Parent and caregiver intimate partner violence (IPV), to which 1 in 5 children are exposed, has profound health effects for survivors and their children.1–3 The health, economic, and social ramifications of the coronavirus disease 2019 (COVID-19) pandemic have created unique challenges for families experiencing IPV, by increasing isolation, decreasing available safe and secure services and spaces (eg, schools), and compounding preexisting inequities, especially for families from marginalized communities.4,5 Pediatric health care settings play an important role in supporting families experiencing IPV, particularly through developing partnerships with IPV agencies.
In this issue of Pediatrics, Rahman et al6 examined data from an established IPV prevention advocacy program (the Advocacy for Women and Kids in Emergencies or AWAKE program) embedded in a children’s hospital to assess referral patterns before and during the COVID-19 pandemic.6 They found an increase in consults, particularly for emotional abuse, which aligns with work demonstrating an overall increase in IPV during the pandemic and challenges survivors faced accessing resources.7,8 Pediatric health care providers should be aware of the emotionally abusive coercive control used by abusive partners during the pandemic, including social isolation, manipulating child custody, and taking stimulus money, among other tactics.8
The study authors note a decrease in face-to-face consults aligned with the overall increase in virtual service provision in multiple sectors. Supporting IPV survivors virtually offers potential opportunities, including being able to speak individually with the survivor (often not possible during in-person visits with children in the room). However, there are also challenges to consider especially around confidentiality.9 In particular, screening for IPV through telemedicine is potentially harmful because it may be impossible to ensure privacy.4 The rise of virtual services has created an important opportunity to consider use of universal education and resource provision (ie, brief IPV education and resources for all parents and caregivers) rather than screening and case identification.2,4,10 Universal education centers the experiences and needs of survivors and recognizes that survivors may not always feel safe disclosing or feel like the medical system is a trustworthy entity. Universal education also encourages individuals to share resources with others in their social networks and reduces the isolation often associated with IPV.
AWAKE, a comprehensive hospital-based IPV advocacy program collocated at a children’s hospital, represents an innovative example of how pediatric health care settings can provide healing-centered care through health care provider training and direct support for IPV survivors. Healing-centered engagement is a strength-based approach, which focuses on connecting survivors with supports that help them meet their unique needs.11,12 The AWAKE program was instrumental to linking families to care, especially during the pandemic when health care settings represented an important social support for families. We encourage other pediatric health care settings to develop similar IPV advocacy programs. It is also important to note that there was no change in referrals for non-English speaking survivors, likely because of AWAKE’s established multilingual services. Non-English-speaking survivors have faced challenges during the pandemic because of the worsening of preexisting barriers accessing linguistically affirming services.8 All clinic and hospital-based IPV advocacy programs should ensure easy access to safe and confidential interpreter services and bilingual advocates.
Interestingly, the study authors found that primary care was the only setting with increased referrals. As they suggest, this may be because many other settings were shut down during the earlier phases of the pandemic; however, emergency rooms and inpatient settings did remain open. Primary care offices are well-situated to support IPV survivors because many providers develop longitudinal relationships with families. However, it is critical to leverage the entire health care system. For example, families may be present longer in emergency departments and inpatient settings, compared to primary care; further, many subspecialists develop longitudinal relationships with their patients, especially those with medical complexity. Each health care setting should develop workflows to incorporate universal IPV education and resources into their clinical practice, as well as develop partnerships with IPV agencies.
Many pediatric offices may currently not have access to a comprehensive service like AWAKE, highlighting the importance of developing partnerships with community-based IPV agencies. Community-based IPV agencies have been working tirelessly during the pandemic to support families experiencing IPV and have used innovative strategies to avoid service disruptions including chat or texting lines, virtual support groups, and alternative housing solutions for emergency shelter (eg, hotels).13 Pediatric health care providers should work to develop formalized partnerships with IPV agencies to assist with staff training, clinical protocols, and policies to address IPV, including survivor-centered approaches to care when IPV is disclosed. Futures Without Violence, a national violence prevention advocacy and policy organization, has multiple recommendations for how to collaborate through their IPV Health Partners Web site.14 Simultaneously, authors found that there was a decrease in community-based referrals provided by AWAKE advocates, likely because of disruption of services during the pandemic. IPV should be considered another ‘social determinant of health,’ and safety for survivors include housing and economic stability. As health care systems are increasingly addressing health-related social needs, there is an opportunity to promote cross-sector collaborations across various systems and services critical for supporting survivors.
As we begin to emerge from the COVID-19 pandemic, pediatric health care settings must consider ways to engage in sustained partnerships with clinic, hospital, and community-based IPV agencies. Health care settings must recognize that IPV agencies are integral to the pediatric medical home and essential collaborators in the provision of healing-centered care for IPV survivors and their children.
FUNDING: Dr Ragavan is supported by a National Center for Advancing Translational Sciences University of Pittsburgh KL2 (TR001856; Rubio). Dr Miller received no external funding. The funder had no role in this study.
CONFLICT OF INTEREST DISCLOSURES: Dr Ragavan has no conflicts of interest relevant to this article to disclose. Dr Miller receives royalties for writing content for UpToDate (Wolters Kluwer).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-055792.