⁾

Convictions for domestic violence crimes are to be considered when family court judges make decisions regarding the custody of minor children but often are not. Batterers frequently collude with their attorneys to delay legal process, postpone hearings, and engage in other stalling practices for the purpose of depleting the victim's funds and other resources and convincing the victim of the futility of further opposition.

Often, an award of joint custody results in much lower child support awards and the residential custodian faces a real financial burden raising the children.

More than 50% of the child abductions result from domestic violence. Most of these abductions are perpetrated by fathers or their agents. Access to children during visitation is a tool often used by batterers to terrorize victims and punish and retaliate for separation. Annually, more than 350,000 children are abducted by parents. Of these abductions, 54% are short-term manipulation around custody orders, 46% involve hiding the child or taking the child out of state. Abduction causes mild to severe mental harm in three out of ten subjected to it.⁽²⁹⁾

Visitation often results in ongoing manipulation of the child used as spy, messenger or ally of the batterer against the victim and causes much pain and ongoing distress to the children, as well as the victim.

How Do We Help The Children?

It is of paramount importance to provide for and ensure the safety and protection of victims and children who witness domestic violence. To achieve this end, it may be necessary to separate the parents until the batterer has successfully completed a mandatory intervention program.

Shelters with specially trained children's case workers to lead support groups for them as well as the adult victims can do much to help children deal with the trauma of domestic violence. If crisis shelter is unnecessary, outreach programs which offer children's support and therapy activities must be available, preferably adjacent to public transportation.

Close collaboration between domestic violence workers, court-appointed guardians, child protection teams, educators, advocates, medical and mental health professionals and the custodial victim parent must exist to promote the sound health and development of children caught in domestic violence. However, the impact of domestic violence may affect a child differently, depending upon their age. (see Figure 5)

Figure 5. Changing Needs of Growing Children

Medical professionals have a particularly important role; when informed about domestic violence, they will know to examine and assess the child for abuse and neglect if they have identified the parent as a victim in a violent relationship.

Communities can help by supporting and expanding programs to help and protect children. Visitation centers which are safely located and monitored can be established to allow the batterer time and space to visit the children while he or she is involved in intervention treatment, without causing either the children or the victim parent fear for their safety.

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Section V. Health Care Response to Domestic Violence

How the Health Care Provider Can Help

Nurses, physicians and clinicians who accept the challenge and responsibility of caring for abuse victims must recognize domestic violence as a major health care problem, understand the power and control issues which drive partner abuse, accept the victims' choices non-judgmentally, and support the empowerment of battered victims.

The nursing assessment should always include the consideration of domestic violence, regardless of the chief presenting complaint. When taking the initial history, several actions suggest battering and abuse as a possibility. How does the patient interact with his or her partner if the partner is present? What is the partner's behavior? What is the patient's affect, style of communicating, and finally what is the medical history given?

Is the partner reluctant to leave the patient's side? Does the patient "flinch" when partner speaks? Does the partner answer for the patient? Watch facial expression, vocal inflection and body language for clues to the patient's emotional condition. Are the patient's responses inappropriate (giggling, for instance) or is the patient giving weak clues like stating, "I've had a bad time lately"?

Is the medical history as given inconsistent with injuries or complaints? Are there old injuries in various stages of healing? Are there complaints of insomnia, nightmares, inability to cope, or anxiety? Are any of the injuries consistent with sexual assault?

When the nurse is ready to pursue the source of injuries or problems, the patient must be in a secure, private environment, where no one can overhear her responses. If the partner refuses to leave, follow the protocols in place at the health care setting, including summoning security or others to assist in examining and interviewing the patient alone.

The health care professional must maintain a positive, supportive attitude: caring, objective, and accepting. Teaching may be a prominent part of the interaction, as many victims, particularly those with a long history of abuse, may not recognize the violence as abusive and criminal, as well as undeserved.

Nurses and other health professionals should:

Assess all females for current, past or family history of battering
Educate patients about the cycle of violence and the impact of violence on children. They are accountable to victims by giving referrals in the community, as well as providing follow up care and advocacy
Document, in detail, in the medical record, the physical condition of the patient, as well as the measures taken to treat
Validate the magnitude of the problem with research as opportunities arise
Interact with other disciplines in the community to provide primary, secondary and tertiary prevention of violence against victims

The six steps that the healthcare professional should follow when assisting patients who are the victims of domestic violence are:

ASSIST: (Six steps to assist patients with domestic violence)

ASK about domestic violence.
SEND messages of support.
SAFETY assessment and planning is done.
INFORM patients of their options with referrals.
SUPPORTIVE documentation is provided.
TELL other health care providers.

Have you used your RADAR?

Remember to ask about abuse routinely.

Ask directly, and kindly, as well as non-judgmentally.

Document your findings.

Assess for patient's safety.

Review options and

Referrals with patient.

Guiding Principles for Medical Professionals

The Florida Coalition Against Domestic Violence (FCADV) published the following five principles for health care professionals in its' comprehensive Health Care Training Manual presented in 1995.

1. Regard the safety of victims and their children as a priority.

2. Respect the integrity and authority of each battered woman over her own life choices.

3. Hold perpetrators responsible for the abuse and for stopping it.

4. Advocate on behalf of victims of domestic violence and their children.

5. Acknowledge the need to make changes in the health care system to improve the health care response to domestic violence.

Important Questions to Ask

Is anyone in your family hitting you?
Has anyone ever hit you while you were pregnant?
Have you ever received medical treatment for any abuse injuries?
Can you mark on the body map where he hit you the last time he hurt you?
Does your partner ever threaten you?
Does your partner prevent you from leaving the house, from getting a job or returning to school?
What happens when your partner doesn't get what he wants?
What happens when you disagree with your partner?
Does your partner destroy things you care about: family photos, your clothes, hurt your pets?
Are you forced to have sex when you're not feeling well, or do sexual things you don't want to do?
Do you have to have sex after a fight to "make up"?
Does your partner watch you all the time? Call home frequently? Accuse you of "coming on" to everyone?
Do you know where to go or who could help you if you were abused?
Some patients say they had an argument, then later say they were beaten. Has this happened to you? Are you being beaten?

Red Flags of Battering

Behavioral: Change in appointment pattern; multiple visits for vague complaints, or multiple missed appointments; frequent walk-ins or emergency room visits; patient can't be contacted at home; doesn't take medication as directed.
Past History: States history of child abuse; history of previous emotionally or physically abusive relationships.
Illness: Chronic pain (headache, pelvic pain, abdominal pain, irritable bowel); Gynecologic problems such as recurrent STD's, low birth weight deliveries, etc; Depression, other stress-related symptoms.
Injury: Delay seeking care for injuries, minimizing injuries.
Pattern of Injury: Primarily central region: face with fractures, hematoma, lacerations around eyes, lips, perforated tympanic membrane; chest: breast injuries, broken ribs; abdomen and genital injuries. Old injuries or bruises in various stages of healing. Bites, burns, injury to a pregnant woman, especially to the abdomen. Recurrent minor trauma.
Psycho-social: Suicide attempts, alcoholism, substance abuse, low self-esteem.

Clinical Warning Signs

General Appearance: Increased anxiety, fatigue, flinching on touch, overweight, underweight, hypertensive, flat affect, depression, anxiety, fear, suicidal ideation, low self-esteem.

Any Injury or Multiple Injuries: Presentation of medically insignificant trauma may be a sign that abuse is pending or that fear and anxiety related to abuse are affecting health.

Skin: Burns, bruises or old healed scars.

Head: Decreased hearing from multiple blows, subdural hematomas, headaches.

Eyes: Swelling, subconjunctival hemorrhage, detached retina.

Gastrointestinal: Non-ulcer dyspepsia, irritable bowel syndrome, globus.

Genital/urinary: Bruises, tenderness, dyspareunia, recurrent vaginitis, vague pelvic pain, miscarriage, preterm labor, low birth weight delivery, rape, sexual assault.

Rectal: Bleeding, edema, irritation.

Musculoskeletal: Fractures, (especially facial, radius, ulna, ribs, shoulder dislocation), limited motion, old fractures, chronic pain, primary fibromyalgia.

Battering and Pregnancy

Physical abuse during pregnancy can be dangerous to the health of the mother and her infant. It can cause miscarriages, still birth, low-birth weight and pre-term deliveries. Direct blows to the pregnant abdomen, injuries to the breast and genitals, and sexual assault are some of the ways pregnant women are abused.

Women abused during pregnancy are at increased risk for poor weight gain during pregnancy, selected infections, first or second trimester bleeding, anemia, smoking and using alcohol, and are twice as likely not to begin prenatal care until the third trimester.

In a study done by The March of Dimes, it was discovered that battering often starts or worsens during pregnancy. Also, 25-45% of all battered women are battered during pregnancy. Men who batter pregnant women are three times more violent outside the home. Battering during pregnancy may be an indication of what life holds in store for the unborn child. Women battered during pregnancy are more likely to seek health care for injuries than women battered before pregnancy.⁽³⁰⁾

Telling an abused pregnant woman that she has the right to live in peace may one day save her life as well as her baby's life. Gently informing her about the risks to her baby may help her make an informed decision about her next moves. Providing her with information about available community resources can help, along with information about accessing those resources. She may have been isolated throughout the pregnancy and be unaware of shelters, hot lines, financial support and legal services. Give her the telephone numbers and contact information for future reference.

How to Assess a Battered Woman

Talk to her in a private place, away from her partner. If her children are with her, find a staff member to stay with them if possible. Approach the topic of domestic violence as you would any other health risk. If the patient becomes upset or denies abuse, simply explain that all patients are screened for domestic violence, and that health care professionals are gravely concerned about the danger to women.

A victim will choose when she wishes to share the history of abuse, but failing to do so does not mean she is not listening and paying attention to the information. Describing the dynamics of power and control, the cycle of violence and other factors may help her evaluate her own situation more objectively. You may be the first person, particularly the first professional to acknowledge her problems. Often that factor alone helps the victim patient see that she is not in fact, alone in this experience and that there is help available.

The Victim Acknowledges the Abuse

When the patient discloses that she is being battered, ask her if she would like to stay in a private area for a while. If her partner is waiting for her, ask if she feels safe now. Create a supportive atmosphere so she can discuss her feelings. Inform her about any reports that need to be filed (police, child protective services, etc.). Acknowledge the danger and injustice of her situation. Let her know she is not at fault and that you are glad she has confided in you.

She has several options including immediate transport to a shelter, shelter information for a later date, returning to the partner after getting a follow-up appointment to return to the health care setting, or waiting for the police to file a report for visible injuries.

Teach her the signs of escalating physical danger, particularly access by the partner to weapons, threats he has made, and others. Most victims are acutely aware of the signs a partner sends of escalating violence.

Give her information about a protective order, and any other resources available in the community for her immediate protection and the protection of her children, as well as the domestic violence shelter.

Batterer's Lethality

There is no absolute method of predicting lethal behavior but experience has taught that past assailant behaviors are, when clustered, accurate predictors of danger. These include, but are not limited to, threats and fantasies about homicide and suicide, along with a history of attempts. Also, depression and situational stress, like job loss, are a predictor of lethal behavior, combined with other factors. Possessing and using weapons, being obsessed about the partner, making statements such as "I can't live without her", and isolation with a complete dependency on the victim are all predictors of dangerous behaviour. Rage over any hint that the victim may leave, consuming alcohol or other drugs while furious or depressed and having ready access to the victim or stalking her after she has obtained a protective order are other dangerous signs.

If a victim discloses any of these behaviors by the partner, extraordinary measures should be taken to protect the victim and her children. These measures might include emergency transportation, and meticulous follow-up. The victim needs to be supported in any attempt she wishes to take to protect herself and health care professionals should contact the local domestic violence center for assistance with immediate safety planning for the victim.

Documentation

Well-documented, thorough medical records are essential for preventing further abuse. They can further provide crucial evidence in any legal action as they are generally considered the most credible evidence a victim's advocate can summon to assist her. Documentation should be detailed, in the patient's own words whenever possible, and should include a complete medical and social history. Description of injuries should be thorough and detailed, and recorded either on a body chart, or drawing, and if possible, amplified with photographs (in color) and/or imaging studies. Names of all medical and law enforcement personnel should be included.

Laboratory tests, x-rays and any other diagnostic procedures should be included, with their relevance to the abuse clearly explained.

For medical documentation to be properly admissible in court, health care professionals need to be prepared to testify that the records were made during the regular course of examination or interview, that they were made in accord with routinely followed procedures, and that they have been properly stored, and access limited to professional staff.

Basic Intervention Strategies

Interventions will vary from patient to patient depending on the assessment, the nature of the abuse, impact on and condition of the patient, as well as the patient's motivation and resources to deal with the presence of domestic violence in the patient's life. Once the abuse has been identified, there are some basic interventions which can be made in all domestic violence cases. These include: validating and naming the problem of domestic violence, assisting the patient in identifying abuse as a problem, listening to the patient's concerns, educating the patient about abuse and its connection to medical issues, as well as the dynamics such as power and control strategies employed by the batterer and the cycle of violence.

Of vital importance is the need to discuss options with the patient, help with safety planning, make appropriate referrals and establish some method of follow-up with the patient and her children.

Expressing concern about patient's safety, understanding how difficult it is for her to make changes that are necessary, and reassuring her that she is not alone are all appropriate actions to take. Reaffirming that the violence is not her fault is very important since the batterer routinely blames her for all his behaviors. Remind her that only the abuser can stop the battering and that it is a conscious choice he has made.

Finally, and emphatically state that no one deserves to be beaten and that there is no excuse for violence and that she and her children deserve peace and safety are very strong steps to take with the victim patient. Always remind the victim that there are options and resources available and that health care professionals are there to help her with access to them.

Child Abuse and Neglect

Children are affected by domestic violence at all ages from prenatal to adolescence, physically, developmentally, behaviorally and cognitively as well as emotionally and psychologically. Without intervention and treatment, the injury done to children carries on well into adulthood, often manifesting in a new generation of victims and batterers.

Newborn infants born to abused women often suffer poor health due to the abuse she received, the stress she suffered, and lack of proper nutrition and prenatal care. Later, these infants are subject to prolonged crying and irritability, sleep disturbances and digestive problems.

Toddlers and preschool children may be either more aggressive and violent than their peers, or more withdrawn than others. They demonstrate impaired cognitive abilities, delays in verbal development, poor motor abilities, general fearfulness and anxiety, stomach aches, nightmares, lack of bowel and bladder control over three years of age, and an extreme lack of confidence to begin new tasks.

School aged children may have poor grades or be place in special classes, may fail one or more grade levels, show poor social skills, and general aggressiveness with outbursts of anger. They have low self-esteem, may be excessively dependent, or be bullies. They also often have nightmares, and may experience bedwetting. Frequently, they complain of headaches (not related to eyestrain or sinus problems), and may experience digestive problems.

Teenagers may have poor grades, fail or even drop out of school. They often refuse to bring friends home or stay away from home. Some feel responsible for the victim parent's safety and may be injured trying to protect the victim of battering. Runaways are often from a violent home as are delinquents and pregnant teens. They too experience nightmares, anxiety, depression, ulcers and other digestive problems and headaches. Some are immature, withdrawn, have few friends, and cannot communicate their feelings.

Dating teens replicate the behaviors they have seen at home, with males hitting their girlfriends. Non-intimate violence by teens against others is rising at an alarming rate, and many of these young people were abused and saw abuse in their homes, between the adults.

Teens from violent homes are at greater risk for suicide and homicide, delinquency, sexual promiscuity and sexually transmitted diseases, and drug and alcohol abuse.

Children of all ages who live in violent homes need not only the safety and stability of a non-violent environment, but support, therapeutic intervention and education just as their victim parents do. Children tend to assume responsibility and feel blame for what is happening in the home. They are often injured attempting to intervene and protect the victim. Some are hit with objects thrown at the victim, and infants and toddlers are injured as they are held by the victim who is being battered.

Children presenting injuries in an emergency department may very well be sending clues to the health care professional that there is domestic violence in the home and need to be assessed as thoroughly and carefully as adult victims.

Mandatory Reporting of Domestic Violence

Presently, five states have statutes requiring that domestic violence be reported to either law enforcement or a social welfare agency. They are California, Kentucky, New Mexico, New Hampshire, and Mississippi. Rhode Island did not renew its Mandatory Reporting statute as no discernible improvement could be cited. Domestic violence professionals feel that the risks of such statutes far outweigh the benefits which were anticipated: greater awareness and prompt response to victims.

There is evidence to support that retaliation by the batterer is a risk which results in even greater danger to the victim and her children. It is also felt that such statutes will keep victims away from the health care system. Many batterers now forbid their victims to seek medical attention for injuries even where there is no risk of being "turned in".

Trust and security in the patient-provider relationship, with its veil of confidentiality is severely hampered under these statutes to the frustration of the caring medical professional who may have spent considerable time building a relationship with the victim patient where she felt safe and comfortable disclosing her experience.

Most health care professionals and domestic violence service providers feel that improved training, particularly in assessment and screening techniques is by far the safer and more effective way to serve victims of domestic violence. Many medical professionals are extremely uncomfortable being placed in the role of law enforcement on this issue.

Finally, unlike the vulnerable populations of children and elderly abuse victims, battered women are often extremely resourceful and reach out several times for assistance before finally leaving the batterer. The philosophy supporting their successful resumption of control over their lives and their futures rests in self-help, empowerment and advocacy as the most effective support in returning families to peace and stability. Advocates provide options, as do medical professionals, but do not make choices or take action for the victim. Each victim is encouraged to build on her own inner strength and design her own future action plan. In short she is encouraged to take control of her own actions and decisions and most victims are able to do so when they are safely away from the batterer.

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Section VI. Case Studies

Avis, Elderly Victim of Domestic Violence

Avis, a 75 year-old white female, slim, well-groomed with beautiful, snow-white hair, arrived at the walk-in clinic with her daughter-in-law. The daughter-in-law appeared very concerned about Avis' wellbeing and related the following incident to the admitting nurse who verified that Avis had never been to the clinic before. Rose, the daughter-in-law, states that she called earlier that morning and when Avis sounded as if she had been crying on the phone, she went over to her in-laws' home in a nearby upscale retirement community.

She found Avis sitting at the dining room table, staring at a number of medicine containers in apparent confusion and distress. Rose questioned the older woman and learned that Avis did not appear to remember what the prescriptions were for, nor recognize any of the doctors' names. Rose gathered all the containers in a bag and brought them with Avis to the clinic. She shared what she knew of Avis' history with the nurse.

Rose related that her in-laws had been married for almost fifty years; her husband was their youngest of four children with an older brother and two older sisters. He related a history of a domineering father who "ruled the roost" and a mother who was always "nervous". She did not recall hearing of any particular problems. The older couple had moved upon the husband's retirement to the lovely home they now occupied and Avis' husband was something of a neighborhood leader, organizing social and civic activities, and appeared well thought of by neighbors. He was known to express his views forcefully on occasion and to get angry if people did not immediately agree with him. Lately, Rose recalled, her father-in-law had complained about Avis' mood swings and physical complaints. He had even stated his concerns that she "couldn't keep up with him". He also on one occasion stated he thought he saw signs of Alzheimer's Disease in his wife's behavior.

Rose continued by saying she had never seen any such signs, that she found her mother-in-law to be warm, kind and interesting, and often felt even closer to Avis than her own mother. She did note that Avis was quiet and subdued when with her husband. She also commented that her husband's two sisters had both been divorced and since remarried. She could shed no light on the pill containers. She had heard her husband comment on his father's apparent care and concern, "always taking Mom back and forth to the doctor".

The admitting nurse recorded the medications Rose handed her, noting several different anti-depressants, two tranquilizers, and a sleeping medication. She also listed four separate doctors who had prescribed for Avis. One container was for a prescription for migraine headaches yet Rose stated she had never heard Avis complain of them.

Avis was taken to an examining room, her vital signs noted and assisted into a gown for examination by the staff physician. The nurse noticed several bruises on Avis' upper arms, in various colorations of healing, including some which appeared to be oval shaped finger marks. When asked about these marks, Avis stated "I'm not always steady on my feet and my husband holds me." She appeared distressed when relating this. As the nurse assisted Avis up on the examining table, she noted two large fresh bruises on the patient's right leg. When asked about those, Avis began to cry, quietly. "He gets so angry when I can't keep up with him". Further gentle questioning by the nurse brought forth a confession that the patient was confused and upset by her husband's behavior: sometimes loving and caring: "he always gives me my medication in the morning and at night, and leaves my doses out on the table while he's away"; sometimes angry and impatient: "this doctor isn't helping you - we'll see another one". She went on to say she thought her husband might be seeing another woman and that he had become more critical of Avis' appearance.

After a thorough examination by the physician, Rose was consulted and informed that her mother-in-law had been the victim of physical and emotional abuse. She supplied other information which appeared to corroborate this finding and agreed to call her husband to the clinic. Rose and her husband were informed that the clinic would have to inform the elder abuse hotline of the situation and that Avis had agreed to talk to a counselor at the local domestic violence center and a legal advocate based there, as well.

Rose and her husband agreed to take Avis into their home, and to return with her to the clinic for further examination, laboratory work and X-rays. Subsequent findings indicated no medically sound reason for the medications she had been prescribed, and they were all discontinued. Bob, Avis' son, informed his siblings of the situation and all appeared concerned and supportive of their mother's health and wellbeing.

Avis began attending a special support group for elderly victims of abuse by a spouse held at the domestic violence center and took courses at a local community college, making many new friends. She gained ten pounds and a much improved sense of self-esteem and confidence through her new experiences. She has talked of moving in with another woman friend who has just bought a condominium unit nearby, and although she has no plans to divorce her husband at this time, she has made it very clear that she will no longer live with him nor will she tolerate his behavior. When they meet at family gatherings he showers her with attention but she responds civilly but firmly that she will not return to her former life.

YoLin, Immigrant Victim of Domestic Violence

YoLin, a 46 year-old Vietnamese woman, moved here with her American GI husband, Thomas Sr., after the Vietnamese war. They brought her mother and brother over a short while later, and now live just a few miles away from her family. They have three children, daughters 16 and 6, and a son, Thomas, Jr., 8. Thomas Sr. has held the same job ever since returning from Vietnam, is a deacon in their church and serves on the school board. His family lives in a nearby city.

Thomas SR. has always criticized and controlled YoLin; the children tell of often hearing fights between their parents. Thomas Sr. has physically abused his wife on many occasions. When YoLin went to her family with her children after one bad episode when she was threatened with a knife during one of his drunken rages, they told her to try harder to please him since they all owed their lives to him.

The most recent physical violence brought YoLin to the hospital emergency room for treatment of a burn from a hot iron in the middle of her back. Thomas Sr. brought her for treatment but threatened her further if she disclosed how she was burned. Under gentle questioning from the examining nurse, she broke down and disclosed how she had been burned.

Thomas St., who had refused to leave her side, had been called away by another nurse who also served on the school board, so that the emergency room nurse could complete the interview.

After determining that YoLin had no safe place to go, the nurse contacted the domestic violence center who dispatched a volunteer to pick up the children at their home. YoLin also agreed that the police could be called. She called the children to explain that their father was getting help and that they would be brought to a safe place with her.

YoLin and the children stayed in the shelter. She was an excellent seamstress and found work quickly. The children were able to continue their school classes and also attended groups with other children in the shelter. YoLin obtained the services of a legal advocate through the shelter and filed for divorce. Thomas Sr., was ordered by the courts to be assessed for his violent behavior and ordered to attend a batterers' intervention program. He does have visitation rights to see his children. YoLin's family no longer speak to her, but entertain Thomas regularly, with his children.

She continues to attend support groups and programs at the shelter although she and the children no longer live there. They are saving money to buy their own mobile home. Thomas Jr. has been having problems and getting into fights at school but has since been transferred to an alternative school where he is able to gets more individualized help.

Elizabeth, Remarried Widow Victim of Domestic Violence

Elizabeth is a 56 year-old retired phone operator who has been widowed 8 years. She has one grown daughter who is currently going through a divorce. After a whirlwind romance, she has married Fred, a widower with a 13-year old daughter who now lives with them. Sandy, the 13 year-old, loves Elizabeth and is very supportive of her.

On their honeymoon, Fred insisted on being in control at all times, not letting Elizabeth out of his sight. He also insisted on handling all finances and ordered her to put all her money in their joint accounts and put his name on all her investments, as well. After nine months with him, she had her first experience with his violence. He pushed her down the stairs and she broke two ribs.

In the emergency room, Fred would not leave her side, and she told of "falling down the stairs". Finally, going in to X-ray, the nurse was able to question her quietly, and she still denied abuse. She did agree to take the phone number of the domestic violence shelter. The nurse wrote it inside her hospital wrist band, without any hyphen so it would look like a hospital case number. When Fred went to sleep that night, she called the shelter and talked to a crisis counselor. Sandy heard her on the phone and promised her help and support.

Fred was so controlling he had her call when she left to go grocery shopping, again when she got to the store, and immediately when returning home. He was always angry if she had taken too long. The shelter counselor helped her make safety plans and discuss how to escape. A counselor met her at the store, and did her shopping while Elizabeth went to a nearby bank and opened new accounts, moving her funds into them. They would repeat the process the following week, and Elizabeth was to go to her financial adviser. This time the plan did not work, Fred found out what was happening and there was another beating.

Sandy heard Elizabeth scream out a code word they had agreed upon and called the police on her cordless phone. This was part of the safety plan, as well. Fred had had business lines installed in the home so he would always have a record of all calls made from home, so Sandy had asked her grandmother for a cordless phone for her birthday. Police came and arrested Fred. Elizabeth went to the emergency room for stitches on her forehead. They stayed in the home that night but Elizabeth called the shelter and made arrangements for both herself and Sandy to attend support groups. Sandy moved to her grandmother's and Elizabeth got an apartment near her daughter. She filed for divorce and endured a long battle over her money. She ultimately lost about $100,000 of her life savings, and has since returned to work to build her retirement again. She and Sandy talk regularly by phone and Sandy relates that her father is attending a court-ordered counseling program which appears to be helping. Elizabeth attends church regularly and also attends a church-sponsored divorce recovery group.

Lisa, Pregnant Victim of Domestic Violence

Lisa is a 27 year-old woman, 15 weeks pregnant who arrived at a clinic complaining of spotting and severe cramping. While being examined, a nurse notes several scars and bruises on Lisa's arms, as well as two large bruises on her abdomen. Checking her clinic file, the nurse notes Lisa has been to the clinic at least four times prior to this visit, for injuries: a fractured left wrist sustained when she "fell down the apartment stairs", a possible concussion from a fall sustained while her boyfriend was "tickling her and she lost her balance", cuts on her arm, from "a glass broken in the kitchen sink", and burns on her eyes and face when bleach "splashed on her, while she and the boyfriend were at the laundromat". She states to the nurse that she is still living with this boyfriend, and that the baby is his. They have one other child, a 2-year old boy, who has also been seen at the clinic.

The nurse also notes that Lisa's weight is down 11 pounds from her last clinic visit, even though she is now pregnant. She is not taking any prenatal vitamins, and has not seen a doctor since she got pregnant. Careful questioning reveals a pattern of much physical abuse, a partner who drinks and abuses other drugs, and who attacks her frequently. She becomes alarmed when the nurse expresses concern for not only Lisa's safety but the safety and wellbeing of her unborn child. She agrees to talk to a domestic violence shelter worker and takes a small card with emergency numbers on it, at the conclusion of the examination. She agrees to return to the clinic the following week for a follow up exam.

She returns the next week and tells the nurse she is going to the shelter the next day, that she has talked to a worker about getting a protective order and that she now is beginning to understand that the boyfriend is not likely to change his behavior no matter how many times he promises to do so, without professional help. Lisa informs the nurse that she saw her own mother abused, and that she wants better than that for her own children who mean everything to her. She thanks the nurse for pointing out the danger to the baby she is carrying. "If you hadn't said that, I don't know if I'd have done anything. Thank you for listening -- and for asking in the first place. No one else ever did."

Karen, Teenage Victim of Domestic Violence

Karen is a 16-year old cheerleader, with excellent grades who visits the school nurse after complaining of nausea in one of her classes. The nurse pulls Karen's file after noting some startling changes in her appearance. Always popular and well-liked by teachers and classmates alike, Karen had always appeared perfectly groomed, neatly and stylishly dressed, nicely made up. The girl sitting next to her desk is wearing wrinkled, soiled clothing, unkempt hair and showing a listless, expressionless face with no makeup.

Karen states she thinks she is getting her period a little early and that must be why her stomach hurts and she is nauseated, although she admits she has never been nauseated prior to a menstrual period before. The nurse records Karen's vital signs and leaves the room, while Karen puts a gown on over her underwear. In the outer office, the nurse calls the attendance officer only to discover Karen has missed several days of school recently with no satisfactory explanation, although she has brought in signed notes. The attendance officer has been unable to contact her parents.

The nurse returns and examines Karen, when she notices what appear to be fresh bruises and abrasions on Karen's thighs and abdomen, and redness in the genital area. Further gentle questioning brings a somewhat garbled explanation about "rough" play by her boyfriend Rick, also 16, whom she has dated for about three months. Karen dresses, and the nurse asks more questions about her recent experiences. When she states that she is afraid for Karen, and asks where she has been when not at school recently, Karen begins to sob.

"It's Rick - he won't let me go to cheerleading practice, and I've just been dropped from the squad! Mom's upset because my grades are down, but Rick says I'm stupid anyway so there's no point in doing homework. He wants to be with me all the time, and gets mad if I see or talk to anyone else. He doesn't like my family. If I try to stop seeing him he cries and says he loves me and he'll kill himself if I don't stay with him!"

After several more minutes of similar disclosures, Karen agrees to meet with a volunteer counselor who has an office down the hall from the nurse's and who provides on-campus service to students with problems in dating and family relationships. She also agrees to attend at least one meeting of a support group of teen victims of violence in their dating relationships. She promises to stop back and see the nurse regularly.

Six weeks later, Karen has been reinstated on the cheerleading squad. Midterm report cards have just come out and she has brought up two of her lowest grades. She tells the nurse she attends group meetings twice a week and that they really have helped her see she isn't the only victim to have experienced physical, emotional and sexual abuse. She understands now that she is and always has been a good person undeserving of the abuse and that Rick must get help for his behavior or he is unlikely to change. She admits to being sad and missing him sometimes, but says that she and her mother can talk about it now, and that helps, too.

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Section VII. Forms & Worksheets

Summary

This section contains forms and worksheets that can be used by the health care professional for interviewing and diagnosing of the presence of domestic violence in the patient's life.

Domestic Violence Self-Assessment- This self-assessment worksheet can be used by anyone that the health care professional suspects is the victim of domestic violence. It is a way for the victim to determine for themselves the presence of domestic violence in their lives.

Screening For Domestic Violence In Healthcare Settings- This form contains screening questions and a checklist that the healthcare professional can use to identify general signs and symptoms of relationship violence.⁽³¹⁾

Diagnostic Interviewing When General Signs of Distress Are Detected- This forms contains diagnostic questions and a checklist for identifying specific signs and symptoms of relationship violence.

Diagnostic Interviewing When Specific Signs Are Detected- This form contains suggested questions and comments that the healthcare professional can use in discussing the issue of domestic violence with the victim.

Abuse Assessment Screen- This worksheet should be used to document the specific verbal and physical abuse.

Helping An Adult Who is a Victim of Relationship Violence- This form can be used by the healthcare professional in interviewing, assessing violence and developing a plan for support and safety for adults who are the victim of relationship violence.

Identifying Child Abuse or Neglect: General Signs & Symptoms- With the high incidence of child abuse in cases of domestic violence, it is important that the healthcare professional screen for child abuse. This form will assist in the identification of general signs and symptoms of child abuse.

Identifying Child Abuse or Neglect: Specific Signs & Symptoms- As a follow up to the previous form diagnosing the general signs of child abuse, this form should be used to identify the specific signs of child abuse.

Name:_____________________

Domestic Violence Self-Assessment

Ask yourself these questions: Is your relationship bad for your health or heading into dangerous territory? Take this test and find out.

If you answer yes to more than two of the categories, turn to someone for help.

Is he someone who...

____ Is jealous and possessive toward you, won't let you have friends, checks up on you, won't accept breaking up?

____ Tries to control you by being very bossy, giving orders, making all the decisions, doesn't take your opinion seriously.

____ Is scary? Do you worry about how this person will react to things you say or do? Does this person threaten you, use or own weapons?

____ Is violent? Does this person have a history of fighting, lose his temper, brag about mistreating others?

____ Pressures you for sex, is forceful or scary about sex? Thinks that women or girls are sex objects, attempts to manipulate or guilt trip you by saying, "If you really loved me, you would...", or gets too serious about the relationship too fast for comfort?

____ Abuses drugs or alcohol and pressures you to take them?

____ Blames you when you are mistreated? Says you provoked it?

____ Has a history of bad relationships, and blames the other person for all the problems?

____ Believes that men should be in control and powerful and that women should be passive and submissive?

____ Has hit, pushed, choked, restrained, kicked or physically abused you?

____ Makes your family and friends concerned about your safety?

(This self-assessment survey was developed by the Mount Auburn Hospital Prevention and Training Center, Waltham, Massachusetts.)

Name:_____________________ Patient Name:_____________________

Screening For Domestic Violence In Healthcare Settings

When to screen: Some of the healthcare setting in which a healthcare professional can screen for the signs of domestic violence include: Annual or general exams, adolescent general exams & sports physicals, initial visit with first-time patients, pre-employment physicals (don't note on employer's form), OB visits and premarital exams.

Screening questions: Discussing domestic violence can be a socially uncomfortable so you should consider asking the following kind of questions of the suspected victim violence in private.

Screening for current violence:

"In my practice I'm concerned about prevention and safety, especially in the family. Are you in any relationships now where you are afraid for your personal safety, or where someone is threatening you, hurting you, forcing sexual contact, or trying to control your life?"

Screening for past violence

"As an adult, have you ever been a victim of violence such as assault or sexual assault?"

"Have you ever been in a relationship where your partner hurt you, threatened you, forced sexual, or tried to control your life?"

"When you were a child or adolescent did anyone ever physically hurt you, force sexual contact or hurt you psychologically (for example by telling you that you were worthless or unwanted)?

Course of Action: If screening is positive ask further diagnostic questions

Identifying relationship violence: General Signs and Symptoms

General Signs and Symptoms Warrant Further Assessment:

____ Multiple Emergency Department visits

____ Stress related illness:

____ Fatigue

____ Headaches

____ Abdominal & pelvic pain

____ Chronic pain or frequent use of pain medication

____ Sexual dysfunction

____ Palpitations, dizziness, paresthesias, dyspnea

____ Frequent vague complaints

____ Gastrointestinal problems

____ Drug and alcohol abuse by patient or partner

____ Depression symptoms

____ Anxiety symptoms

____ Suicide attempts

____ Self-injury

____ Post-traumatic stress disorder

____ Divorce or separation

____ Missed appointments or limited access to routine care

____ Lack of independent transportation or finances

Name:_____________________ Patient Name:_____________________

Diagnostic Interviewing When General Signs of Distress Are Detected

Interviewing: Always talk with patient in private. Assure confidentiality: "Our discussion will remain strictly confidential". Simultaneously evaluate organ-system and psychosocial factors as causative or contributory.

Diagnostic Questions: Initially the healthcare provider should identify or rule out violence as a possible source of stress. Some questions include:

"In my experience these types of symptoms are sometimes caused or made worse by stress. Are there any sources of stress in your personal life, family life or at work?"

"Are you in a relationship where you are afraid for your personal safety, or where someone is hurting you, threatening you, trying to control your life, or forcing sexual contact?"

"As a child, adolescent or adult, has anyone ever hurt you physically, forced sexual contact, or hurt you psychologically, for example by telling you that you were worthless or unwanted?

Other sources of stress that can be identified include: Major life events (e.g.: move: new job), primary depression or anxiety, or death of friend or relative. There may be acts of violence involved in each of these situations.

Identifying Relationship Violence: Specific Signs and Symptoms

____ Specific Signs of Partner Violence

____ Positive response to screening for family violence.

____ Suspicious injury

____ Contusions, abrasions, minor lacerations

____ Fractures and sprains

____ Burns

____ Injury to: head and neck, breast, or abdominal, genital, or anal area

____ Reported mechanism of injury inconsistent with findings

____ Injury during pregnancy

____ Multiple sites of injury

____ Pattern of repeated injury

____ Delay in seeking medical care

____ A person describes their partner as

____ Jealous, controlling or domineering:

____ Prone to anger

____ Frustrated with them or their children

____ Patient is reluctant to speak or disagree in front of partner

____ A person's partner

____ Accompanies the patient to the exam room and answers all questions

____ Shows angry, threatening or aggressive behavior toward health care professionals

Name:_____________________ Patient Name:_____________________

Diagnostic Interviewing When Specific Signs Are Detected

Interviewing: Talk with the person in private. Assure confidentiality: "Our discussion will remain strictly confidential." Ask directly about injuries and abuse:

"In my experience, this type of injury is sometimes caused by other people's actions. Are you safe? Is anyone hurting you or threatening you?"

"Are you in any relationships where you are afraid for your personal safety, or where someone is hurting you, threatening you, trying to control your life or forcing sexual contact?

"As a child, adolescent or adult, has anyone ever hurt you physically, forced sexual contact, or hurt you psychologically, for example by telling you that you were worthless or unwanted?"

Screening & Case Finding For Relationship Violence

Screening for Current Partner Violence

"Are you in any relationships where you are afraid for your personal safety, or where someone is hurting you, threatening you, forcing sexual contact, or trying to control your life?"

Screening for Past Violence

"As an adult, have you ever been a victim of violence such as assault or sexual assault?"

"Have you ever been in a relationship where your partner hurt you, threatened you, forced sexual contact, or tried to control your life?"

"When you were a child or adolescent did anyone ever physically hurt you, force sexual contact or hurt you psychologically (for example by telling you that you were worthless or unwanted)?

Case Finding With General Signs of Distress

"In my experience these types of symptoms are sometimes caused or made worse by stress. Are there any sources of stress in your personal life, family life or at work?"

Screen for current violence and past violence.

Screen for other causes of distress (positive and negative life events: family problems; depression or anxiety; etc.)

Case Finding With Specific Signs of Violence

"In my experience, this type of injury is sometimes caused by other people's actions. Are you safe? Is anyone hurting you or threatening you?"

Screen for current violence.

When you suspect abuse, But the Patient Denies Abuse

"I'm concerned about your safety and would like to tell you about several community resources you can use if you ever need them"

Describe resources available in your community, offer follow-up and document as in protocol.

Do not confront or challenge the patient.

Name:_____________________ Patient Name:_____________________

Abuse Assessment Screen

Instructions: Use this Abuse Assessment Screen to document the following information:

1. What the patient said. Use quotation marks to document exact words.

2. Use the chart to score the injuries you observed. Drawings and photographs describe location and quality of injuries. Include a ruler in photos for scale, and victim's face for identity.

WITHIN THE LAST YEAR, have you been hit, slapped, kicked or otherwise physically hurt by someone? YES NO

If YES, by whom? __________________________________________________

Total number of times ________________________________________________

SINCE YOU'VE BEEN PREGNANT, have you been hit, slapped, kicked or otherwise physically hurt by someone? YES NO

If YES, by whom? __________________________________________________

Total number of times ________________________________________________

MARK THE AREA OF INJURY ON THE BODY MAP. SCORE EACH INCIDENT ACCORDING TO THE FOLLOWING SCALE:

Score

1= Threats of abuse including use of a weapon

2= Slapping, pushing, no injuries and/or lasting pain

3= Punching, kicking, bruises, cuts and/or continuing pain

4= Beating up, severe contusions, burns, broken bones

5= Head injury, internal injury, permanent injury

6= Use of weapons; wound from weapon

Total Score ___________

If any of the descriptions for the higher number apply, use the higher number.

WITHIN THE LAST YEAR, has anyone forced you to have sexual activities? YES NO

(Developed by the Nursing Research Consortium on Violence. Readers are encouraged to reproduce and use this assessment tool.)

Name:_____________________ Patient Name:__________________

Helping An Adult Who is a Victim of Relationship Violence

Interviewing: Talk with the person in private (without the partner). Communicate Belief, Support and Confidentiality: Make eye contact when talking with the victim:

"Our discussion will remain strictly confidential"

"You have a right to be safe and respected and nobody deserves to be hit or hurt"

"The abuse is not your fault."

"How can I help?"

Help Patient Assess Danger: Patient's assessment of safety, "Do you feel safe going home/"

Assessing Violence: To move from general, open-ended questions to specific, direct questions that help you thoroughly assess violence in a relationship.

"Tell me about your relationship with your partner."

"People have different ways of showing disagreement or anger in relationships. Sometimes people talk loudly, shout, threaten, hit, or use weapons. How does your partner show anger and disagreement?"

Wait for a response, then ask "Anything else?" or "And then what happens?" Repeat until patient offers nothing else.

Probe for specific types of violence, beginning with the least severe.

"Has your partner ever yelled at you, demeaned or berated you?"

"Have they ever threatened you, your children or someone else?"

"Have they ever destroyed your property or other things?"

"Have they ever tried to control your movements and activities?"

"Have they ever pushed or hit you?"

"Have they ever forced unwanted sexual or physical contact?"

"Have they ever hurt you with a weapon or object?"

Indices of lethality: Severity of injuries:

____ Increasing severity; weapons used/available.

____ Threats to kill.

____ Forced or threatened sexual acts

____Dangerous life transitions: pregnancy, divorce, leaving home

____ Drug and alcohol abuse.

____ History of violence or suicide attempts by partner or patient.

Children's safety: "Are your children safe" (Report suspected child abuse to child protective services.)

Plan for Support & Safety:

Offer telephone numbers: These include the local Woman's Shelter, legal advocacy, police and 911

Help Make an Emergency plan. Some of the topics that you should discuss with the victim include:

"If you decided to leave, where could you go?"

"Can you keep some clothes, money and important papers in a safe place?"

"Where could you go in an emergency? How would you get there?"

"Do you have relatives or friends you could stay with who would be supportive?"

Offer Follow Up: You should consider scheduling another doctor's appointment or ask the patient to call you.

Name:_____________________ Patient Name:__________________

Identifying Child Abuse or Neglect: General Signs & Symptoms

General signs of distress in a child that warrant further assessment. Check those signs which apply:

____ Symptoms of anxiety or depression

____ Social Withdrawal

____ Aggressive, mean or violent behavior toward others

____ Low self-esteem

____ Attention problems, failure to learn or developmental delay

____ Extreme perfectionist, fearful or intolerant of own mistakes

____ Extreme need for attention

____ Regressive or childlike behavior

____ Inappropriate hygiene

____ Parental Child: Child takes parental role with siblings or has excessive domestic responsibilities.

____ Sudden change in behavior or school performance

____ In late childhood and adolescence: eating disorders; sexually active before age 15, or multiple partners; pregnancy; self-mutilation; attempted suicide; running away.

Action: When you observe general signs of distress:

____ Interview the parent(s) and child

____ Document in the comments:

1. What the child and parent(s) said. Use quotation marks to document exact words.

2. What behavior, signs and symptoms you observed.

3. Your assessment of stress and related problems

4. Describe follow up plans

a. Schedule follow-up appointments to assess changes over time.

b. Refer to a mental health professional with training in child development and request a report.

c. Consult school (teacher or social worker)

Name:_____________________ Patient Name:___________________

Identifying Child Abuse or Neglect: Specific Signs & Symptoms

Specific signs and symptoms of child abuse and neglect that warrant action:

____ Unusual or suspicious bruises, burns, rectal or genital pain or bleeding, or injury inconsistent with reported event.

____ Sexually explicit play with dolls or other children including playing with dolls or other children that illustrates intercourse, oral intercourse or anal intercourse (Distinguish from normal self-exploration and masturbation).

____ Inappropriate touching of other children's private areas (buttocks, genital areas)

____ Specific comments or complaints about being maltreated, neglected or sexually touched.

____ Lack of basic needs (e.g. food, clothing, medical and dental care).

____ Grossly inappropriate hygiene.

____ A child left unsupervised for long periods of time.

____ In your professional opinion you suspect the child is being abused or neglected.

Action (When you observe specific signs of abuse or neglect):

____ Immediately file a report with child protective services (CPS) & engage your clinics protocol.

____ Involve parents in filing the report when this does not place the child at risk.

____ Hospitalize the child when necessary to treat injuries or place child in safe environment.

____ Document the nature of injury and observations carefully in the child's chart.

-What the child and parent(s) said. Use quotation marks to document exact words.

-What behavior and injuries you observed. Drawings and photographs describe location and quality of injuries. Include a ruler in photos for scale and the victim's face for identity.

-Assessment of potential child abuse

____ Describe any safety and follow up plans

-If you are unsure about reporting, consult a trusted colleague, a local expert, or a child abuse case worker at child protective services. Discuss a hypothetical situation to maintain confidentiality. Trust your own professional judgement.

-Develop a treatment plan for the child and family that engages clinical and community resources.

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Section VIII: Bibliography and Additional Information Sources

Along with the recognition that we can identify abuse comes the responsibility of knowing where to send the patient for help:

Hotline numbers for battered women

NATIONAL HOTLINE 1-800-799-SAFE

Arkansas 1-800-332-4443

Florida 1-800-500-1119

Indiana 1-800-334-7233

L.A. County 1-800-978-3600

Michigan 1-800-996-6228

Montana 1-800-655-7867

Nevada 1-800-922-5757

New Hampshire 1-800-852-3311

New Jersey 1-800-572-7233

New York 1-800-942-6908 (English)

New York 1-800-942-6908 (Spanish)

North Dakota 1-800-472-2911

Oklahoma 1-800-522-7233

Pennsylvania 1-800-642-3150

Texarkana area 1-800-876-4808

Vermont 1-800-228-7395

Virginia 1-800-838-8238

West Virginia 1-800-352-6513

Washington 1-800-562-6025

Wisconsin 1-800-333-7233

Wyoming 1-800-445-7233

National Resource Center on Domestic Violence has a listing of every domestic violence coalition: 1-800-537-2238.

The Academy of Facial Plastic and Reconstructive Surgery and the National Coalition Against Domestic Violence will provide free reconstructive surgery to any domestic violence victims: 1-800-842-4546

Additional resources are available for abused, missing, runaway or exploited children:

800-1-AM-LOST Child Find Hotline (parents reporting lost children)

800-4-A-CHILD Child Help USA (for victims. Offenders, and parents)

800-999-9999 Covenant House Hotline (for problem teens and runaways)

800-A-WAY-OUT Hotline for parents considering abducting their children

800-843-5678 National Center for Missing and Exploited Children

800-231-6949 National Runaway Hotline

800-442-HOPE National Youth Crisis Hotline

800-782-SEEK Operation Lookout, National Center for Missing Youth

800-HIT-HOME Youth Crisis Hotline (reporting child abuse and help for runaways)

For information on specific state laws and statutes, visit the web page for the Cornell Law School at: www.law.cornell.edu/statutes.html

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Section IX. Authors

About the Authors:

TERRIE J. McGUIRE, B.S.,M.B.A. She is currently Training Coordinator and Curriculum Consultant to The Harrell Center for the Study of Domestic Violence, College of Public Health, Department of Community and Family Health, University of South Florida for the Distance Learning Teleconference Program on Domestic Violence. Terrie is also a Training Coordinator for the Spring of Tampa Bay, Inc., one of the oldest, largest and busiest domestic violence programs in the southeastern United States. Terrie has been in the field of family violence for almost twelve years; she has operated a shelter for battered women and their children in Norfolk, VA and has been with The Spring since 1995.

Terrie has facilitated support groups and services for victims (men, women and children) and has taught classes for male and female offenders court-ordered to The Spring's Family Violence Intervention Program. She has designed and developed out-reach programs to serve children witnesses to adult violence, and has served as expert witness in Criminal, Civil and Family Courts in Hillsborough County, FL and in Bexar County, TX, on the subjects of the impact on children, post traumatic stress disorder (PTSD), the dynamics of violent relationships and other related topics.

Contributing Editors:

BETH C. ARRINGTON, RN, MSN. Beth has worked for 20 years in critical care and staff development settings. She currently works as the Education Manager for two community hospitals. while practicing in critical care settings, she has given nursing care to victims of domestic violence in both large university medical centers and small community hospitals. Beth is active in the National Nursing Staff Development Organization and Sigma Theta Tau. She lectures on such topics as AIDS/HIV, Domestic Violence, Clinical Delegation Skills for Nurses and Developing Charge Nurse Skills.

KAREN MILLS-THOMAS, RN, AAS, BFA., Diaconal Minister, United Methodist Church. Karen has worked for 20 years in a variety of nursing positions including Advocate and Patient Care Manager at the Charlottesville Free Clinic, a Charge Nurse for Labor, Delivery and Postpartum Care at Martha Jefferson Hospital, in Charlottesville, VA. She also worked as a counselor at the Charlottesville Center for Sexual and Reproductive Health. In 1994, Karen received recognition from the local chapter of the National Organization for Women (NOW) for her work with women and children at a local shelter. She currently volunteers as a nurse-minister at the Charlottesville Free Clinic.

This publication is designed for educational purposes only. Vantage Professional Education is not engaged in rendering medical advice or professional services. Any medical or other decisions should be made in consultation with your doctors. Vantage Professional Education will not be liable for any complications, injuries or other medical accidents arising from or in connection with the use of the subject matter covered.

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Section IX: Footnotes

1. C. Everett Koop, Surgeon General, USA, 1984

2. Florida State Statute: F.S.S.741.278

3. Kantor and Straus, 1990

4. Browne, 1983

5. Straus, 1977b

6. "AMA Diagnostic & Treatement Guidelines on Domestic Violence",1994.

7. "First Comprehensive National Health Survey of Women Finds Them At Risk", NY Commownwealth Fund, 1993.

8. Chez. R.A. "Battering During Pregnancy" Biltmore, Williams & Wilkins. 1992.

9.Schiavarone, Fred M. "My Experience Screening in the Emergency Department". 1996.

10. US Department of Justice. "Violence Against Women Estimates from Redesigned Survey". August 1995.

11. McFarlane Christoffel, et al.

12. Schneider, Elizabeth. "Legal Reform Efforts for Battered Women". 1990.

13. Family Violence Prevention Fund. 1996.

14. Public Health Nurse. "Assessment for Abuse: Self Report vs. Nurse Interview". 1991;8:245-50

15. Florida Coalition Against Domestic Violence. 1998.

16. Johnson,1980

17. L. Walker,1979

18. Coulter & Freya, 1991

19. Island, D.& Letellier,P. "Men Who Beat The Men Who Love Them". 1991.

20. Pfout, Schopler & Henley, "Forgotten Victims of Family Violence", Social Work, July, 1982.

21. Straus & Gelles, "Physical Violence in American Families". 1990.

22. Giles-Sims, Jean. "A Longitudinal Study of Battered Children of Battered Wives", Family Relations, 1985.

23. NCADV Voice, Winter, 1993

24. National Center on Women and Family Law, The Effect of Woman Abuse on Children, 1990.

25. Stark, Evan and Fkutcraft, Anne. 1988

26. Campbell, Diana Onley, NCADV Voice, Fall, 1991.

27. NCADV Child Advocacy Task Force, 1993

28. Hart, Barbara. "Children of Domestic Violence: Risk and Remedies," in Protective Services Quarterly, Winter, 1993.

29. Finkelhor, David; Hotalin,, Gerald; Sedlak,Andrea 1990.

30. The March of Dimes. Doemstic Violence Study. 1997

31. Ambuel, B, & Hamberger, L.K.: Family Peace Project & Community Medicine, Medical College of Wisconsin. Source : http://www.vantageproed.com/viol/viol.htm

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