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Domestic Violence: How Can We Help?

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Deborah Marshall

on 18 December 2015

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Transcript of Domestic Violence: How Can We Help?

Domestic Violence:
How Can We Help?

1) Halton Women's Place
2) SAVIS
3) Halton Family Services
4) Nina's Place
References:
JBH Grand Rounds: December 18, 2015
Drs. Jackie Ang and Deb Marshall
PGY2 Family Medicine
McMaster University, Halton Campus

Objectives
Definitions & epidemiology
Investigate the health care burden & cost
Identifying individuals at risk
Screening Tools
How to Help
Mandatory reporting guidelines
Halton/Burlington resources
Who is at Risk?
social class
race
ethnicity
gender
sexual orientation
women experience abuse by partner in their lifetime
in
Defining Domestic Violence
"A
pattern of behaviour
used
by one person to
gain power
& control

over another with
whom he/she has had an
intimate relationship"
2) Situational Couple Violence
: arguments escalating into violence
3) Violent Resistance:
victim of coercive control fights back
1) Coercive Control
Types
EMOTIONAL SOCIAL PSYCHOLOGICAL FINANCIAL VERBAL SEXUAL CULTURAL CHILDREN PROPERTY/PETS (PHYSICAL)
1. National Coalition Against Domestic Violence
2. "Homicide in Canada, 2009", Sara Beattie and Adam Cotter,Juristat Article, Volume 30, Number 3, Statistics Canada, page 14
3. Domestic Violence Toolkit for Health Care Providers in BC August 2014
Andrea Etheridge, BPN, RPN Lovepreet Gill, BPN, RPN Jessica McDonald, BA
4. Nelson, Heidi D., Christina Bougatsos, and Ian Blazina. “Screening Women for Intimate Partner Violence: A Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation.” Annals of Internal Medicine. Vol. 156 No. 11 June 2012.
5. MacMillan HL, McMaster Violence Against Women Research Group. Screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2009;302:493-501.
6. Brennan, S. 2011. Violent victimization of Aboriginal women in the Canadian provinces, 2009. Juristat. Statistics Canada Catalogue no. 85- 002. Retrieved Jun 2, 2014 from http://www.statcan.gc.ca/pub/85-002-x/2011001/article/11439-eng.pdf
7. WorldHealthOrganization,Consultation on Violence Against Women.
8. Understanding and Addressing Violence Against Women: Intimate Partner Violence WHO, 2012; Intimate Partner Violence: Risk and Protective Factors, CDC, 2013
9. UpToDate: Intimate partner violence: Childhood exposure: 2015.
10. Thackeray, J.D., Hibbard, R., Dowd, M. D. & The Committee on Child Abuse and Neglect & The Committee on Injury, Violence, and Poison Prevention.
Intimate Partner Violence: The Role of the Pediatrician.
Pediatrics. May 2010, VOLUME 125 / ISSUE 5.
11. Shonkoff, J.P., Garner, A.S., et al.
The Lifelong Effects of Early Childhood Adversity and Toxic Stress
. Pediatrics. January 2012, VOLUME 129 / ISSUE 1

1
partner
murdered
every
6 days,
a woman
is
by
her
2
Canada,
In
EPIDEMIOLOGY
age
SCREENING
HOW TO HELP
people around the victim knew what was going on...
but didn't know what to do about it."
- Al O'Marra, Chief Counsel Coroner's Office of Ontario
In almost every case of domestic homicide, we found
HALTON RESOURCES
Safe Shelter
Burlington (30 beds), Milton (22 beds)
24 Hour Crisis Line
905-878-8555 / 905-332-7892
Outpatient Services
Danger Assessment & Safety Planning
Transitional Support Worker
Court Support & Accompaniment
Counseling (Individual & Group)
Referrals to other agencies
Legal Aid Clinic
Finding Housing
Support Groups
24 Hour Support Line: 905-875-1555
Counseling Program
Up to 24 sessions, up to 1 year
Skype + Face-to-Face
Services for Men
Support Groups

Sexual Assault & Violence Intervention Services
Victimization of Aboriginal women
is estimated at 2.5X that of
non-Aboriginal women
Aboriginal women are 5X more likely to die as the result
of violence
5
5
Lesbian or bisexual were > 3X as likely
as heterosexual women to have
experienced spousal violence
3
2 times
the rate of
domestic
violence
3
Where Might We Encounter Domestic Violence at JBH?
ER
Trauma to head, face, neck
Fractures and broken bones
Orbital fractures
Black eyes
Bilateral bruising
Unusual bruising
Burns
Internal injuries
Family Medicine
OB-Gynae
Psychiatry
depression
anxiety
PTSD
sleep disturbance / insomnia
suicidal ideation / self-harm
social isolation
nightmares
alcohol or drug misuse
disordered eating
Pediatrics
BURDEN OF DOMESTIC VIOLENCE
Chronic pelvic pain
Genital injuries
STIs
Miscarriage
Still births
Premature labour
Infants with:
Low birth weight
Feeding problems
Failure to thrive
Why?
Reduces recurrence
Improves QoL outcomes
35% decrease in doctor visits
11% decrease in ER visits
Nelson et al, 2012
No harms to screening
Delet
Brain Injury
HOW TO SCREEN
Abdominal Pain
IBS
Avoid close ended questions
Use specific and directed questions
Chronic Fatigue
Fibromyalgia
Aches/Pains
Shortness of Breath
Heart Palpitations
Allergies
Headaches / Migraines

HITS
86 99
WAST
88 89

HITS
Tool for IPV Screening
During pregnancy
~11% of Canadian
women experience
violence from
their partner
How often does your partner..
1) Physically
H
urt you
2)
I
nsult or talk down to you
3)

T
hreaten you with harm
4)
S
cream or curse at you
WAST:
Woman Abuse Screening Test
1) In general, how would you describe your relationship?

A lot of tension | Some tension | No tension
2) Do you and your partner work out arguments with:
Great difficulty | Some difficulty | No difficulty
3) Do arguments ever result in you feeling down or bad about yourself?
4) Do arguments ever result in hitting, kicking or pushing?
5) Do you ever feel frightened by what your partner says or does?
6) Has your partner ever abused you physically?
7) Has your partner ever abused you emotionally?
Often | Sometimes | Never

No scoring system = guides clinical judgement
Hypertension
Cardiovascular Disease
Traumatic/Acquired Brain Injury
WHAT TO LOOK FOR
Thinking
Speech
Memory
Learning
Fatigue
Mood Swing
Depression
Anger
Aggression
Epilepsy
Paralysis
Tremors
Fatigue
Cognitive
Partner present at office
Partner speaks for woman
Problems with children
Delay in getting treatment for injury
Cancelled appointments
Repeat Rx before regimen complete
Frequent visits for chronic and somatic complaints
"Accident prone"
Neurological
Hx of domestic violence
Perpetrator is depressed
Actual or pending separation
Escalating level of violence
Stalking behaviour
Obsessive behaviour
Threat to kill
Osteoporosis
Pelvic Pain
STIs/UTIs
Asthma
IBS
Liver Disease
Somatization
Chronic Stress/Trauma Induced
Thyroid Disease
7
HOW TO HELP
Provide options - don't direct her what to do
Ask if she is safe to go home after the appointment
Allow her to make calls from your office
Offer she can come back if she needs to
Assure confidentiality
But note your need to document & duty to report
Ensure she has a safety plan
Make appropriate referrals
“I am concerned for you”
“Abuse is not acceptable”
“You are not alone”
“You are not to blame”

A
sk and keep asking
B
elieve
C
ounsel
D
anger Assessment
E
scape Plan


Story doesn't fit injuries
Increased Risk Characteristics
Relationship
Victim
8
Young
Low level of education
Witnessed or experienced physical or psychological abuse as a child
Mental health concerns
Prior history of being abusive
ETOH/Drug Abuse
Cultural / Social viewing violence as acceptable
Perpetrator
Young
Low level of education
Witnessed or experienced violence or abuse as a child
Cultural / Social viewing violence as acceptable
Dominance and control of one partner over the other
Conflict in or dissatisfaction with the relationship
Economic stresses
REFER FOR RISK ASSESSMENT!
Leave management to the experts!

Danger Assessment
Evidence based tool
Assesses risk of homicide in intimate relationships
19 Y/N questions & evaluating pattern of abuse
Referrals:
Halton Women's Place
Halton Family Services / Access Counseling
Can be done over the phone

Safety Planning

Allows discussion with client regarding present risk
Referral to safe housing
Biological manifestations of "toxic stress"
can include alterations in immune function and measurable increases in inflammatory markers
MANDATORY REPORTING
Infants
Disrupted feeding and sleep routines
Excessive crying
Developmental delay
Becoming more aggressive
School-Age
Somatic complaints (headache, stomach ache, etc.)
Anxiety
Depression
Aggression
School absenteeism
Decreased school performance
Toddlers
Comforting
Acting out
Distracting behaviors to defuse inter-parental aggression by redirecting the attention of the adults
Preschool
Recreate the violent act during play
Withdrawn
Regressive behavior (eg, bed-wetting or thumb-sucking)
Nightmares
Stutter
Anxiety
Clinging behavior
9
Future
Perpetrators
Future
Victims
Smoking
Cardiovascular Disease
COPD
Asthma
Autoimmune Diseases
Obesity
Viral Hepatitis
Liver Cancer
Children witnessing OR exposed to
domestic violence = "Toxic Stress"
11
Mental Health Concerns:
Depression
Anxiety
PTSD
Increase Suicidal Attempts
Recreational Drug Use
Alcohol Abuse
Toxic Stress
+/-
Increase Risky / Unhealthy Behaviours
=
10
Health Care

Utilization
Screen women of childbearing age
Provide/refer to intervention services
Macmillan et al, 2009
Halton Family Services / Access Counseling
Danger Assessments
4 Locations:
Oakville
Burlington
Milton
North Halton
Outpatient Services
Counseling
Individual (Men, Women and Children)
Family
Employee Assistance Program
Support Groups
Do you ever feel
controlled or
coerced in your
relationship?
Nina's Place
Sexual Assault Services (youth & adult)
Domestic Violence Services (youth & adult)
Examination, treatment, and documentation of injuries
Risk Assesment
Safety Planning
Emotional Support
Counseling and referral to community resources
Children's Services
Examination and Treatment of Injuries
Collection of forensic evidence
Work with CAS
Counseling
Short-term counseling for those who have experienced violence in last 2 years
Do you have any concerns about abuse in your current relationship?
Evidence Based Tools
Sensitivity Specificity
Private, non-profit agency
sliding scale cost based on income
Persistent pattern of behaviour
Story not in keeping with injuries
Scoring
Never (1)
Rarely (2)
Sometimes (3)
Fairly Often (4)
Frequently (5)
>10 = Screen Positive
RISK FACTORS
For Homicide
sensitivity
86%
specificity
99%
sens 92
spec 56
sens 88
spec 89

TWO versions
WAST-SF
WAST
Thanks to:

Halton Women's Place
CPSO
Mandatory Reporting Guidelines
Child Abuse or Neglect
"Under the Child & Family Services Act, physicians who have reasonable grounds to suspect a
child is or may be in need of protection
, must immediately report the suspicion, and the information upon which it is based, directly to a children’s aid society (CAS)"
Disclosure to
Prevent Harm
There is a
risk of serious bodily harm

or

death
Personal Health Information Protection Act
AND
AND
There is a
clear risk
to an
identifiable

person
or a
group of persons
The
danger is imminent
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