The patient was well appearing but congested. Through gown, gloves, goggles, and a mask, I asked the mom if there was anyone at home who could help bulb suction. “He’ll never help,” she said. As tears dripped down her cheek, she described struggles with a partner who was controlling and disinterested in co-parenting, who took her money and tried to destroy her credit. She wanted him to leave, but the pandemic happened, and child care was limited. She had to keep working, and he was watching her children. She felt exhausted, saying, “Being here, in clinic, is like a break for me.” She shared that her partner has never physically abused her or injured her children. She felt safe taking resources about a local intimate partner violence (IPV) agency and was open to a follow-up visit.
IPV and the COVID-19 Pandemic
IPV, which includes physical, emotional, sexual, financial, or immigration-related abuse by a former or current partner, is a pervasive public health epidemic, with myriad child health impacts.1–3 During the coronavirus disease 2019 (COVID-19) pandemic, physical distancing, school and child care closures, and unemployment are contributing to additional stressors within households, associated with worsening IPV. Whereas empirical data on IPV and COVID-19 is nascent, emerging work, with data from Los Angeles and Indianapolis, reveals an increase in IPV reports in March to April 2020 compared with January to March 2020.4 Pediatric clinicians have a vital role in connecting adult caregivers with supports and resources to mitigate the consequences of IPV for both survivors and their children.
COVID-19 may be used to control, frighten, or manipulate IPV survivors. Although physical distancing is critical to reduce virus transmission, abusive partners may use this time to further isolate IPV survivors. IPV survivors often seek respite from violent relationships through their workplace and activities with trusted family and friends, which is challenging in the current climate. Abusers may also shut off phones or Internet service as a form of control, further compounding isolation. Physical distancing may limit a survivor’s access to support groups and individual counseling. For example, at the time of writing this article, an IPV agency in our community has seen a decrease in helpline calls, likely because individuals experiencing IPV do not feel safe calling for support while sheltering-in-place with abusive partners. Abusive partners may also withhold health insurance, information about COVID-19, and protective equipment (eg, hand sanitizer).
Children exposed to IPV may experience similar isolation and stress. Like their parents, children have less access to their usual sources of support, particularly trusted adults, such as teachers, after-school workers, and coaches. Children may also become victims of violence themselves; Hamby et al5 found that >50% of children exposed to IPV also experienced child maltreatment. The lay press has written that reports to Child Protective Services have decreased across the country. This is less likely reflecting a reduction in abuse, but rather decreased interactions between children and their adult supports, many of whom are mandated reporters.
Marginalized families experiencing IPV, such as those living in poverty, those identifying as racial and ethnic minorities or immigrants, or those who have limited English proficiency, face unique challenges. The pandemic’s economic ramifications disproportionately affect those living in poverty, and the impacts of poverty and IPV often compound one another.6 Additionally, emerging research reveals racial and ethnic disparities in COVID-19 testing, morbidity, and mortality.7 Pediatric clinical teams should be aware of how overlapping stressors and structural inequities faced by IPV survivors from marginalized communities are amplified during this pandemic.
Privacy and Telehealth
The rapid switch to telehealth during this pandemic may provide creative solutions for IPV survivors for whom clinical visits are inaccessible, for example, if abusive partners are withholding transportation or preventing their partner from leaving the home. However, telehealth also creates safety and privacy concerns. Abusive partners may monitor communication used through telehealth in multiple ways, including listening in during calls and video visits; reading texts; impersonating IPV survivors through texts, e-mails, or patient portal messages; changing patient portal passwords; and accessing e-mails. Telehealth may also be less accessible if an abusive partner has shut off data plans or Internet service.
Recommendations for Clinicians
We offer recommendations to support IPV survivors and their children during the current pandemic and in the foreseeable future, as more health care is delivered virtually. Table 1 provides sample scripts that pediatric clinical teams (nurses, health care clinicians, medical assistants, etc) can tailor for their setting. We focus on parents and caregivers; recommendations for adolescents experiencing violence are available elsewhere.8
Sample Telehealth Scripts Following the CUES Framework
| . | Sample Script . |
|---|---|
| Confidentiality and privacy | Assessing privacy when scheduling the visit: “During the pandemic, we are recommending virtual visits whenever they can be done safely. We know virtual visits are new to many families. We share with all families that a virtual visit will mean that the healthcare provider will talk with you and see your child through a video. Other people in your home may be able to see and hear the visit. We know virtual visits work for some parents, but others prefer an in-person visit for many reasons, such as wanting an in-person examination, not feeling safe speaking in their home, not having access to the Internet or a data plan, or for other reasons. All parents may choose an in-person visit for their child.” |
| Assessing privacy when starting the visit: “Are you in a private place right now?” If not: “If you would like, you can move to a private place, we can schedule an in-person visit, or I can schedule the visit at a later time.” | |
| Universal education and empowerment | Broad script offering education and support for multiple stressors, including IPV: “Being a parent is so hard now and parents don’t always get to hear how important they are, so I am thanking you for all you do for your children and family. Because people are more stressed than ever, we are sharing ideas about helping yourself and people you care about. Some types of stress that parents are feeling are not having enough food to eat, not having a stable place to live or getting behind on the rent, worries about having enough hot water or heat, not having childcare, feeling lonely or sad, or experiencing stress in a relationship. We want to you to know that we are here for you. We send over a resource sheet to all families, such as fresh food, who to call for help with utilities, numbers to call if you are stressed, lonely, or experiencing violence, and childcare. Before we end our visit, I want to take a pause and see if there is anything that this conversation has brought up for you that you would like to discuss. It is your choice if you want to share, and we provide resources to all families.” |
| IPV-specific script: “One of the things on the resource list we talk to everyone about is how more stress in our relationships may come with fighting or harm, and that can affect our health. There is free, confidential help available if you know someone who is being hurt in their relationship. Before we end our visit, I want to take a pause and see if there is anything that this conversation has brought up for you that you would like to discuss. It is your choice if you want to share, and we provide resources to all families.” | |
| Support if a parent discloses IPV, with a focus on validation | Validation: “Thank you for sharing that, I am so sorry that this is happening. What you are telling me makes me worry about your safety and health. A lot of parents experience things like this.” |
| Dynamic assessment of privacy: “Are you in a private place where we can talk more about this? At any point while we are talking, if you are no longer in a private location, you can say, ‘I am breaking up, I cannot hear you’ and then call me back.” | |
| Connection to resources: “I can connect you today with people who can help if that interests you. I can send you a list of resources, connect with someone right now if you like, or we can talk more about different resources, whatever you prefer.” | |
| Converting to an in-person visit: “Based on what you are telling me, how would you feel about coming to the clinic to talk about this in safe, private location.” | |
| Mandated reporting: “I am so sorry for all you are going through. Because your child is being injured, I will need to file a report to Child Protective Services. I will support you through this process [if in a private location]. Can we call Child Protective Services together, right now, to talk about what you told me? If you would like, I can also connect you with a local organization who can help you come up with a safety plan.” |
| . | Sample Script . |
|---|---|
| Confidentiality and privacy | Assessing privacy when scheduling the visit: “During the pandemic, we are recommending virtual visits whenever they can be done safely. We know virtual visits are new to many families. We share with all families that a virtual visit will mean that the healthcare provider will talk with you and see your child through a video. Other people in your home may be able to see and hear the visit. We know virtual visits work for some parents, but others prefer an in-person visit for many reasons, such as wanting an in-person examination, not feeling safe speaking in their home, not having access to the Internet or a data plan, or for other reasons. All parents may choose an in-person visit for their child.” |
| Assessing privacy when starting the visit: “Are you in a private place right now?” If not: “If you would like, you can move to a private place, we can schedule an in-person visit, or I can schedule the visit at a later time.” | |
| Universal education and empowerment | Broad script offering education and support for multiple stressors, including IPV: “Being a parent is so hard now and parents don’t always get to hear how important they are, so I am thanking you for all you do for your children and family. Because people are more stressed than ever, we are sharing ideas about helping yourself and people you care about. Some types of stress that parents are feeling are not having enough food to eat, not having a stable place to live or getting behind on the rent, worries about having enough hot water or heat, not having childcare, feeling lonely or sad, or experiencing stress in a relationship. We want to you to know that we are here for you. We send over a resource sheet to all families, such as fresh food, who to call for help with utilities, numbers to call if you are stressed, lonely, or experiencing violence, and childcare. Before we end our visit, I want to take a pause and see if there is anything that this conversation has brought up for you that you would like to discuss. It is your choice if you want to share, and we provide resources to all families.” |
| IPV-specific script: “One of the things on the resource list we talk to everyone about is how more stress in our relationships may come with fighting or harm, and that can affect our health. There is free, confidential help available if you know someone who is being hurt in their relationship. Before we end our visit, I want to take a pause and see if there is anything that this conversation has brought up for you that you would like to discuss. It is your choice if you want to share, and we provide resources to all families.” | |
| Support if a parent discloses IPV, with a focus on validation | Validation: “Thank you for sharing that, I am so sorry that this is happening. What you are telling me makes me worry about your safety and health. A lot of parents experience things like this.” |
| Dynamic assessment of privacy: “Are you in a private place where we can talk more about this? At any point while we are talking, if you are no longer in a private location, you can say, ‘I am breaking up, I cannot hear you’ and then call me back.” | |
| Connection to resources: “I can connect you today with people who can help if that interests you. I can send you a list of resources, connect with someone right now if you like, or we can talk more about different resources, whatever you prefer.” | |
| Converting to an in-person visit: “Based on what you are telling me, how would you feel about coming to the clinic to talk about this in safe, private location.” | |
| Mandated reporting: “I am so sorry for all you are going through. Because your child is being injured, I will need to file a report to Child Protective Services. I will support you through this process [if in a private location]. Can we call Child Protective Services together, right now, to talk about what you told me? If you would like, I can also connect you with a local organization who can help you come up with a safety plan.” |
Clinicians can tailor these scripts to their unique clinical settings.
Assessing Privacy During Virtual Visits
When a visit is being scheduled, front desk staff should describe telehealth and assess whether the parent can speak privately. An in-person visit should be provided as an option. At the start of a telehealth visit, the medical assistant or clinician should assess for privacy. If not in a private location, the clinician can ask if there is another time to talk or if they can move to another location. Clinicians should be aware of limited privacy and avoid asking sensitive questions directly. Finally, clinical teams should advocate for telehealth platforms with built-in privacy features, such as chat and “quick exit” functions.
Providing IPV Education, Resource Provision, and Support
Screening for IPV and other adversities may be dangerous via telehealth, especially because privacy cannot be guaranteed. With the Confidentiality, Universal Education and Empowerment, and Support (CUES) framework,9 adapted for a virtual setting, the clinician begins by offering parents positive reinforcement during these challenging times and then provides education and resources about IPV, which can be shared with friends or family. Unlike screening, which confers resources only to those who disclose, CUES promotes parent-clinician relationship building by deprioritizing disclosure and providing resources to all families. Marginalized populations, many of whom have experienced historical trauma from the medical establishment and may not wish to disclose stressors, are disproportionately impacted by this pandemic. Therefore, providing universal education and resources helps to ensure privacy and promote health equity. Clinicians may choose to use CUES for IPV specifically or embed this approach to address overlapping health-related social needs, such as food insecurity, unemployment, and child care. Resources should also include supports for children, including behavioral health, virtual support groups, and strategies for parents to mitigate child stress symptoms.
Although disclosure is not the goal with the CUES framework, clinicians should be prepared to safely support IPV survivors who disclose through telehealth. Validation of the experience alone is healing. If the parent is no longer in a private location, the clinician can communicate using chat functions or suggest potentially private locations, such as going for a walk, speaking in the bathroom, or using headphones so the perpetrator cannot hear the conversation. Because IPV survivors know best how to keep themselves safe, clinicians should follow their lead in terms of further discussion. Clinicians can offer options for support, such as connecting the survivor with an IPV advocate in the moment (a “warm referral”), offering an in-person follow-up visit, and providing suggestions on storing resources (such as helpline numbers) safely.
Mandated Reporting of Suspected Child Maltreatment in the Context of IPV
Mandated reporting may be particularly challenging in situations in which a clinician is concerned about co-occurring IPV and child maltreatment, especially during a telehealth visit. Clinicians should be aware of state-mandated reporting laws, including if their state requires reporting for child exposure to IPV.10 When filing a mandated report, clinicians should clearly state the concern for co-occurring IPV and child abuse to protect the safety of the IPV survivor. Whenever possible, clinicians can call Child Protective Services with the IPV survivor (a “warm handoff”) to include them as part of the mandated reporting process. Clinicians can also connect families with IPV agencies to discuss safety options.
Collaboration With IPV Agencies
IPV agencies are developing innovative ways to connect with clients virtually. For example, in our community, Women’s Center and Shelter of Greater Pittsburgh has moved shelter residents who are immunocompromised to safe off-site locations, is displaying information about their services at supermarkets and other stores deemed essential, and has created a texting line, which may be more confidential than a phone call. The National Domestic Violence Hotline (https://www.thehotline.org/) is using virtual chat groups, and Futures Without Violence, a national violence prevention organization, has compiled a list of resources for IPV survivors during the pandemic (https://www.futureswithoutviolence.org/get-updates-information-covid-19/).
Conclusions
As pediatric clinical teams support families during this unprecedented time, we must be aware of the compounding stress and challenges faced by IPV survivors and their children. Developing creative solutions and collaborative partnerships to support IPV survivors and their children during the COVID-19 pandemic is crucial to protecting the well-being of the families we serve and promoting health equity.
Acknowledgments
We thank Lisa James and Rebecca Levenson for their critique of this article.
Dr Ragavan conceptualized, drafted, and revised the manuscript; Ms Garcia and Drs Berger and Miller co-conceptualized the manuscript and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Dr Ragavan is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award KL2TR001856. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funded by the National Institutes of Health (NIH).
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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