NO HITTING!! February is Teen Dating and Violence Awareness and Prevention Month

A number of our terrific seniors are engaged in teen health activities this month, Sonia on teen attitudes on sources of sexual health information, Jen and Rita on interactive strategies to raise awareness and knowledge about core health education important for youth, Patti Jo on college health issues.

During our group discussion, Rita mentioned the unhealthy trend of Date Fighting and it's association with relationship violence. (e.g. a young man grabbing a girl's wrist and punching her in the arm). Many of you may have seen youth 'horsing around' - punching each other or grabbing someone. This may seem innocuous, but the rates of interpersonal violence tell us another story. The inability to address anger and frustration or have role models who show how to do so in a healthy fashion;  the role of trauma as an layer that confounds health all contribute to interpersonal violence. Clinicians play a pivotal role in talking with youth and highlighting that they have different options. 

Here's the AAP's policy statement about the role of the Pediatrician in Youth Violence

Prevention http://www.clemson.edu/olweus/aap.pdf and here's ACOG's Tool Kit for Teen Care Tool Kit for Teen Care ACOG 2009 

There was another article of interest that I came across - Attitudes Affecting Physical Dating Violence Perpetration and Victimization: Findings From Adolescents in a High-Risk Urban Community   Ali, Bina; Swahn, Monica; Hamburger, Merle. Violence and Victims26. 5 (2011): 669-83.  This article discussed factors in adolescent hitting and dating violence behavior across gender difference lines. Boys and girls hit, maybe for different reasons. The support of their friends associated with behavior, among other items was associated with interpersonal / dating violence. There are number of interesting risk factors they found. One that I found interesting was that they found the lack of self-efficacy and illicit drug use were unique important factors associated with physical dating violence perpetration for girls only.

Violence prevention is a health issue - as clinician's we need to develop our antennaes and help young women and men to heal from trauma and to be able to lead healthier lives.

That’s Not Cool.com, is a national public education campaign that uses digital examples of controlling, pressuring, and threatening behavior to raise awareness about and prevent teen dating abuse. OVW also funds the National Dating Abuse Helpline at 1-866-331-9474. Teens can also text “loveis” to 77054 to reach an advocate or chat on line by clicking on the icon found on loveisrespect.org.

Universal Screening - Child Maltreatment and Intimate Partner Violence

Screen everyone. When it comes to violence and trauma - screen everyone. One of your classmates used the term 'exuberant' screening - be exuberant. Physicians err on the side of caution in screening when the outcome of missing the diagnosis has a significant impact. This is true for a quiet tender abdomen in a patient with a fever - thus we look for appendicitis so as to not miss a ruptured appy that will result in life long abdominal pain. It is equally true for child maltreatment and intimate partner violence. Screen everyone.
Universal screening is the best way to do this. Universal screening means telling everyone that we do this with everyone.  By creating your clinical habit to ask everyone, you eliminate the challenge of deciding the if, when and who of screening about unhealthy relationships, abusive situations or being abusive to others.
How do you actually ask? Whether of a child with suspicion injuries or upon a first visit with a woman or man consider stating "We ask everyone these questions so that we make sure that people who are being harmed know that we are here to help." "There is a lot of abuse out there and we are mandated reporters." To a child (age dependent) ' You're here because you are hurt - we need to check you head to toe to make sure everything's ok.'
Won't I offend? We (should) ask everyone about use of drugs and alcohol; sexual habits including safe sex; status of HIV screening as well as history of trauma. The concern about offending a patient needs to be on the back burner. If a patient states it isn't an issue to them - it may not be (or it may be that they do not yet feel safe enough with you to divulge this.) If you inform the patient that you need to ask everyone (it's your job!) - then if it isn't true for them, you move on. If parents of a child with a suspicious injury get evaluated because we do it universally as our pledge to keep children safe - those for whom it was unfounded will be unfounded. But for others, we will have kept a child safe. Universal screening means seeing past personal bias of who seems to be at risk (certain groups) versus who really is at risk (every economic class and ethnicity.) - everyone.
How and where do I do this in the medical history? Here's some options -
1) Under Health Promotion issues - Stress screening [e.g. (On a scale of 1 - super mellow to 10 - ready to jump out of my skin - How stressful is work? How stressful is home? When stress becomes 10 or higher - what do you do to take care of yourself?] Has there every been a time when something traumatic happened to you? when something bad happened? What was that? How are you doing now? Has there every been a time when someone forced you to have sex? When they hurt you (hit/kick/punched)? When they kept you away from friends or family?)
2)  Include IPV screening as a dedicated part of the history on health maintenance (including wearing seat belts; alcohol; self breast/testicular exams)  "There is a lot of relationship violence that we see (as well as the health effects from it.)" "Have you ever been in a violent or abusive relationship?"

"When you get upset - how do you handle it? Have you ever felt that you 'lost it' when you got angry? Does this worry or concern you? Do you wish you could deal with frustration better?"
3)Include in the surgical history (Have you ever broken anything and how? Ever hospitalized? What for?)
4)The sexual history - "When was your earliest sexual experience? Did anyone ever force themselves on you? etc."
5) A sleep history - "Do you have good quality sleep? Do you have nightmares or bad dreams?"
6)In the mental health history - "There is a lot of violence and trauma in our world and it influences how people live even after it happened. Was there ever a time when something bad happened to you? How did you handle that?"
There is also some information in the literature that people who present with problems such as chronic pain, GI disorders, functional gyn problems; sexual dysfunction; aversion to dentists/oral health; and chronic headaches should be screened.

Here's a listing of some of our wonderful local Drexel collaborators and experts 

DUCOM
At Women's Health Education Program
     Candace Robertson, MPH Healthy relationship education for teens and IPV health screening
     Ana Núñez, MD IPV health education screening; Philadelphia Ujima - culturally and health literacy    appropriate health outreach
      Jill Foster, MD  Ped/Adol HIV/AIDs Center; St Christopher's Hospital for Children; expertise in the intersection of intimate violence and adolescent sexual health, child maltreatment, sexual health and LGBT youth
      Ted Corbin, MD - ED Physician  Violence Intervention Program "Healing Hurt People"; expertise in outreach to young men with trauma
       Ralph Riviello, MD - ED Physician, Sexual Assault Treatment Center; expertise in helping victims of rape/assault
       Susan McCleer, MD, Psychiatry forensic psychiatry
School of Public Health violence prevention collaborators
  Sandy Bloom, MD - Creating sanctuary: toward the evolution of sane societies and more resources here
  John Rich, MD, MPH - Wrong Place; Wrong Time
DU collaborators
Julie Mostov, PhD International Violence and Women's Advocacy
Maria McColgan, MD, MEd, FAAP Child Protection Program, St Chris (Seminar Series speaker 2010!)


References regarding New Jersey maltreatment case

IPV and Curricular Opportunities to Learn About It Update on Intimate Partner Violence and Medical EducationThe Drexel University College of Medicine Women’s Health Education Program is a model for training medical students to screen for and respond to intimate partner violence.
Ana E. Nunez, MD, Candace J. Robertson, MPH, and Jill A. Foster, MD

Intimate Partner Violence - More and Deadlier For Women

Violence against women is an enormous health issue in the United States. According to an FBI report in 2001, nearly a third of female homicide victims were killed by an intimate partner. Intimate partner violence, or IPV, is violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. IPV includes physical violence, sexual violence, threats of such acts, and emotional abuse. Although both genders are affected, the vast majority of this physical and psychological burden is borne by women.

In 2003, the CDC published a report on the costs of Intimate Partner Violence and estimated that 5.3 million IPV victimizations occured in adult women each year, 2 million of which were injuries and 550, 000 which required medical attention. The costs associated with IPV totalled over $4 billion for medical services and nearly $1 billion in lost work productivity and earnings. The health sequelae are well-established; IPV is linked to low self-esteem, eating disorders, depression, suicidal thoughts, and harmful health behaviors such as smoking, alcohol abuse, drug use, and risky sexual behavior.

So how well do physicians screen their patients for IPV? An ongoing 2010 multi-center Canadian study (Bhandari, et. al) looked at IPV screening attitudes and behavior amongst orthopaedic surgeons. 87% of orthopods believed that less than 1% of female patients in their care were victims of IPV. This was in stark contrast to prior data from fracture clinics that found one-third of women had been victims of IPV within the past year and 2.5% had presenting injuries directly resulting from IPV.

It also turns out that primary care physicians are slightly better at screening for IPV than orthopods, yet still fall far short of expectations. The American Academy of Family Physicians cites on their website a recent study that estimated that 10% of physicians routinely screen for domestic violence during new-patient visits. Where patients presented with physical injuries from abuse, only 79% of physicians asked patients direct questions about domestic violence. 17% of obstetrician-gynecologists routinely screen, compared with 10% of family physicians and 6% of internists.

Resources on Intimate Partner Violence:
National Domestic Violence Hotline  1-800-799-SAFE (7233), 1-800-787-3224 TTY, or
http://www.ndvh.org/
National Coalition Against Domestic Violence  http://www.ncadv.org/
National Sexual Violence Resource Center  http://www.nsvrc.org/
Family Violence Prevention Fund  http://www.endabuse.org/
When Closeness Goes Wrong - Podcast


 PRevalence of Abuse and Intimate Partner Violence Surgical Evaluation (P.R.A.I.S.E.): rationale and design of a multi-center cross-sectional study.BMC Musculoskelet Disord. 2010; 11: 77.Published online 2010 April 23.

Blog Submission by Olivia Wang, MS4; WH Pathway, Class of 2011