Screening for Family Violence
There is insufficient evidence to recommend for or against
the use of specific screening instruments to detect family
violence, but recommendations to include questions about
physical abuse when taking a history from adult patients
may be made on other grounds (see Clinical Intervention).
Clinicians should be alert to the various presentations
of child abuse, spouse and partner abuse, and elder abuse.
Burden of Suffering
Family violence is a serious public health problem for many
Americans. Family violence includes child abuse (physical
and sexual abuse), domestic violence (physical or sexual
abuse of spouse or intimate partner), and elder abuse
(abuse or neglect of older persons).1 Because many cases
of family violence go unreported, the true magnitude of
the problem can only be estimated.2
Child Abuse. In 1993, child protective service agencies
substantiated maltreatment of over 1 million children in
the U.S. (a rate of 14/1,000 children); over 1,028 deaths
due to child maltreatment were reported in 1993.3
Intentional injury is the leading cause of injury-related
death in children under 1 year of age.4 Parents or other
relatives are responsible for over 90% of reported cases
of child maltreatment.3 In addition to physical injuries,
children who have been victims of or witnesses to violence
often experience abnormal physical, social, and emotional
development; adolescents and adults who were abused as
children are more likely to abuse tobacco and alcohol,
attempt suicide, and exhibit violent or criminal behavior.2,5-7
Approximately 140,000 cases of child sexual abuse were
reported in 1993,3 but the true incidence has been estimated
to be as high as 450,000 cases per year.8 In sexual abuse
cases where the abuser was known to the child, over two
thirds involved abuse by family members.9 Girls are victims
of sexual abuse two and a half times more frequently than
boys.10 Child sexual abuse often results in severe
psychological trauma,11 has been associated with a variety
of psychological problems persisting into adulthood, and
can cause medical complications such as sexually transmitted
diseases. Teens who had been sexually abused were
significantly more likely than nonabused controls to be
sexually active, to abuse alcohol or drugs, and to have
A number of parental and family characteristics have been
identified as risk factors or risk markers for child physical
abuse_poor social support, low socioeconomic status, single
parent family, and unplanned or unwanted pregnancy13_but
abuse is usually the result of multiple interacting
factors.14 Abuse of drugs or alcohol, although not clearly
an independent risk factor, often coexists with conditions
(poverty, social isolation, etc.) that increase the risk of
abuse.15 Abusive mothers are often themselves victims of
physical violence by their spouse or partner,16 and abusive
parents often experienced abuse as children. A poor
understanding of normal child development, poor anger
control, and use of physical punishment as a discipline
technique are more common among abusive parents.13 In
contrast, demographic or family characteristics are of
little value in predicting risk of child sexual abuse.17
Domestic Violence. Estimates of the prevalence of domestic
violence among couples vary depending on the source of data
and definition of violence.18 A national survey of 50,000
households conducted in 1992 and 1993 estimated that over
1 million women (9.3/1,000) and nearly 150,000 men (1.4/1,000)
are victims each year of assault, robbery, or rape committed
by their spouse, ex-spouse, or intimate partner;19 over half
of these incidents result in minor injury, and 3% in serious
injury (broken bones, loss of consciousness, hospitalization,
etc.).20 This estimate may be conservative due to
underreporting. In a comprehensive survey of family violence,
involving detailed interviews of a total of 8,145 families in
1975 and 1985, 16% of couples reported instances of violence
in the previous year (including shoving, slapping, or grabbing);
40% of these episodes involved more serious actions such as
kicking, punching, or use of a weapon.21,22 In recent surveys,
2-3% of women reported being kicked, bitten, or hit with fist
or some other object by their partner in the preceding
year.22,23 Family studies indicate that both men and women
engage in violence against partners, but women are the primary
victims of chronic battering and episodes leading to injury.24
In 95% of episodes of domestic violence leading to criminal
investigation,20 and 59% of spouse murders,25 women were the
victims. The prevalence of domestic violence is also high among
female patients in clinical settings: 15% of women visiting an
emergency department26 and 12-23% of women in family practice
settings27,28 reported having been physically abused or
threatened by their partner within the last year. Domestic
violence tends to be repetitive_female victims reported an
average of six violent incidents per year.22 The psychological
consequences of abuse can be as important as physical injuries:
abused women may suffer from posttraumatic stress disorder, and
they are more likely than nonabused women to be depressed,
attempt suicide, abuse alcohol or drugs, and ransfer their
aggression to their children.29,30
Violence between spouses or partners can occur in families
from all demographic and economic strata of society,22 but
risk of physical assault appears higher for some groups of
women. Women who are under age 35, have not attended college,
are of lower socioeconomic status, or are unmarried are more
likely to report being victims of domestic violence.20 A review
of 52 studies found that only one risk marker_witnessing
parental violence as a child or adolescent_was consistently
associated with being a battered spouse.31 Childhood family
violence and alcohol problems are more common among abusive
partners.22 In general, however, the primary care physician
is not able to predict reliably which patients are likely
to be affected by domestic partner violence.32
Pregnant women are also at risk from domestic violence.33,34
In surveys of pregnant women (primarily from urban, public
clinics), 7-18% of women reported physical abuse (including
forced sexual activity) during the current pregnancy.35-38
Many studies have reported an association between violence
and worse outcomes in pregnancy. Battered women are more
likely to register late for care, suffer preterm labor or
miscarriage, or have low birth weight infants than
Elder Abuse. Elderly persons are also vulnerable to
physical or psychological abuse or neglect by family
members or other caregivers.40,41 Community surveys in
Boston and Canada estimated that 3-4% of persons over
age 65 are victims of physical abuse, neglect, or regular
verbal abuse.42,43 Factors that appear to increase
vulnerability to abuse among older persons include poor
or failing health, cognitive impairment, and lack of
family, financial, or community support.41 The abuser is
usually a relative, most often the spouse.44 Family
members who have a history of substance abuse, mental
illness, or violence, or who are financially dependent
on the elder person, are more likely to be abusive.41
Accurate estimates of the medical consequences of
elderly abuse (patient visits, hospitalizations, or costs
of care) are not available.42 It is estimated that less
than 1 in 5 cases of elder abuse is reported, due to
denial or minimization of the problem by the victim,
abuser, or health professionals.45 In one report, up
to 60% of elder abuse victims admitted for acute medical
care remained permanently institutionalized.46 The
incidence of mistreatment of elders in institutions is
not known. A survey of nursing home staff revealed that
36% of the staff had witnessed physical abuse, and 81%
had witnessed psychological abuse of patients.47
Accuracy of Screening Tests
Family violence may come to attention when it results in
severe injuries, but ongoing abuse often goes unrecognized
in the clinical setting. The clinician can identify victims
of domestic violence through the patient interview, use of
a standardized questionnaire, or the physical examination.
There are few reliable techniques for screening for child
abuse. Questionnaires can identify risk factors for child
abuse and neglect, but the potential to falsely label
families as "potential abusers" is a limitation to their
use in clinical practice.48 Eliciting evidence of child
physical or sexual abuse through patient interview is
difficult. Young children may not be able to answer reliably,
both child and parent may be ashamed or fearful of admitting
to abuse, and some abusive parents may not regard their use
of physical punishment as abuse. Most authorities recommend
exploring for potential problems with open-ended, nonjudgmental
questions about parenting and discipline (e.g., "What do you do
when he misbehaves? Have you ever been worried that someone was
going to hurt your child?").14,49 The value of standardized
questions or screening instruments to improve the detection
of child abuse is not known. Physical findings suggestive of
abuse noted during routine or symptomatic examinations have
been described.50 Burns, bruises, and other lesions can be
suggestive due to their appearance (e.g., patterns resembling
hands, belts, cords, and other weapons) or location (buttocks,
lower back, upper thighs, and face). Multiple traumatic injuries
without a plausible explanation are also suspicious. At the same
time, accidental injuries may produce similar findings in
children, and many abused children (especially victims of sexual
abuse) have no obvious physical findings. In a survey of studies
of sexually abused children, normal examinations were reported
in up to 73% of girls and 82% of boys.51 Neither the sensitivity
nor specificity of screening for abuse with physical examination is known.
Some studies report that less than 10% of battered women are
accurately diagnosed by physicians, even in hospitals with an
established protocol for this problem.30,33 The routine patient
interview often fails to detect abuse in adult patients, in
large part because physicians do not routinely ask about
domestic violence. Only a third of physicians in one survey
felt that routine questions on abuse should be part of the
annual examination.52 Many physicians are reluctant to ask
about abuse, out of fear of offending their patients,
inability to "fix" abusive relationships, frustration in
dealing with resistant patient behavior, and lack of time
to deal with the problem.53 Both victim and abuser may deny
abuse for a variety of reasons_embarrassment, psychologic
repression, or fear of reprisal, abandonment, or legal consequences.
Consistent use of screening protocols significantly improves
the detection of abuse as a cause of trauma,54 and similar
measures have been shown to increase the detection of
domestic violence affecting pregnant and nonpregnant
outpatients. The large majority of abuse victims favored
routine questions about abuse, and half indicated that
they would volunteer information about domestic violence
only if specifically asked.52 Directly asking individuals
about the occurrence of abuse has been shown to elicit
more positive reports (29% vs. 7%) than the use of a written
self-report.55 The Abuse Assessment Screen, containing five
questions on the frequency and severity of past and current
physical abuse and forced sexual activity, has been
validated against more comprehensive instruments in
pregnant women.56 Incorporation of this instrument into the
standard social service interview of pregnant patients
significantly increased the detection of recent abuse
compared to historical controls (15% vs. 3%).35
There are fewer studies on screening for elder abuse.
The value of the patient interview may be limited if
the abuser is present. A 15-item instrument for detecting
elder abuse had a sensitivity of 64% and specificity of
91% in a pilot study, but has not been validated for
screening in routine practice.57
Effectiveness of Early Detection
The repetitive nature of family violence suggests that
early detection may be important in preventing future
problems from abuse. Specifically, patients can be
counseled about the nature and course of family
violence, given information about available resources
(community counseling and support groups, shelters,
protective service agencies, etc.), and counseled
about means to prevent further abuse. Psychological
counseling, by either the primary care clinician or
a mental health professional, may help the patient
terminate personal relationships with violent
individuals. The clinician may also identify
individuals who are at increased risk of committing
abuse in the future. Such persons may be referred for
psychiatric counseling or family therapy to learn
stress management and nonviolent alternatives for
conflict resolution. Finally, the clinician is able
(in many instances, required) to report suspected
cases of abuse and neglect to appropriate protective
service agencies for further evaluation and intervention.
Intervention studies in child abuse have concentrated
on primary prevention.48 Two randomized clinical trials
have shown that home visits to high-risk families
decrease the rate of child abuse and the need for
medical visits early in life.58,59 Interventions may
need to be ongoing to retain effectiveness: extended
follow-up of one of these trials found no effect of
intervention on the rate of abuse and neglect later
in life (ages 25-50 months).60 Unfortunately, most
clinicians do not have the option of providing this
level of intervention. Studies evaluating the
effectiveness of treatments for abused children are
limited, and their results have been mixed.61
Recurrent abuse despite interventions may occur in
up to 60% of cases.62 The effectiveness of treating
sexual abusers of children remains controversial;
one outpatient program reduced recidivism by half.63
The effectiveness of early intervention for domestic
violence is also difficult to determine. Most
interventions for spouse abuse (e.g., shelters, legal
action) are crisis oriented and have been directed at
women who have already been injured by domestic
violence. The options available to women are often
limited by associated factors common in abusive
relationships: financial dependence on an abusive
partner, fear of retribution, alcohol or drug problems,
or psychological vulnerability.22,64 As a result, many
abused women decline offers of help.65 For women who do
attempt to terminate an abusive relationship, the
available resources to assist them are often limited
and temporary. In a controlled study of battered women
leaving a shelter, women who received services of an
advocate for 4-6 hours per week reported better overall
quality of life, but no significant difference in levels
of physical abuse, compared to controls.66 Whether
treatment of abusive men is effective in reducing
domestic violence remains controversial. A randomized
trial of group therapy (vs. standard care) for convicted
wife-abusers showed that repeat abuse was significantly
lower for the treatment group.67 Effective approaches to
couples who engage in mutual, less severe violence
(pushing, shoving, etc.) have not been developed. A
large controlled study is under way to examine whether
an integrated program to improve detection and management
of domestic violence in the primary care setting leads to
better clinical outcomes.68
Effective interventions for elder abuse may also be limited,
in large part because the abuser is often the primary caregiver
to the victim.41 If the only alternative is nursing home
placement, victims may be reluctant to give up their
independence in order to escape abuse. A review of elder
physical abuse victims in Illinois reported that most
victims received few tangible services from social service
agencies other than case management (primarily monitoring).69
Among abused elders, an advocate program decreased social
isolation and improved services, but a reduction in
subsequent abuse was not demonstrated.70
Recommendations of Other Groups
The American Academy of Pediatrics,71 American Medical
Association,72,73 American Academy of Family Physicians
(AAFP),74 and the Bright Futures guidelines49 all
recommend that physicians remain alert for the signs
and symptoms of child physical abuse and child sexual
abuse in the routine examination. Bright Futures suggests
including questions about child discipline, and abuse of
the child or parents, at the discretion of the clinician.
The AMA's Guidelines for Adolescent Preventive Services
(GAPS) recommend that teens should be asked annually
about a history of emotional, physical, and sexual
abuse.75 The use of screening devices to identify
families at risk for child maltreatment is not
recommended by the Canadian Task Force on the Periodic
Health Examination (CTF).48 Legislation in all states
requires health care professionals to report
suspected cases of child abuse.73
The American College of Obstetricians and Gynecologists
(ACOG),76 the U.S. Surgeon General,77 the American College
of Physicians,78 and the AAFP74 all recommend that
clinicians be alert to the possibility of domestic
violence as a causal factor in illness and injury.
ACOG and AMA guidelines on domestic violence recommend
that physicians routinely ask women direct, specific
questions about abuse.79,80 ACP and AAFP guidelines are
currently under review. An expert panel convened by the
National Research Council and the Institute of Medicine
(Washington, DC) to evaluate the effectiveness of family
violence interventions is scheduled to publish its
findings in 1996. Healthy People 2000, a report of
national health objectives,81 and the Joint Commission
on Accreditation of Healthcare Organizations82 recommend
that all emergency departments use protocols to improve
the detection and treatment of victims of domestic violence.
The CTF determined that there was insufficient evidence to
include or exclude case-finding for elder abuse as part of
the periodic health examination, but recommended that
physicians be alert for indicators of abuse and institute
measures to prevent further abuse.44 The AMA recommends
that physicians routinely ask elderly patients direct,
specific questions about abuse.83 Many states require
reporting of domestic violence84 and elder abuse.41
Family violence is an important cause of physical and
psychological harm in children and adults, yet it often
goes undetected by clinicians. Identifying victims of
domestic violence provides important information to
clinicians and may allow early intervention to reduce
the risk from future abuse. Although the benefit of
routine screening has not been directly assessed, several
factors support greater efforts by clinicians to detect
domestic violence between spouses or sexual partners:
the substantial prevalence of violent behavior among
couples, the repetitive nature of domestic violence,
and its high medical and societal costs.1 Contrary to
common perceptions, most patients appreciate being
asked about possible abuse, and direct questioning
may substantially increase reporting of episodes
of domestic violence.
At the same time, clinicians face important obstacles in
preventing violence or sexual abuse within the family. The
etiology of domestic violence is multifactorial and is a
function of social conditions, family conflict, cultural
attitudes, and biologic factors. Interventions for physical
or sexual abuse, mostly outside of the medical domain, vary
greatly in effectiveness. Although crisis interventions
(arrests, referral to shelters) are appropriate to protect
victims in specific cases, there are few adequately
controlled studies to determine the effect of counseling
or referral on the long-term outcome of family violence.
Appropriate screening methods for child abuse and elder
abuse are also uncertain. Screening for abuse through the
patient history is problematic with young children, may be
unreliable if the abuser is also present, and can be
complicated by denial in all age groups. Errors in
diagnosing abuse are of great concern because of the
serious emotional, legal, and societal implications of
either failing to take action in cases of abuse or of
incorrectly accusing innocent persons.
Despite the limited and imperfect options for detecting
and intervening in domestic violence, the benefits are
substantial for those families where the cycle of abuse
can be interrupted. It is also important for clinicians
to maintain a high index of suspicion when examining
other persons at risk of physical or sexual abuse (e.g.,
children and the elderly), to assess potential risk factors
for domestic violence, and to refer abuse victims and
perpetrators to other professionals and community
services to help prevent future incidents.
There is insufficient evidence to recommend for or against
the use of specific screening instruments for family
violence, but including a few direct questions about
abuse (physical violence or forced sexual activity)
as part of the routine history in adult patients may be
recommended on other grounds ("C" recommendation). These
other grounds include the substantial prevalence of
undetected abuse among adult female patients, the
potential value of this information in the care of the
patient, and the low cost and low risk of harm from such
screening. All clinicians examining children and adults
should be alert to physical and behavioral signs and
symptoms associated with abuse and neglect. Various
guidelines are available to help clinicians in
recognizing abuse and neglect in children,71-73
spouses/partners,80 and elders.81 In all states,
suspected cases of child abuse or neglect must be
reported to local child protective services agencies.
In most states, suspected elder abuse must also be
reported.41 All individuals who present with multiple
injuries and an implausible explanation should be
evaluated with attention to possible abuse or neglect.
Injured pregnant women and elderly patients should
receive special consideration for this problem.
Suspected cases of abuse should receive proper
documentation of the incident and physical findings
(e.g., photographs, body maps); treatment of physical
injuries; arrangements for counseling by a skilled
mental health professional; and the telephone numbers
of local crisis centers, shelters, and protective
service agencies. The safety of children of victims
of abuse should also be ensured.
The draft update of this chapter was prepared for the U.S.
Preventive Services Task Force by Craig F. Thompson, MD, MPH,
and David Atkins, MD, MPH, with contributions from materials
prepared by Christopher Patterson, MD, FRCPC, Harriet L.
MacMillan, MD, FRCPC, James H. MacMillan, MSc, and David R.
Offord, MD, FRCPC, for the Canadian Task Force on the
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Submitted by: Clinical Preventive Services *
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