Thank you for choosing this educational offering, Intimate Partner Violence and Children. Intimate partner violence is a public health problem of epidemic proportions, and children are oftentimes the peripheral victims of intimate partner violence. This educational offering will discuss the consequences to children of exposure to intimate partner violence from infancy or conception even, through adolescence, and explore implications for forensic nursing practice. The authors, presenters, and planning committee for this educational offering have no relevant financial relationships to disclose. Upon attending the course in its entirety and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is accredited as a provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. For the next 90 minutes, we will analyze the presentation of individuals and family members who present with a possible exposure to intimate partner violence, evaluate the impact of intimate partner violence on parenting, describe possible consequences of exposure to intimate partner violence in infants, children, and adolescents, and finally, explore practice implications to address intimate partner violence in pediatric patients. We would like to acknowledge the indigenous peoples on whose ancestral homelands we gather and live, as well as the diverse and vibrant Native communities and people who make their homes here today. The Centers for Disease Control and Prevention define intimate partner violence as abuse or aggression occurring in the context of a romantic relationship that is perpetrated by a current or former partner. Intimate partner violence has several types. There can be physical abuse, which is what we typically think of in intimate partner violence. Speaking of physical violence, hitting, kicking, strangulation, pushing, scratching, shaking, burning. There may or may not be weapons used in the violence. Forceful restraint with or without the use of objects. Using other types of physical restraint. Intimate partner violence can also include sexual violence, rape, forcing or attempting to force a partner to engage in a sexual act, sexual touching, non-physical events like sexting, verbal or behavioral sexual harassment, taking and or disseminating unwanted sexual photos. Stalking can also be a form of intimate partner violence, a pattern of repeated unwanted attention and contact that raises concern for the individual's own safety or safety of a loved one. And certainly, psychological aggression can be a very powerful part of intimate partner violence. Manipulation, intimidation, isolation, name-calling, insults, belittling an individual, shaming an individual, threats of physical or emotional harm, threats to the children or other family or friends or loved ones, controlling the partner's finances, employment, medical care including birth control, forced pregnancy or forced abortion. Intimate partner violence victims often experience severe psychological trauma, physical injury and even death. Intimate partner violence is indeed a public health problem of epidemic proportions. According to the Centers for Disease Control and Prevention, one in four women and nearly one in ten men will experience some form of intimate partner violence in their lifetime. One in five homicide victims in the United States are killed by an intimate partner. Intimate partner violence often begins in adolescence and continues for a lifetime. There are also peripheral victims of intimate partner violence. One in 15 children are exposed to intimate partner violence each year. And children can be exposed to IPV in a number of ways. They may be eyewitnesses to the violence or they may hear the violence but not actually see the violence. And sometimes what they're imagining happening in the next room is actually worse than what is going on. Children may also note the aftermath of violence, bruises to the mother, broken furniture. They may become aware of the violence, overhear talk of the violence or they may be told about the violence. And they may be unaware of the violence but the family dynamics are altered and they are affected by these altered dynamics. After the COVID-19 pandemic and the social isolation that occurred with the pandemic, individuals were not going to work, were not leaving home to go to work, and children were not leaving home to go to school. In the United States, there was an average increase of 12 percent, an average increase in domestic violence or intimate partner violence of 12 percent with a 20 percent increase occurring during working and school hours. Intimate partner violence is well ingrained in human society. The earliest complex societies recorded laws and cultural norms sanctioning men treating women, particularly their wives, with violence. Intimate partner violence often develops into a pattern of repeated physical abuse and injury, repetitive isolation, intimidation, forced sex, and other controlling behaviors. It is important to note that the risk factors for intimate partner violence victimization and perpetration are very similar. One of the strongest risk factors for both victimization and perpetration is witnessing intimate partner violence in childhood. There are also societal factors that increase risk for intimate partner violence, racism, homophobia, transphobia, societal factors that isolate groups, and the general acceptance of violence within society. And certainly, it's difficult to argue that in America, in our society, we have become numb to violence, and there is a general acceptance of violence. Community factors come into play, poverty, high violence and crime, lack of solidarity. There are also individual factors increasing risk, young age, short-term relationships, mental illness. There's a bidirectional relationship between intimate partner violence and mental health disorders. Intimate partner violence increases the likelihood of mental health disorders in women, and mental health disorders increase the risk of intimate partner violence. Also, childhood psychosocial trauma, exposure to child maltreatment of all forms, substance abuse within the household, household mental illness, all increase risk for intimate partner violence, victimization, and perpetration. And finally, there are relationship factors that increase risk, such as separation, divorce, unplanned pregnancy. All of these increase risk for intimate partner violence. Intimate partner violence occurs in heterosexual as well as same-sex relationships. LGBTQ relationships may have a higher risk for intimate partner violence due to homophobia and transphobia that exists within our society. Both men and women can be perpetrators and victims of intimate partner violence. However, men are more likely to inflict severe injury on women. There was a study looking at individuals who sought care for injuries due to intimate partner violence in emergency departments, and 62% of the individuals injured by a partner and seeking medical care were female. Intimate partner violence can have devastating consequences for all victims, but especially women and children. The relationship between child and mother is crucial to a child's emotional and physical well-being. This is especially true for children exposed to trauma, such as intimate partner violence. Many children exposed to intimate partner violence demonstrate resilience and normative adjustment despite experiencing significant adversity. Maternal physical and mental health are the most significant predictors of child resistance among children exposed to intimate partner violence. It is vital for professionals working with children, including forensic nurses, to understand the consequences of maternal intimate partner violence victimization to better appreciate possible impact upon parenting. Homicide is all too often the tragic end point of intimate partner violence. In the United States, more women are murdered by romantic partners than any other type of perpetrator. The single biggest risk factor in the escalation of non-fatal intimate partner violence to homicide is having a gun in the home. Strangulation and head injuries are the most common injuries documented in emergency department visits of intimate partner violence victims prior to experiencing intimate partner violence-related homicide. Non-fatal intimate partner violence can also result in a variety of physical injuries impacting both short- and long-term parenting ability. Data from the National Electronic Injury Surveillance System was used to track injury patterns of intimate partner violence patients presenting to the emergency department over a nine-year period. And there you see the types of non-fatal physical injuries experienced by intimate partner violence victims, primarily bruises and abrasions, but also lacerations, strains and sprains, internal organ injuries, and fractures. Patterns of injury in intimate partner violence often involve the head, neck, such as strangulation, chest, thorax, abdomen, and perineum. Maternal mental health disorders often negatively impact parenting. The mental health consequences of intimate partner violence can be no less debilitating than the physical sequelae. Victims of intimate partner violence often identify psychological abuse as resulting in greater distress or trauma than acts of physical violence. Women experiencing intimate partner violence when compared to their non-abused peers are significantly more likely to have a diagnosis of post-traumatic stress disorder, generalized anxiety disorder, dysthymia, depression, phobias, and substance abuse, all of which can negatively impact parenting. Intimate partner violence can affect an individual for their entire lifespan, from conception until death. Unintended pregnancy can result from intimate partner violence. Women experiencing intimate partner violence are significantly more likely to report an unintended pregnancy than those not experiencing IPV. Unintended pregnancy can occur as a result of forced sexual intercourse, fear of discussing contraception with their abusive partner, or that partner's interference with the use of birth control. And negative maternal and infant outcomes can result from unintended, unwanted pregnancy. The negative maternal pregnancy outcomes include postpartum depression, substance use, drugs, alcohol, tobacco, low to no prenatal care, no engagement in health-promoting behaviors such as prenatal vitamins, folic acid, healthy eating and exercise, and also negative infant outcomes can occur, exposure to substances, the drugs, the alcohol, the tobacco, low infant birth weight, preterm labor, and birth. All of these can result from an unintended, unwanted pregnancy. The negative impact of intimate partner violence can begin at the moment of conception. Pregnancy can increase a woman's vulnerability to experiencing intimate partner violence. Rates of intimate partner violence during pregnancy have been estimated to be as high as 20%. Approximately half of these women report that the first incident of intimate partner violence occurred during pregnancy. It is also not unusual for the severity of intimate partner violence to intensify during pregnancy in the postpartum period. Intimate partner violence during pregnancy places both mother and infant at risk for negative health outcomes. Pregnant mothers experiencing intimate partner violence are three times more likely to suffer perinatal death than their non-abused peers. Intimate partner violence contributes to maternal and infant perinatal death via several mechanisms. Preterm labor, blunt trauma, maternal infections, increased psychological stress, unhealthy maternal coping strategies such as poor nutrition and substance use, and inadequate prenatal care. Fetal death can occur miscarriage, placenta abruption, preterm labor or birth, or low birth weight for the infant. But exposure to intimate partner violence can also have significant negative effect on the developing fetus via additional pathways. Fetal exposure to intimate partner violence has been linked to HPA access dysregulation, hypothalamic pituitary adrenal access dysregulation, which if that sounds familiar to you, it's the chronic stress response. The activation of the HPA access occurs when toxic stress occurs to an individual. And so you have chronic elevation of cytokines and cortisol. And so prenatal exposure to intimate partner violence has been linked to HPA access dysregulation resulting in internalizing problems, externalizing problems, and poor academic performance in middle school. The effects of prenatal exposure to intimate partner violence can persist for decades. Co-occurrence of household intimate partner violence and child maltreatment has been well documented in the literature. Violence in the household is a definite risk factor for child maltreatment among infants and children of all ages. Approximately 26 to 73 percent of children experiencing child maltreatment are living in families where intimate partner violence is present. And approximately 30 to 60 percent of families where intimate partner violence is occurring are also affected by child maltreatment. The Adverse Childhood Experience Study solidified our knowledge that exposures to psychosocial traumas in childhood have negative effects on adult health behaviors and adult health, both mental and physical, in a dose-related gradient. And the Adverse Childhood Experience Study also told us that for individuals who experienced intimate partner violence exposure in childhood, they were six times more likely to suffer emotional abuse, nearly five times more likely to suffer physical abuse, and nearly three times more likely to suffer sexual abuse. Studies suggest that in over 50% of intimate partner violence cases, one or both caregivers are aggressive to children in the home. Mothers who are victims of intimate partner violence are more likely to endorse the use of harsh child discipline and perpetrate physical abuse, psychological aggression and neglect when compared to mothers who are not victims of intimate partner violence. We know that independently, both child maltreatment and exposure to intimate partner violence can result in significant negative consequences for children. Polyvictimization may indeed result in critical implications for children's development and behaviors. A culture of violence often exists within these families, adult to adult and adult to child. Social learning processes may also contribute to the relationship. Childhood exposure to intimate partner violence may lead both women and men to view violence and coercion as acceptable methods to resolve conflicts with partners as well as children. Intimate partner violence can have deadly outcomes for children and adolescents. At HEIA, in 2019, studied homicides of children aged two to 14 years in 16 states over a 10-year period to determine if their deaths were intimate partner violence related. So there were 1,386 child homicides, 20.2% were classified by at HEIA as IPV related, 54% were a type one type where the perpetrator kills the child and also kills or attempts to kill the intimate partner. 46% were classified as type two, murder-suicide. Overall, murder-suicides involving children, it was determined that 98% of them are intimate partner violence related. Children and adolescents can also suffer fatal outcomes as the result of being peripheral victims of intimate partner violence. Adolescents are also at risk to die as a result of teen dating violence or murder-suicide or suicide. Romantic relationship conflicts are a precipitating factor for more than a quarter of suicides among youth aged 10 to 17 years of age. Children and adolescents may also become collateral victims of non-fatal physical injury resulting from intimate partner violence. Young children are at an increased risk due to their close proximity to caregivers. For instance, they may be in their caregiver's arms when violence occurs and then they are accidentally injured in the violence that occurs between the two adults. Older children and adolescents may intervene to stop the violence. Children and adolescents can experience a variety of injuries including contusions, fractures, abdominal trauma, and head trauma. The Adverse Childhood Experience Study solidified knowledge that childhood exposure to intimate partner violence and other psychosocial traumas can lead to negative adult health behaviors such as tobacco, alcohol and drugs, unsafe sex, poor diet and exercise, and adult health consequences, both mental and physical health. And the physical health consequences include things like heart disease, diabetes, cancer, and early death. More recent studies also suggest that negative physical health consequences resulting from childhood exposure to intimate partner violence may also be present in childhood. Intimate partner violence exposure produces stress that is chronic and unpredictable, toxic stress. Toxic stress activates the body's chronic stress response, the hypothalamic, pituitary, adrenal axis, with chronic elevations of cortisol and cytokines. Changes occur over multiple body systems, metabolic, immune, and nervous. Toxic stress is critically implicated in immune dysfunction and chronic health conditions. Emerging literature suggests a link between significant trauma exposure such as intimate partner violence and the development of childhood asthma. Let's consider the impact of exposure to intimate partner violence on child development, behavior, and mental health. It is estimated that up to 30% of children are exposed to intimate partner violence in the first five years of life. Impacts upon child functioning and development can be seen as early as infancy. Infancy is a developmental period where children are most dependent on parents to meet their physical and emotional needs. Intimate partner violence often interrupts parental ability to provide the care and attention necessary to meet the infant's needs adequately, thus negatively impacting infant behavior and development. Violence in the household interrupts caretaker ability to meet the basic needs for safety and security in infants and young children. Thus the child's ability to develop a normal sense of trust is undermined as is later exploratory behavior that leads to autonomy. Young children do not have the verbal skills necessary to adequately express their feelings. Here you can see some symptoms and behaviors experienced by children who are exposed to intimate partner violence in infancy and early childhood. Again, in infants you can see excessive irritability, you may have some regression, sleep disturbance, emotional distress, separation, anxiety, a fear of being alone, various externalizing behaviors, trauma symptoms, language delays as they get older, language delays and attachment disorders, various developmental delays. Preschool children may exhibit somatic problems, stomach aches, headaches, sleep disturbances, insomnia, nightmares, sleepwalking, and ureases. There may be self-regulation difficulties. Reactivity to verbal conflict, internalizing symptoms. Let's take a look at a study by Bernard, 2022. The infant's first year of life is a critical period of bonding, attachment, and development. The mother-infant relationship is crucial for healthy infant development. It provides a context for infants to begin to learn self-regulation, develop expectations of others' behaviors, and engage in dynamic back-and-forth interaction. Touch is a primary form of communication between mother and infant. Touch is used by the mother to respond to the needs of the infant, communicate safety and security, and to teach infants self-regulation. As infants develop, they increasingly initiate touch interactions so that they, that by about one year of age, they can communicate their needs and feelings to their mother. So Bernard and company studied 174 mother-infant dyads at free play. The infants were all 12 months of age. 32, so about a third of the mothers had experienced intimate partner violence during pregnancy, and a fourth of the mothers had experienced intimate partner violence postpartum. And then the other mothers denied experiencing intimate partner violence. So Bernard looked at touch behaviors, maternal touch behaviors and infant touch behaviors. And as far as maternal use of touch behaviors, there were no differences noted between mothers that experienced intimate partner violence and those not reporting intimate partner violence. And when he looked at the infant use of affectionate, passive or instrumental touch, no differences were noted between infants of mothers who experienced intimate partner violence and those not experiencing intimate partner violence. However, when looking at negative behaviors, physically aggressive behaviors when dysregulated, boy infants who were exposed to whose mothers experienced intimate partner violence during pregnancy and or the postpartum period were more likely to use negative touch behaviors to their mother when dysregulated, such as hitting, kicking, pushing. This tendency in risk-exposed infants may continue into childhood, adolescence and adulthood. Living in a household with intimate partner violence is associated with a multitude of developmental, behavioral and emotional problems that can develop early in childhood and may persist for a lifetime. The impact of childhood exposure to intimate partner violence is complex and varies among individual children as well as additional negative consequences. Here you see a list of internalizing symptoms and externalizing behaviors that can be seen in children who are exposed to intimate partner violence. When considering the impact of exposure to intimate partner violence on children, it's important to consider several factors. Number one, there are additional negative exposures. Are they exposed to intimate partner violence and child abuse and maybe substance abuse in the home? What was the frequency of the exposure? The persistence of the exposure to intimate partner violence. The child age at the time of exposure and also the developmental stage of the child at the time of exposure. School-aged children explore, play freely and are motivated to master their environment. When exposed to intimate partner violence, they often exhibit a greater frequency of internalizing symptoms like withdrawal and anxiety and also externalizing behaviors, aggression and delinquency. A decline in social competence and school performance can be seen and an increase in sleep disturbance. Older school-aged children develop a strategy of vigilance. These children appear more responsive to aggressive cues and often attempt to intervene in the violence in the home. The impact of exposure to parental intimate partner violence can be particularly evident among adolescents. Adolescence is a period of significant physical, mental and social developmental changes. The physical changes of puberty and sexual development occur. Adolescents refine abstract thinking capabilities, form a more defined sense of self, both personal and sexual, while leveraging their independence, emotional, intellectual and financial independence. Adolescents begin to define other people in relationship to themselves. Adolescents also possess greater cognitive skills than younger children. And when intimate partner violence is present in their environment, they are better equipped to consider their roles and responsibilities and to decide that events are unacceptable, should be stopped or should be reported to others who can help. Due to these thoughts and behaviors, it is not unusual for adolescents to become victims when they intervene to protect the intimate partner violence victim in their household. The adolescent impact of witnessing or exposure to intimate partner violence can result in aggression, a variety of high risk behaviors like substance use, risky sexual behaviors, delinquency, theft, you know, theft, violence, academic failure, skipping school, and also teen dating violence. And teen dating violence is really rather prevalent among US teens. One in 12 US teens report physical violence in dating relationships. And about the same number report sexual violence. Adolescents who have witnessed parental intimate partner violence are at particular risk for both intimate partner violence perpetration and victimization. Adolescents exposed to both parental intimate partner violence and their own child maltreatment are at particular increased risk for intimate partner violence perpetration and victimization. There are multiple factors contributing to this risk including parental modeled acceptance of intimate partner violence and sexual violence, structural inequities, and controlling responses that create unsafe environments. Youth who witness intimate partner violence may have a greater acceptance of violence. They have become desensitized. Violence is their norm. This increased risk for violence continues into adulthood. With witnessing parental intimate partner violence being the strongest risk factor for both intimate partner violence, victimization, and perpetration. Given the substantial negative impact of living with intimate partner violence upon children of all ages, pediatric healthcare providers, especially pediatric forensic nurses, must feel confident and competent assessing and intervening. Prompt identification coupled with effective intervention are key to preventing life-altering consequences for children. All states have laws mandating child maltreatment reporting and nurses in all states are mandated reporters of suspected child maltreatment. This includes an intentional or unintentional injury to a child that results from a intimate partner violence episode. The American Academy of Pediatrics recommends universal screening of all families for intimate partner violence and other psychosocial risk factors. Prior to screening for intimate partner violence, it is essential that the pediatric forensic nurse be knowledgeable regarding state law defining intimate partner violence mandated reporting. There are some states that require reporting of intimate partner violence when it involves the use of a weapon or occurs in the presence of a child. The Child Information Gateway, and you see the link there, gives you information regarding each state law regarding mandated intimate partner violence reporting. And Futures Without Violence offers considerations to assist pediatric forensic nurses practicing in states without specific reporting requirements, make the critical decision of whether or not a report is warranted when there is a concern of intimate partner violence in the presence of a child. And there you see the Futures Without Violence link. And it's important to consult with other members of the healthcare team, such as social work, when you're making the decision of whether or not a report of intimate partner violence is necessary to Child Protective Services. When making the decision as to whether or not to report intimate partner violence to Child Protective Services, the potential risks to the child must be assessed, such as the use of a weapon, or violence or threats directed towards the child. If so, a report to Child Protective Services and law enforcement is most likely indicated. Explore caregiver ability to protect the child, as well as caregiver social supports, such as family, friends, faith-based, and linkage to community resources, including counseling and financial resources. It is important for the pediatric forensic nurse to be aware that a report to Child Protective Services due to intimate partner violence could compromise survivor safety. Safety planning will be important. Reinforce to the caregiver that the report is not punitive in nature, rather it was made to ensure their safety and the safety of their child. Give the caregiver the option of making the report themselves or helping you make the report. This is empowering and trauma-informed. Inform Child Protective Services of efforts made by the caregiver to ensure the safety of the child. Support must be provided to the caregiver before, during, and after the Child Protective Services report. Prior to initiating screening, it is essential to identify available, affordable, and evidence-based community resources available for both intimate partner violence survivors and children exposed to IPV. Gathering appropriate resources can be a time-consuming endeavor. Children's hospitals, child advocacy centers, local domestic violence shelters or agencies, local health departments, and United Way can be of assistance in identifying resources. Identifying and periodically communicating with key personnel at identified community agencies can be helpful in learning more about the programs and how they meet the needs of intimate partner violence survivors as well as children. Be sensitive to cultural attitudes towards violence against women, not to condone such attitudes, but because they may well affect a woman's willingness to report. Here are some evidence-based screening tools for intimate partner violence, and these tools screen for intimate partner violence only. The hurt, insult, threatened, and scream, or hits. Women abuse screening tool, lost. Humiliation, afraid, rape, kit, children. Slap, threatened, and thrown. And you have the questions for the slaps, threatened, and thrown listed there. The abuse assessment tool. Again, all of these screen for intimate partner violence. Here are some examples of evidence-based screening tools that screen for intimate partner violence. Typically there's one question on these screens that screen for intimate partner violence, but they also screen for other psychosocial risk factors. The screening tool that I'm most familiar with, because we used it in our hospital-based child advocacy center at Nationwide Children's Hospital, is the safe environment for every kid. You see the link to the website there. There is a website that contains SEEK training materials, videos, and written materials that can help the pediatric forensic nurse feel more confident and comfortable talking to families regarding psychosocial risk factors. There's the screening tool, the parent questionnaire that screens for domestic violence, parental mental health, parental substance abuse, harsh punishment, and food insecurity. And there are also algorithms that assist the pediatric forensic nurse work through a problem with a parent. So that is one example of an evidence-based screening tool that can be used in pediatric populations that screen for intimate partner violence and additional psychosocial traumas as well. And then there's also the Bright Futures Pediatric Intake Family Psychosocial Screen, Social Needs Screening Tool, and the Accountable Health Community Screening Tool. Here's a list of national intimate partner violence resources that can be helpful in identifying local resources. The domestic violence hotline is a very crucial number to provide for survivors of intimate partner violence. But there you see a list of national resources and the link to their website. The pediatric forensic nurse must create a safety plan for the intimate partner violence survivor and children, and this plan should be made with the survivor. Provide community resources, phone numbers, websites, educate the survivor regarding shelter arrangements that are available in the community, survivor mental health care, trauma-focused care for children and survivors, and then many communities have intimate partner violence mentors or advocates. Provide legal resources to the intimate partner violence survivor and help the survivor think through their own social support system, be it family, friends, faith-based. Adolescent patients should also be screened for their own experiences with intimate partner violence. Research tells us that conversational questioning, rather than the use of a screening tool, may be more beneficial in this population. Begin with open-ended questions and use more direct questions for clarification. And I'll let you read through these questions. And also, by the way, I should also let you know that research does tell us that in the adult population, the use of an electronic or paper screening tool may be more effective than face-to-face questioning of an adult regarding intimate partner violence. Anticipatory guidance regarding healthy relationships should be provided to all adolescents regardless of their intimate partner violence screening status. Potential limitations to confidentiality should be discussed with the adolescent prior to screening. Inform the adolescent that should they disclose information raising concerns for their safety, as a mandated reporter, the pediatric forensic nurse may need to share information with their parents, child protective services, and law enforcement. The pediatric forensic nurse must be familiar with state law describing mandatory reporting of teen dating violence, as well as adolescent consent and confidentiality. Should the adolescent endorse intimate partner violence, it is crucial to assess for lethality. Did the intimate partner violence involve the use of a weapon, strangulation, did serious bodily injury result? If factors associated with increased lethality are present, a report to child protective services and law enforcement is indicated to ensure adolescent safety. Inform the caregiver of the concern and safety plan with the adolescent and the caregiver. And as with adults, it's important to consult with other members of the health care team, such as social work, because the pediatric forensic nurse recognizes the importance of reporting to child protective services. Exposure to intimate partner violence is a source of trauma for children. For healing to begin, it is critical that trauma exposure be eliminated whenever possible. Caregivers must be educated regarding the potential negative impact of household intimate partner violence on their children. Children exposed to intimate partner violence will need a referral to mental health therapy for at least an assessment by a skilled therapist. Trauma focused cognitive behavioral therapy has the strongest proven efficacy in treating children who have been exposed to trauma. Eye movement desensitization and reprocessing is also a treatment used for trauma exposed children. Understanding the frequent coexistence of intimate partner violence and child maltreatment within families, pediatric forensic nurses must recognize that these children are at increased risk for abuse. A thorough head-to-toe cutaneous exam should be completed looking for any signs of injury. The caregiver and the child, whenever possible, should be asked developmentally appropriate questions regarding discipline. They should be separated for that discussion. And in pediatric health care in general, the anagenital exam offers an opportunity to educate children regarding the concept of private parts and to screen for sexual abuse. And so I urge all of you who have young children who are seeing pediatricians, pediatric nurse practitioners, or other health care providers on a regular basis to have this expectation that your child's health care provider performs an anagenital exam and uses that exam as an opportunity to educate the child regarding the concept of private parts and sexual abuse. Here you see an example of questions that can be used to screen caregivers regarding their discipline practices. And again, child and caregiver should be separated for this questioning. Simply asking, how do you discipline your child? How does your partner discipline your child? Does anyone ever spank your child with their hand? Where on their body? How often? Does it ever leave a mark? Does anyone ever hit your child with an object? What object? Where on their body? How often? Has it ever left a mark? Do you or anyone else ever use other physical methods of discipline, such as pinching, pulling hair, kicking? Or do you or anyone else ever use non-physical methods of discipline? And it's important to praise and encourage non-physical methods of discipline. Here's an example of some questions that can be used to screen the child regarding discipline. And again, parent and child should be separated. What happens when you get in trouble? What does mommy do when you get in trouble? What does daddy do when you get in trouble? Does anyone ever hit, whoop, or spank you? What do they hit you with? Or where on their, where on your body do they hit you? How often do you get hit? And does it ever leave a mark on your body? And I know I'm preaching to the choir when I talk about the anagenital exam being used as a vehicle for sexual abuse education and screening. But during the anagenital exam, explain to the child that everyone has private parts. Parts on their body that should not be touched, kissed, tickled, hurt, or anything put in it. And then ask the child, what are your private parts? And have the child verbally tell you or point to their private parts. What should you do if anyone bothers or tries to bother your private parts? Do you tell or keep it a secret? And you want the child to be able to verbalize that they should tell. Who could you tell if anyone bothered your private parts? And make sure the child can name at least two adults. You could also tell your teacher, nurse, policeman, and then ask has anyone ever touched, tickled, kissed, or hurt your private parts? And then who is allowed to help you with your private parts if you need help? Intimate partner violence is a serious public health problem. Children exposed to intimate partner violence are at risk for a multitude of short and long-term developmental, behavioral, and emotional consequences. Pediatric forensic nurses and all professionals working with children must possess knowledge and competency in the identification of intimate partner violence, implementation of interventions to ensure intimate partner violence victim and child safety, and local and national evidence-based resources for both survivors and exposed children. Monitoring to ensure linkage with offered community resources is crucial. Pediatric forensic nurses providing care to children demonstrating these skills will be better prepared to intervene when intimate partner violence is present and more able to provide comprehensive care to children and their families. This slide contains a audio recording of a 9-1-1 call, a child making a 9-1-1 call regarding intimate partner violence. And I included this in my presentation because I think it really points out just how we need to make a difference for these vulnerable children. Now let's work through some case studies together. Michelle is a 22-month-old who presents to the Child Advocacy Center for concerns of sexual abuse by a paternal uncle accompanied by her mother. On universal screening, mother endorses intimate partner violence and the pediatric forensic nurse as she's starting the exam notes the injury to the child's eye and asks them about the injury, asks her how she got the boo-boo on her eye and the child will not answer. Mother states she fell and hit her eye on the coffee table. As the exam progresses, the pediatric forensic nurse asks the child again about her eye. Michelle then answers, daddy. Mom starts crying and states that father accidentally hit child last night when she was holding her. Mother states he meant to hurt me, not Michelle. He never hurts her. No additional physical injuries are noted on Michelle's exam. Mom goes on to state that the intimate partner violence began in pregnancy and has continued. She states father gets frustrated with things at work and takes it out on her. States that the incidents occur pretty frequently. Michelle has never been injured before and father feels really bad about it. Mom denies any strangulation or use of a weapon in the course of the intimate partner violence. Mom states she has thought about leaving and states she could go to her parents home. What interventions are indicated? So what interventions are indicated? A, should a report be made to Child Protective Services and law enforcement? B, does Michelle need to be sent to the emergency department for a physical abuse workup? C, does there need to be a safety plan developed? D, does mother need to be provided with local intimate partner violence resources and counseling? E, should there be monitoring to make sure that there is linkage with offered resources? Or F, all of the above? The correct answer is F, all of the above. A report to Child Protective Services and law enforcement is indicated because Michelle has an injury that resulted from the intimate partner violence incident. And even though it was an unintentional injury, it's still concerning for physical abuse and needs to be reported to Child Protective Services and law enforcement. Michelle needs sent to the emergency department for a physical abuse workup because at the very least she's only 22 months of age, so she'll need a skeletal survey to rule out any acute or non-acute fractures and also some blood work to screen for abdominal trauma. The safety plan with the mother should also include exploring mom's social supports. And mom does need resources and counseling regarding local intimate partner violence, resources that are available in the community for both mom and Michelle, and there should be some monitoring regarding linkage with the resources. Case study number two. Six-year-old Jarrett presents to the emergency department accompanied by his mother for concerns of sexual abuse. Mom endorses intimate partner violence on universal screening. Mother and child both deny the use of any corporal punishment. What interventions are indicated? So what interventions are indicated? A. Does the pediatric forensic nurse need to know about state intimate partner violence reporting requirements? B. Should intimate partner violence, should it be explored with the mother? Does the pediatric forensic nurse need to find out exactly what the intimate partner violence means in this situation? C. Should the risk to the child be determined? D. Should the pediatric forensic nurse discuss with mother any potential negative impact of her child witnessing intimate partner violence? E. Should there be a safety plan developed? F. Should the pediatric forensic nurse provide local resources regarding intimate partner violence to mother? G. Should there be some monitoring of linkage with these resources? Or H, all of the above? The correct answer is H, all of the above. The pediatric forensic nurse knows that her state does not mandate universal reporting of intimate partner violence unless use of a weapon or a child is in imminent danger of injury. The pediatric forensic nurse explores the intimate partner violence with mother. Mom states, oh, things happen occasionally. The last incident was probably about two weeks ago. Dad came home from work drunk, yelling at her, hit her a few times. Jarrett witnessed the violence. Mom denies that dad has ever used a weapon. She further denies strangulation or ever needing to seek medical care for injuries. Mom denies threats of violence towards Jarrett. States father does not even spank him. Mom states father is always sorry after these incidents. Father is the sole breadwinner. Mother states, I will tell Jarrett to go to his room when the father is like that. But sometimes he sees things. A safety plan is developed with mother, including exploration of social supports and potential financial options for mother. Local resources are provided, survivor-focused therapy, trauma-informed therapy for Jarrett and mother, and information regarding intimate partner violence mentors that are available and legal resources. Is a report to Child Protective Services indicated? What do you think? Now keep in mind in this state, reporting is only mandated in the case of the use of a weapon, mom denied this, and a child in imminent danger. Mom denies any threats toward Jarrett, any physical violence ever directed toward Jarrett. So is a report to Child Protective Services indicated? I do not think so in this situation. A report to Child Protective Services is not indicated. If you have questions and you're debating in your mind back and forth whether this is something you need to report, first of all, always discuss the situation with other members of the healthcare team. If you're in the ED, the ED attending, if there's a social worker there, discuss with them. You can also call Child Protective Services and say, this is the situation. Is this a case that you all would accept? Case study number three, nine-year-old Malia presents to the emergency department for dysuria and vaginal bleeding. Now there are no concerns for sexual abuse, but the ED calls the pediatric forensic nurse because they hear dysuria and vaginal bleeding, and rightly so, vaginal bleeding does raise possible concerns for sexual abuse. So the pediatric forensic nurse is called into the emergency department. Mother endorses intimate partner violence on universal screening and also the use of corporal punishment. You explore intimate partner violence with mother. Mom states Malia's stepfather has issues with his temper. When he is angry, he hits mother and chokes mother. He has threatened her with his gun when she does not want to have sex. Mom denies he has ever hit Malia except to spank her on her bottom with a belt, but sometimes she feels uncomfortable because he talks about how beautiful Malia is. She says, I'm afraid he will touch her. Mom denies Malia ever disclosing to her that stepfather has done anything at all inappropriate, and mom also denies ever seeing any inappropriate interaction between Malia and stepfather. So what interventions are indicated? A, anogenital exam with sexual abuse education and screening, B, safety planning with mother, C, local intimate partner violence resources, D, report to child protective services and law enforcement, E, survivor-focused mental health resources, F, trauma-informed mental health care referral for Malia, G, all of the above. The correct answer is G, all of the above. Cases of intimate partner violence that involve a weapon and strangulation warrant reporting to child protective services because it is concerning for the mother's safety and the gun certainly raises concerns of safety for the child. The anogenital exam is just an essential element of a thorough medical forensic exam, and it certainly can be used as an opportunity to educate the child who is not disclosing sexual abuse and the caregiver regarding the concept of private parts and to tell if private parts are ever touched, hurt, kissed, etc. Malia had denied sexual abuse prior when the pediatric forensic nurse was talking alone with Malia, gathering any history of potential sexual abuse. Malia denied any history of sexual abuse at that point in time, but now Malia starts crying during the anogenital exam and the private part discussion, and she states her stepfather touches her coochie, vagina, with his coochie, penis, and it hurts. The pediatric SANE clarifies with anatomical drawings that coochie, she means coochie as a vagina and a penis, and the pediatric forensic nurse further clarifies when the last incident was, and Malia states last night, and so of course the pediatric forensic nurse then at that point realizes that evidence collection will be indicated, and that also a consideration includes HIV prophylaxis, offering HIV prophylaxis. Upon hearing the sexual abuse disclosure, mother is tearful and appropriately protective. She's cooperative with the idea of a referral to child protective services and law enforcement. Mom expresses that she will be protective and that she is finished with the stepfather. Mother states that her sister lives in town and she and Malia can stay with her. Mother is given the intimate partner violence resources, child protective services is notified, and they are fine with the safety plan of discharge to mother, home to mother's sister. Now some questions for you. Question number one, intimate partner violence can include which of the following? A, physical violence, B, sexual violence, C, psychological aggression, D, stalking, or E, all of the above? Correct answer is E, all of the above. Intimate partner violence can include physical violence, sexual violence, psychological aggression, and stalking. Question number two, which of these is the most significant risk factor for both intimate partner violence victimization and perpetration? A, poverty, B, living in a violent neighborhood, C, childhood exposure to parental intimate partner violence, D, mental health concerns. Correct answer is C, childhood exposure to parental intimate partner violence is the most significant risk factor for both victimization and perpetration. Question number three, all of these are true regarding the co-occurrence of intimate partner violence and child maltreatment except A, 26% to 73% of children experiencing child maltreatment are living in families where intimate partner violence is present, B, mothers who are victims of intimate partner violence are more likely to endorse the use of harsh child discipline than mothers who are not victims of intimate partner violence, C, in about 30% to 60% of homes in which intimate partner violence is present, the children are also victims of child maltreatment, or D, research evidence shows that adults raised in homes in which they were exposed to intimate partner violence as a child are less likely to have been physically or emotionally abused as a child, but more likely to be the partner in a relationship that invokes intimate partner violence. The correct answer is D, all of these statements are true except research evidence shows that adults raised in homes in which they were exposed to intimate partner violence as a child are less likely to have been physically or emotionally abused as a child, they are more likely to have been physically or emotionally abused, and it is true that they are more likely to be the partner in a relationship that invokes intimate partner violence. Question number four, what is the most significant predictor of resilience among children exposed to intimate partner violence? A, socioeconomic status, B, maternal physical and mental health, C, siblings, D, high child cognitive functioning. The correct answer is B, maternal physical and mental health is the most significant predictor of resilience among children exposed to intimate partner violence. Question five, intimate partner violence can result in unintended pregnancy via which of the following? A, forced sexual intercourse, B, fear of discussing contraception use with partner, C, partner interference with contraception use, or D, all of the above. The correct answer is D, all of these, forced sexual intercourse, fear of discussing contraception and partner interference with contraception can lead to unintended pregnancy. Question six, what is the greatest risk factor for intimate partner violence escalating to homicide? A, frequency of the violence, B, violence involving stalking, C, having a gun in the home, D, LGBTQ relationship. The correct answer is C, having a gun in the home is the greatest risk factor for IPV escalating to homicide. Question seven, the following are true regarding teen dating violence except A, childhood exposure to intimate partner violence increases risk for adolescent intimate partner violence victimization and perpetration, B, romantic relationship problems can be a precipitating factor in adolescent suicide, C, adolescent intimate partner violence never results in death, D, about 6.5% of all violent deaths in youth are intimate partner violence related. The correct answer is C, all of the following statements are true except adolescent intimate partner violence never results in death, that is not true. Question number eight, adolescent primary care should include A, discussion of healthy relationships, B, screening for teen dating violence, C, assessing lethality risk related to any reported violence, D, all of the above. The correct answer is D, all of the above. Question number nine, the following statement is are true regarding parental caregiver screening for intimate partner violence, A, only high-risk families should be screened, B, face-to-face screening may be more effective than electronic screening, C, prior to screening identify local evidence-based accessible affordable community resources, D, use of an evidence-based screening tool is not necessary. And the correct answer is C, prior to screening identify local evidence-based accessible affordable community resources, A is incorrect, screening should be universal, B is incorrect, research tells us that when screening adults, electronic screening may be more effective than face-to-face, and D is not correct because the use of an evidence-based screening tool is important. What is true regarding reporting of intimate partner violence to law enforcement and slash or child protective services? A, all states require reporting of intimate partner violence in the presence of a child, B, state law varies regarding the reporting of intimate partner violence, C, healthcare providers should consider the lethality of the intimate partner violence when making the decision to report, D, children who suffer collateral physical injuries in the midst of intimate partner violence are victims of physical abuse, E, all but A. The correct answer is E, all but A. All states do not require reporting intimate partner violence in the presence of a child. Well I asked you 10 questions, so if you have any questions for me, please shoot me an email, you see my email listed there. And again, I thank you for attending this virtual session. And the next two or three slides will be a partial list of references for this presentation. If you would like a complete list of references, just let me know, just shoot me an email. Again, some additional references. Additional references, again if you would like the complete list, just shoot me an email. And then also thank you for attending Intimate Partner Violence in Children.

Intimate Partner Violence

Children

Forensic Nursing

Psychological Trauma

Child Maltreatment

COVID-19 Pandemic

Safety Plans

Healthcare Professionals

Mental Health Support

Cultural Sensitivities

Community Resources