"Screening for Intimate Partner Violence in Health Care Settings" Presentation with the Waterloo Region Crime Prevention Council by Dr. Pat Mousmanis.

1. ONTARIO COLLEGE OF FAMILY PHYSICIANS
HEALTHY CHILD DEVELOPMENT:
IMPROVING THE ODDS
Interpersonal Personal Violence Screening in
Pregnancy and Creating Opportunities In Primary
Care: Impact on Infant Mental Health and Optimizing
Child Developmental Outcomes

2. The Early Years Intervention
Opportunities to intervene
Early Years
Biological Environment
Birth
Genetic
Conception
Social / Ecological
Environment

5. AAP Technical Report on the lifelong effects of early
childhood adversity and toxic stress
(Pediatrics Vol. 129 No. 1 January 1, 2012
pp. e232 -e246 )

6. Hyper arousal
arousal
Disrupts Dysregulated CNS
Sympathetic
HPA axis Catecholamine
Nervous system HPA system
Pathway
Hyper vigilant
Suppressed
Hyper-reactive
immune system
“survival mode”

7. What is infant mental health?
• Infant mental health is the social, emotional & cognitive well being of infants and
toddlers
• An infant’s mental health begins at conception
• An infant can have serious mental health and emotional problems
• Poor mental health of an infant and/or toddler is sometimes about the absence
of “normal experiences, interactions or reactions”
• An infant who experiences poor mental health this early in life, will be vulnerable
for poor mental health throughout life
• Infant mental health = healthy social & emotional development that
includes the infant’s capacity to:
• Experience, regulate, & express emotions
• Form close interpersonal relationships
• Explore the environment & learn

8. Developmental Consequences for
Trauma Exposure
• Sleep problems • Anxiety
• Eating problems “Re- • PTSD
experiencing” or playing out • Relationship problems –
memories of the event including poor attachment or
• Toileting problems attachment disorders
• Withdrawal • Depression
• Increased • Dysregulation of stress system
clinginess/separation • Low self-esteem
• Unresponsive • Preoccupation with the
• Verbal or language difficulties traumatic event such as
• Developmental regression bringing up the episode
• Onset of new fears repeatedly or uncontrollably
• Aggressive outbursts or
increased activity level

9. Traumatic
events/experiences
Limited
Protective
Factors
Baby or Toddler unable to
recover from trauma
Infant or Toddler suffering from
poor mental health

10. Traumatic
events/experiences
Protective Factors that may
mitigate or minimize impact
Baby or Toddler who has
recovered from traumatic
experience/event

11. Trauma
Stress
Brain Overall
development Overall Relationship/ health
development attachment

12. Children need nurturing, loving environments
for healthy development…
Source: National Scientific Council on the Developing Child (2004)

13. We Need to Move Beyond Surveillance
and Beyond the Physical
Typical Well Child Visit: Monitoring of physical growth and development
• Counseling about development, safety, nutrition and community
resources
• Providing immunization and other preventive care
In IPV: Review safety concerns for the child
• Think about, discuss, and together identify any risks/problems for action
• Consider referral to consultants, and community resources to support the
child’s needs
Consider Child Protection Referral if required for supervised access visits
NEW: Assess parent-child interactions and look at the emotional needs of the
infant. Interpersonal violence can cause major impact to the mental health of
the child. Providing community support for the mother can be a supportive
factor that can buffer risk factors. Provide early intervention by screening at
well child visits.

14. Early Action for Suspected
Infant Developmental / Mental Health Concerns
when IPV is present
• Family assessment in depth- identify supports and strengths
• Refer to Public Health for Home Visiting and for family support
• Consider whether Child Protection Services ( CPS) are required
• Provide information about shelters and emergency agencies
• Further assessment / monitoring of child’s developmental status
• e.g. Hearing assessment / vision assessment
Speech, language, motor assessment
Psychological assessment /evaluate attachment concerns
Full socio-emotional assessment
Parenting Capacity assessment – role of supervised access visits
• Early infant / child intervention programs
• Family centers, play groups, child care centers
• Respite care if required – includes Shelters in IPV
• Social work referral for financial or housing issues

15. Comprehensive Assessment
• Consider screening for intimate partner violence at all
well woman visits and especially during pregnancy and
the post partum period when risks are higher
– ALPHA (Antenatal Psychosocial Health
Assessment)
– Three key questions:
• Have you ever experienced abuse?
• Are you or have you ever been afraid of your partner?
• Are you safe?
ALPHA: http://dfcm19.med.utoronto.ca/research/alpha
ALPHA Video illustrates interviewing techniques

16. The ALPHA Forms
Antenatal Psychosocial Health Assessment
The ALPHA Forms are a reliable, valid, user-friendly tools to be used by
obstetrical care providers for the systematic assessment of the psychosocial
health of pregnant women.
Suggestions for Use
•Complete after 20 weeks gestation
•Can be completed in 1 visit (20 mins) or over several regular prenatal visits
•Give the self-report out for completion in the office –avoid sending home if
worries about woman abuse
•Can bill for counseling/psychotherapy when appropriate
•Be sensitive to cultural issues; use non-family interpreters
•Discuss with the woman before sharing information (ie CPS concerns) ;
maintain confidentiality
Remember that associations do not imply causality!

17. The ALPHA Forms / Antenatal Factors
1) Family Factors - Social Support (CA, WA, PD )
Recent Stressful Life Events (CA, WA, PD, PI )
Couple’s Relationship ( CD, PD, WA, CA )
2) Maternal Factors - Prenatal Care ( Late onset ) (WA)
Prenatal education ( refusal or quit) ( CA)
Feelings towards pregnancy after 20 weeks ( CA , WA )
Relationship with parents in childhood ( CA)
Self-esteem (CA, WA )
History of psychiatric/emotional problems (CA , WA , PD)
Depression in this pregnancy (PD)
3) Substance Use - Alcohol and Drug Abuse ( WA, CA )
CAGE utilized ( Cut down, Annoyed, Guilty, Eye opener)
4) Family Violence - Woman or partner experienced or witnessed abuse
(physical, emotional, sexual ) ( CA, WA)
Current or past woman abuse (WA, CA, PD)
Previous child abuse by woman or partner (CA)
Child discipline (CA)
Critical Review of the Literature
15 antenatal factors associated with adverse postpartum outcomes of:
woman abuse (WA)
child abuse (CA)
couple dysfunction ( CD)
postpartum depression ( PD)
increased childhood physical illness (PI)

18. FAMILY FACTORS
Social support (CA, WA, PD)
How does your partner/family feel about
your pregnancy?
Who will be helping you when you go home
with your baby?
Recent stressful life events (CA, WA, PD,
PI)
What life changes have you experienced
this year?
What changes are you planning during this
pregnancy?
Couple’s relationship (CD, PD, WA, CA)
How would you describe your relationship
with your partner?
What do you think your relationship will be
like after the birth?

19. MATERNAL FACTORS
Prenatal care (late onset) (WA)
First prenatal visit in third trimester?
Prenatal education (refusal or quit) (CA)
What are your plans for prenatal classes?
Feelings toward pregnancy after 20
weeks (CA, WA)
How did you feel when you just found out
you were pregnant? How do you feel about
it now?
Relationship with parents in childhood
(CA)
 How did you get along with your parents?
 Did you feel loved by your parents?
Self esteem (CA, WA)
What concerns do you have about
becoming/being a mother?
History of psychiatric/emotional
problems (CA, WA, PD)
Have you ever had emotional problems?
Have you ever seen a
psychiatrist/therapist?
Depression in this pregnancy (PD)
How has your mood been this pregnancy?

20. SUBSTANCE USE
Alcohol/drug abuse (WA, CA)
How many drinks of alcohol do you have per week?
Are there times when you drink more than that?
Do you or your partner use recreational drugs?
Do you or your partner have a problem with alcohol
or drugs?
CAGE:
1. Have you tried to Cut down?
2. Do you feel Annoyed if someone mentions your
drinking?
3. Do you feel Guilty for drinking?
4. Do you ever need a drink in the morning to get
going?, Eye-opener)
OR
T-ACE (Tolerance, Annoyed, Cut-down, Eye opener)

21. FAMILY VIOLENCE
Woman/partner experienced or witnessed
abuse
(physical, emotional, sexual) (CA, WA)
What was your parents’ relationship like?
Did your father ever scare or hurt your mother?
Did your parents ever scare or hurt you?
Were you ever sexually abused as a child?
Current or past woman abuse (WA, CA, PD)
How do you and your partner solve arguments?
Do you ever feel frightened by what your
partner says or does?
Have you ever been hit/pushed/slapped by a
partner?
Has your partner ever humiliated you or
psychologically abused you in other ways?
Have you ever been forced to have sex against
your will?
Child discipline (CA)
How were you disciplined as a child?
How do you think you will discipline your child?
How do you deal with your kids when they
misbehave?

22. Setting the Context within Primary Care
Practice
• You are the health care professionals who see many
women and children at regular intervals
• You can provide women exposed to Intimate Partner
Violence with insight into the impact on her child
• You can be the broker for her to obtain support
• You are able to observe the family “in action” including
moments of distress for the child (ie immunization,
illness).
• There are questions you can ask as a Family Health
Team member (physician/nurse/ midwife/ social worker)
about many of the determinants of health including risk
factors

23. Risk Factors
Normal Child Child with
CNS insult
Nurturant
Dysfunctional Nurturant
Caring dysfunctional Dysfunctional
IPV Caring
Environment IPV
Environment
At risk Opportunity High
To thrive risk
For Child: Interactions & Relationships with Caregivers are the most crucial elements in the
Environment EPIGENTICS Nature and Nurture continuously Interacting