Children's Doctor

Violence and Children

Intimate Partner Violence: The Silent Epidemic

Joel A. Fein, MD, MPH; and Megan H. Bair-Merritt, MD, MSCE

A mother brings her 6-month-old for a well-child visit and tells you that the baby cries frequently and is hard to comfort. Her weight has fallen to the 10th percentile from the 25th at her last visit. Her exam is otherwise unremarkable. At the end of the visit, the mother discloses that her partner sometimes hits her. How do you proceed?

Discussion: Every year in the United States, approximately 2 million women are abused by an intimate partner, and as many as 10 million children witness these events. Children exposed to intimate partner violence (IPV) are more likely to have poor emotional and physical health outcomes in both childhood and adulthood. Child abuse and IPV occur together in 40% to 70% of households.

The American Academy of Pediatrics recommends routine IPV screening in the pediatric setting. Routine screening makes the pediatric office a safe place in which to discuss IPV and receive help, improves our understanding of the child’s current illnesses or chronic complaints, and breaks the traditional silence surrounding IPV.

The care provider should try to contextualize the questions. (“The safety and health of a mother affect the health of her children. I ask all my patients about safety in their homes.”) For women with children younger than 3 years, direct IPV questioning is preferable. (“Have you been hit, kicked, punched, or otherwise hurt by a romantic partner in the past year?”) To prevent older children from inadvertently relaying the conversation to the abuser, screen while the child is at hearing or vision tests, or ask more general questions, such as “How would you describe your relationship with your partner: a lot of tension, some tension, or no tension?” Continued concern should prompt an interview with the woman alone to ask specific questions.

Because the child’s father has access to the medical chart, documenting an IPV conversation potentially increases risk if he is the perpetrator. It may, however, be beneficial to document IPV in case the victim needs this information in court. Some outpatient practices develop a code used only in their office to denote provider concerns about IPV.

When a patient’s caregiver discloses IPV, first support the parent for her disclosure, emphasizing that the abuse is not her fault and that she does not deserve to be treated that way. It is important to assess the parent’s perception of the family’s safety, including questions about escalation of violence, weapons, and child abuse. Families in immediate physical danger require emergent referral to local IPV shelters. Otherwise, offer a listing of community IPV resources (and child mental health resources, as appropriate). Provide abused women with information by displaying IPV posters and/or placing information in patient rooms and bathrooms.

Pediatric providers are obligated to report suspected child maltreatment to Child Protective Services. Additionally, a few states have mandated reporting of childhood exposure to IPV. To determine your state’s reporting requirements, may be a helpful resource. If required to report IPV exposure, inform the parent of this responsibility before screening, and encourage her also to file a report herself, which can lessen later accusations of “failure to protect.”

IPV is pervasive and harmful to children. As pediatricians, we are in an important position to discover IPV and to connect our families with beneficial resources.

References and Suggested Readings American Academy of Pediatrics. The role of the pediatrician in recognizing and intervening on behalf of abused women. Pediatrics. 1998;101:1091-92.

McAlister Groves B, Augustyn M, Lee D, et al. Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. San Francisco: Family Violence Prevention Fund (, 2004.

National 24-hour, toll-free Domestic Violence Hotline [800-799-SAFE (7233)].

An Injured Infant

Cindy W. Christian, MD

A 12-week-old infant was well until the day of hospital admission, when she awoke difficult to console. During her feeding, the baby began vomiting and coughing up bright red blood. She developed respiratory difficulty and was brought by her parents to Children’s Hospital’s Emergency Department. There was no fever nor diarrhea, and she had no URI symptoms. She had a single previous episode of hematemesis, which resolved rapidly. The parents’ pediatrician said it was likely related to a nose bleed, and to seek medical care if the problem persisted. The baby was cared for by her parents, and occasionally by her maternal grandmother.

In the ED, the baby was irritable with mild-moderate respiratory distress. She was afebrile, with stable vital signs, and a respiratory rate of 44. She had a few petechiae over the right eyelid, and crepitus over the scalp and neck. She had stridor with retractions when agitated, but no wheezing nor rales. The infant was given racemic epinephrine for her stridor, and an intravenous line was placed. Laboratory evaluation revealed a white blood cell count of 18 700/uL, hemoglobin 9.6g/dL, and platelet count of 530 000/uL. A chest X-ray revealed a pneumomediastinum, with clear lung fields and a normal bony thorax, and a lateral neck radiograph showed significant amounts of subcutaneous air, with moderate widening of the retropharyngeal soft tissues with small focal air collections.

The infant was admitted to the Pediatric Intensive Care Unit. A bedside endoscopy revealed a posterior pharyngeal wall tear with early eschar formation, a posterior pharyngeal bulge, and laryngeal edema.

During an interview with the child protection team, the parents denied trauma to the baby. Further evaluation included a skeletal survey, which revealed acute fractures of the forth through seventh right lateral ribs, confirmed by bone scintigraphy. An MRI of the brain was normal. The medical team made reports to Child Welfare and the police, and after recovery, the baby was discharged to maternal relatives.

Discussion: Each year in the U.S., Child Welfare receives nearly 3 million reports of suspected maltreatment, and investigations find evidence of abuse in approximately 1million of these cases. Injuries to the face, mouth, and neck are among the most common.

All physicians are mandated by law to report suspected child abuse and neglect to Child Welfare. Physicians who report in good faith are protected from liability if the abuse is not confirmed, but failing to report abuse can occasionally result in criminal or civil penalties.

When children are severely injured by abuse, a referral to police is necessary. Police investigation can result in the arrest and criminal prosecution of a perpetrator of physical abuse.

The need to report should always be discussed with the child’s family. Unique communication skills are required because discussions of maltreatment can be emotionally difficult. The focus of the conversation should always be on the welfare and well-being of the child, not on apportioning blame to an adult. Parents need to be informed of the plans for both medical treatment and investigation. Initial honesty with the family about reporting allows open discussion of social matters during later medical visits. Arranging for follow-up also indicates a willingness to work with the family during a crisis. Reporting suspected abuse can save a life and may be a first step toward improving family functioning.

References and Suggested Readings
Reece R, Ludwig S (Eds.) Child Abuse Medical Diagnosis and Management. 2nd ed.
Philadelphia, Lippincott,Williams and Wilkins, 2001.

Kellogg, Nancy D, and the Committee on Child Abuse and Neglect. Evaluation of Suspected Child Physical Abuse.
Pediatrics. 2007 Jun;119:1232-1241.

Bullies and Victims

Stephen S. Leff, PhD, and Jill C. Posner, MD, MSCE

A previously well 10-year-old girl comes to the office for an evaluation of chest pain. This is her third visit in 2 weeks for the same complaint. She describes the pain as dull, located midsternally, and nonradiating. She denies fever, cough, palpitations, diaphoresis, syncope, or other constitutional complaints. There is no personal or family history of asthma, cardiac disease, or hearing loss. The physical examination, chest radiograph, and electrocardiogram are normal. Over-the-counter analgesics have brought little relief. The girl has missed 8 days of school. On further questioning, she reveals that a classmate has been spreading rumors about her and she feels as if “all her friends are turning on her.”

Discussion: When physical complaints are accompanied by reports of peer-relationship concerns, a youth may be in psychological distress related to bullying and victimization. There are many things pediatric health providers can do to assist parents in recognizing and responding to these types of troubling concerns.

Bullying is a form of aggression that is intended to harm another individual either physically (through behaviors such as hitting or pushing), and/or socially (by harming one’s reputation through social exclusion or gossip). For aggressive behavior to be considered bullying, the aggressor must have more power than the victim, either physically or socially, and the behavior must occur repeatedly over time.

Recent research suggests as many as 30% of school-age youth are involved in moderate to severe bullying episodes several times a month. Further, children who frequently bully others often have difficulties with problem-solving, friendships, and controlling anger. Victims of aggression also have friendship difficulties, sometimes experience somatic complaints, occasionally avoid school, and may have problems with self-confidence.

The American Academy of Pediatrics has called for pediatric health care professionals to take an integral role in preventing youth bullying. One method is for pediatric care providers to screen for and briefly assess four primary dimensions, which include the child’s: (1) involvement in low level peer conflicts at school, (2) ability to form and maintain friendships, (3) problem-solving abilities, and (4) relationship and communication with their parents and/or with key school staff. When it is clear a child is having a bullying problem, there are several strategies care providers can use (See Table.) First, it is important to help youth recognize important bullying “hotspots” at school, such as unsupervised areas of the playground, the lunchroom, and hallways. Second, providers should advise parents on strategies to promote strong friendships at school. Research is clear that having 1 good friend is a powerful buffer against peer victimization. Third, care providers can help parents and youth open lines of communication with one another and with important school staff such as a teacher or counselor. Providers can also enhance youth’s problem-solving and empathy skills through brief treatment modalities.

In these ways, pediatric healthcare providers play a key role in working with parents, youth, and schools to recognize, treat, and prevent bullying and victimization.

References and Suggested Readings
Leff SS, Costigan TE, Power TJ. Using participatory-action research to develop a playground-based prevention program.
Journal of School Psychology. 2004;42,3-21.

Leff SS, Tulleners C, Posner J (in press). Aggression, Violence, and Delinquency.

In Carey WB, Crocker A, Coleman W, Elias E, Feldman HM (Eds).
Developmental-Behavioral Pediatrics, Fourth Edition. Philadelphia: Elsevier.

In the Crossfire

Michael L. Nance, MD

On a warm summer evening, 15-year-old Isaac was caught in the crossfire of a neighborhood gun battle and sustained gunshot wounds to his chest, abdomen, and extremities. Transferred to the Trauma Bay at The Children’s Hospital of Philadelphia, Isaac was awake but hypotensive. The Emergency Team identified at least 10 bullet holes and initiated standard Advanced  Trauma Life Support protocols. They placed tubes in both thoracic cavities, yielding more than 1500 cc of blood. Isaac’s blood pressure waned despite aggressive resuscitation with blood products and the Trauma Bay interventions. In the operating room, he underwent a left thoracotomy, an exploratory laparotomy, and a right thoracotomy. He was found to have multiple lung lacerations, a diaphragmatic tear, large liver and splenic lacerations, and an extensive esophageal injury. Because of the extent of his injuries, the team abbreviated his laparotomy, packed his abdomen for hemostasis, and transferred him to the PICU to continue aggressive rewarming and resuscitation. After 21 days in the PICU and another 7 days on the surgical ward, Isaac was transferred to Children’s Seashore House for inpatient rehabilitation. He needed 2 more surgeries but has since returned to school and is counted among the lucky—a survivor.

Discussion: The city of Philadelphia currently has the highest murder rate among the 10 largest cities in the U.S. Our city has experienced a dramatic surge in gun violence over the past 2 years, with children and young adults hit particularly hard. Since January 2006,nearly half (251 of 519) of all firearm homicides were in Philadelphians aged 0 to 25 years.Because of the inability to curb the appetite of Americans for firearms, we live in a heavily armed nation.

With far more than 200 million small arms (90 firearms per 100 Americans) in circulation in the U.S., the injury-prevention paradigms must shift from how to limit weapons, to how to live safely in a world with guns. Efforts to effectively combat this injury epidemic have fallen short.

As cities struggle with ways to cope with the prevalence of guns and gun violence, the pediatrician has a unique role and traditionally early access into the life of the child. Such access may be ideally suited to initiate firearm education with the patient and family. To that end, the American Academy of Pediatrics, as part of a policy statement, recommends that pediatricians ask about guns during patient histories and urge parents who have guns to remove them from the home. The statement says adolescents who have a history of violent behavior are at particular risk.

A survey of pediatricians regarding gun injury prevention revealed that most consider violence prevention (including firearm violence) as a priority for pediatricians (92%) and regard anticipatory guidance on firearm safety as a means to reduce injury (83%). Despite recognition of the problem, fewer than 50% of survey respondents reported they always offered firearm-safety counseling. Barriers to educating patients and their families were insufficient time (73%) and insufficient practitioner training (67%).

With the resurgence of gun violence, we need to redouble educational efforts in hopes of easing the epidemic. While the true efficacy of such labors is unclear, one cannot help but think that early and frequent reminders of the potential devastation of firearm exposure are warranted. A quick fix is highly unlikely, and vigilance is in order.

References and Suggested Readings
AAP Policy statement: Firearm-related injuries affecting the pediatric population. Committee on Injury and Poison Prevention, American Academy of Pediatrics.
Pediatrics. 2000 Apr;105(4 Pt 1):888-95.

Olson LM, Christoffel KK, O’Connor KG. Pediatricians’ involvement in gun injury prevention.
Inj Prev. 2007 Apr;13(2):99-104.

Residents’ Corner

Jordan Rettig, MD, Resident Contributor

Suicidal Teen

A 16-year-old female presented to a clinic at a local homeless shelter with abdominal pain and a history of endometriosis. The patient described intermittent right lower quadrant (RLQ) pain, without any aggravating or alleviating factors. She denied nausea, vomiting, or constipation. She was afebrile, and her last menstrual period was 2 weeks ago. She was taking Tylenol for her pain. She did not have similar pain with endometriosis.

On physical exam she was well-appearing, afebrile with age appropriate vitals. She had RLQ tenderness without rebound or guarding. She had normal bowel sounds without hepatosplenomegaly. There was no equipment at the shelter to conduct a gynecological exam.

Upon further history, the patient reported that she moved into a shelter with her mother 2 weeks ago. She reported that she is sexually active with 2 partners, and she does not use either condoms or oral contraceptives. Pregnancy and HIV tests 2 weeks ago were negative. During a review of psychiatric symptoms, the patient said she had thought about killing herself by taking a bottle of Tylenol. It was further revealed that her mother had attempted suicide several times.

Discussion: Among the concerns for this patient was her report of suicidal ideation. In addition, there was a broad differential for her abdominal pain, including pregnancy, pelvic inflammatory disease, endometriosis, ovarian cyst, torsion, or abscess. In the context of both suicidal ideation and clear concern for a medical process, it was difficult to find an appropriate disposition for this adolescent patient.

An all-too-common problem in the primary care setting is how to address psychiatric problems. Depression among adolescents typically presents in primary care. and is generally underdiagnosed and undertreated. Researchers estimate that 70% of depressed teenagers do not receive treatment.

In this case, the patient was referred to an on-call crisis team and ended up at an adult ED, where the crisis team felt she was more likely to have access to both psychiatric and medical services, including OB/Gyn.

The encounter was not entirely satisfying. Ideally, we wanted this patient in a pediatric/adolescent-friendly setting, both from medical and psychiatric standpoints. Perhaps the most important lesson from this encounter is that to better serve our patients, we as pediatricians must seek out and advocate for the development of such services.

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