Intimate partner violence (IPV) is an urgent pediatric health epidemic, with 1 in 5 children exposed to caregiver IPV1 and 1 in 3 adolescents experiencing adolescent relationship abuse (ARA).2 IPV is often understood as escalating cycles of control and coercion, which can become lethal for people experiencing IPV and their children.3 Firearms are responsible for >60% of IPV-related homicides in the United States4 ; an IPV perpetrator owning a gun increases risk for IPV-related homicides.5
Using data from the Centers for Disease Control and Prevention National Violent Death Reporting Systems, Wilson et al, in this issue of Pediatrics, document the prevalence and characteristics of firearm-related child homicide precipitated by IPV over a nearly 20-year period.6 They found that 12% of child homicides were related to IPV, with IPV homicides more likely to occur among younger children and girls. The authors note the disproportionate impact of community violence on non-Hispanic Black boys, rooted in structural racism and oppressive policies that have led to concentrated poverty. The current analysis highlights that non-Hispanic Black children were also disproportionately impacted by IPV-related homicides (29% compared with 14% of children in the United States who identify as Black7 ). These findings are aligned with racial and ethnic disparities in IPV homicide among minoritized adults. Black pregnant women are 3 times more likely than non-Hispanic White women to be killed by an intimate partner,8 and Black, Indigenous, and Latina women die 9 years earlier than non-Hispanic White women because of IPV.9 These cross-cutting disparities underscore how structural racism and concentrated poverty affect survivors and cut them off from affirming and life-saving resources.10
The authors also found that child homicides in the context of IPV are often accompanied by homicides of the parent experiencing IPV, demonstrating the critical need to advance family-centered prevention efforts. Lethality assessments, which include a series of questions indicating when an IPV survivor is at high risk of IPV homicide,11 have been developed for use by law enforcement. Access to firearms, threatening with a weapon, and children at home can all be indicators of higher lethality risk. Less is known about whether such assessments should be used in pediatric clinical settings because there are several concerns including survivor safety, clinician knowledge and comfort, and survivors’ fears regarding disclosing IPV. What is clear is that pediatric health care settings represent an important prevention opportunity to support IPV survivors and their children. The AAP Clinical Guidelines recommends use of a strengths-based healing-centered approach, which includes universal empowerment around IPV and its impact on children with provision of resources to everyone, not only those who disclose IPV.12,13
Key to a healing-centered approach is developing strong partnerships with victim services agencies. The importance of such connections was affirmed in this study, which showed that more than one-third of IPV-related child homicides were precipitated by a dissolution of the relationship. For IPV survivors, leaving an abusive relationship can be incredibly dangerous, and victim services agencies are well equipped to support survivors through safety planning, provision of emergency shelter, legal services, and family resources. Furthermore, only 4% of the perpetrators of IPV-related homicides had a restraining order against them, indicating another prevention opportunity to connect survivors with victim services agencies that can guide them through obtaining a restraining order. Pediatric health care settings must invest in developing strong, sustainable, bidirectional relationships with victim services agencies, including colocated IPV advocates3,12 because health care settings may be 1 of the few safe places for IPV survivors in high lethality situation.
Although less common than homicides in the context of caregiver IPV, authors have found that 14% of IPV-related child homicides were adolescents killed by their intimate partner. ARA is common and increasing14,15 and, like adult IPV homicide, adolescent homicide can be precipitated by the dissolution of a relationship and is most likely to be perpetrated by a firearm.16 Pediatric clinicians should provide universal education around healthy relationships and support to ARA survivors, including connection to ARA-specific helplines (eg, love is respect).2,17
The analysis by Wilson et al provides a rigorous examination of the link between IPV homicide and firearms. A public health approach focused on evidence-based policies and practices is urgently needed. The Bipartisan Safer Communities Act, passed in 2022, expanded the prohibition of firearm ownership to include all individuals convicted of an IPV crime, rather than just partners with whom the survivor was married or cohabitating. This law is currently under review in the Supreme Court (United States v Rahimi) after being overturned in the US Court of Appeals. Firearm safety laws grounded in the best available science must be passed and enforced to protect IPV survivors and their children. Additionally, there must be a significant investment in evidenced-based prevention programming focused on strength-based approaches to prevent youth violence. Health care, community, and policy-level solutions are critical to protect IPV survivors and their children and promote family-centered thriving.
Drs Ragavan and Culyba conceptualized this manuscript, drafted portions of the manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-063004.
FUNDING: Dr Ragavan is supported on a K23 from NICHD (K23HD104925) and Dr Culyba is supported on a K23 from NICHD (HD098277). The funder had no role in the design and conduct of this study.
CONFLICTS OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.