Overview
Definition:
Intimate partner violence (IPV) refers to physical, sexual, emotional, or economic abuse experienced by an individual within a current or former intimate relationship
In adolescents, this often pertains to dating relationships, where power imbalances and control tactics can manifest as abuse
Screening involves proactively asking all adolescents about their experiences with dating violence.
Epidemiology:
IPV is a significant public health concern among adolescents, with studies indicating prevalence rates ranging from 10% to over 30% for experiencing dating violence, including emotional, physical, or sexual abuse
Adolescents from marginalized communities, those with a history of trauma, and LGBTQ+ youth may be at higher risk
Early exposure to IPV is associated with a higher likelihood of experiencing it later in life.
Clinical Significance:
Screening for IPV in adolescents is crucial as early identification allows for timely intervention, preventing further harm, promoting safety, and addressing potential long-term physical and mental health consequences
Pediatricians and healthcare providers play a vital role in creating a safe space for disclosure and connecting adolescents with appropriate resources, impacting future health outcomes and breaking cycles of violence.
Clinical Presentation
Symptoms:
Non-specific somatic complaints: Headaches
Abdominal pain
Fatigue
Recurrent infections
Behavioral changes: Anxiety
Depression
Suicidal ideation
Social withdrawal
Academic decline
Substance abuse
Poor self-esteem
Sleep disturbances
Eating disorders
Frequent injuries, especially in adolescents with dating partners.
Signs:
Unexplained injuries: Bruises, lacerations, abrasions, burns, fractures, especially in various stages of healing or in patterns consistent with abuse
Delayed presentation for care
Vague physical findings
Signs of emotional distress: Tearfulness, irritability, withdrawal during interviews
Overly compliant or fearful behavior
Inconsistent injury history.
Diagnostic Criteria:
There are no formal diagnostic criteria for IPV itself in the same way as a specific disease
Diagnosis is based on patient disclosure, corroborated by objective findings and a thorough history
The focus is on recognizing patterns of abuse and ensuring patient safety
Guidelines from organizations like the American Academy of Pediatrics (AAP) recommend universal screening for dating violence in adolescents.
Diagnostic Approach
History Taking:
Establish rapport and privacy
Ask direct, non-judgmental questions about dating relationships: "Do you have a boyfriend/girlfriend? How are things going in your dating relationships? Have you ever felt unsafe or been hurt by someone you were dating?" Inquire about emotional, verbal, physical, and sexual abuse
Ask about control tactics: Who does the adolescent spend time with? Does their partner monitor their phone or social media? Who controls their money? Assess for fear of the partner
Screen for associated mental health issues and substance use
Ask about family history of violence.
Physical Examination:
Conduct a thorough, head-to-toe physical examination, paying close attention to skin, head, and neck
Document all injuries precisely, including location, size, color, and stage of healing
Take photographs if consent is obtained and deemed necessary for documentation and safety
Be observant of the adolescent's demeanor and their interactions with any accompanying adult
Consider a pelvic examination if sexual abuse is suspected, performed with sensitivity and a chaperone.
Investigations:
Investigations are primarily supportive of the history and physical findings, not diagnostic of IPV itself
X-rays may be used to confirm fractures
If sexual abuse is suspected, consider sexually transmitted infection (STI) screening, pregnancy testing, and collection of forensic evidence
Laboratory tests for drug screens might be indicated if substance abuse is a concern
In cases of severe or recurrent physical trauma, further workup for underlying medical conditions or child protective services involvement may be warranted.
Differential Diagnosis:
Accidental injuries: Falls, sports-related trauma, motor vehicle accidents
Self-inflicted injuries: Cutting, burning
Medical conditions mimicking abuse: Purpura simplex, scurvy, osteogenesis imperfecta, bleeding disorders, child maltreatment by a caregiver (distinct from dating violence but needs to be considered in the context of overall safety)
While these can explain injuries, they do not negate the need to screen for IPV if a dating relationship is present and concerning for abuse.
Management
Initial Management:
Prioritize the adolescent's immediate safety
Develop a safety plan, which may involve discussing safe places to go, trusted adults to contact, and emergency numbers
Provide emotional support and validation of their experience
If immediate danger is present, involve law enforcement and child protective services as per local protocols
Ensure confidentiality is maintained to the extent possible, while adhering to mandatory reporting laws
Offer referrals to specialized services.
Medical Management:
Management of physical injuries: wound care, pain management, fracture reduction, and casting
Treatment of STIs and management of pregnancy if indicated
Address associated mental health conditions: pharmacotherapy for depression, anxiety, or PTSD may be considered in consultation with a mental health professional
Provide education on healthy relationships and assertiveness skills.
Surgical Management:
Surgical management is typically indicated for severe injuries resulting from IPV, such as complex fractures, extensive lacerations requiring surgical repair, or debridement of infected wounds
Procedures would be dictated by the specific injury and managed by appropriate surgical specialties (e.g., orthopedic surgery, plastic surgery).
Supportive Care:
Ongoing emotional support is paramount
Connect the adolescent and their family (if appropriate and safe) with resources such as domestic violence shelters, counseling services, legal aid, and advocacy groups
Regular follow-up appointments are essential to monitor safety, assess ongoing risks, and provide continued support
Educate parents or trusted caregivers on recognizing signs of abuse and supporting the adolescent
Encourage participation in support groups for survivors of dating violence.
Complications
Early Complications:
Acute physical injuries: fractures, lacerations, burns, sexual assault-related injuries
Acute psychological distress: anxiety, depression, fear, shock
Unintended pregnancy
Sexually transmitted infections.
Late Complications:
Chronic physical health problems: recurrent pain syndromes, gastrointestinal disorders, neurological deficits
Long-term mental health issues: PTSD, chronic depression, anxiety disorders, substance abuse, suicidal behavior
Repetitive cycle of abusive relationships
Impaired social and academic functioning
Trust issues
Difficulty forming healthy adult relationships.
Prevention Strategies:
Universal screening for dating violence in adolescents
Education on healthy relationships, consent, and communication skills in schools and primary care settings
Empowering adolescents to recognize and report abusive behaviors
Providing accessible resources for support and intervention
Addressing societal factors that perpetuate violence, such as gender inequality and normalization of aggression.
Prognosis
Factors Affecting Prognosis:
Early identification and intervention significantly improve prognosis
The presence of a supportive social network, access to appropriate resources, and the adolescent's resilience are positive factors
Continued exposure to violence, lack of support, and co-occurring mental health or substance use disorders are negative prognostic indicators.
Outcomes:
With effective intervention, adolescents can achieve safety, recover from physical and psychological trauma, and develop healthier relationship patterns
Outcomes can include reduced risk of re-victimization, improved mental health, and successful completion of education
In the absence of intervention, the prognosis is often poor, with a high risk of chronic physical and mental health problems and perpetuation of the cycle of violence.
Follow Up:
Regular follow-up is critical for at least 1-2 years after initial disclosure, or as long as the adolescent remains at risk
This includes monitoring for safety, addressing ongoing physical and mental health needs, reinforcing safety plans, and providing ongoing support and resource linkage
Collaboration with mental health professionals and community support agencies is essential for comprehensive care.
Key Points
Exam Focus:
Remember that IPV screening in adolescents is universal and should be performed annually in a private setting
Key questions focus on dating relationships and feelings of safety
Documentation of injuries and disclosure is critical
Mandatory reporting laws apply to suspected abuse
Focus on safety planning and resource referral.
Clinical Pearls:
Create a safe and confidential environment for the adolescent to disclose
Use direct, clear, and age-appropriate language
Believe the adolescent
Validate their feelings
Empower them by offering choices and resources
Remember that IPV often co-exists with other forms of abuse and mental health issues
Never force disclosure or provide information to an abusive partner without the adolescent's consent (unless mandated by law).
Common Mistakes:
Failing to screen universally
Asking vague questions or questions that imply blame
Not ensuring privacy during the interview
Dismissing or minimizing the adolescent's concerns
Not documenting the disclosure or injuries accurately
Not following through with safety planning or referrals
Violating confidentiality inappropriately
Assuming the adolescent is safe if they present with a caregiver or parent, without asking about their dating life separately.