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According to the American Medical Association diagnostic and treatment guidelines, "...silence, disregard or disinterest convey tacit approval of domestic violence." Stopping domestic violence requires a coordinated community response in which health care providers, criminal justice systems, and social service agencies join forces to confront the violence. Nurses must be part of this coordinated response by becoming knowledgeable about the dynamics of domestic violence and the ways to recognize it. Topics include a medical and legal overview, gender involvement, solution approaches and program examples, outcomes, and implications for nurses.

Studies estimate that domestic violence is present in at least one-third of the families involved in child protective services (CPS). Yet, until recently, CPS has not directly addressed domestic violence in its handling of child abuse and neglect cases. By the same token, domestic violence programs have historically emphasized services for battered women, with limited understanding of the child safety goals of CPS. Despite these historical differences, collaborative efforts between CPS and domestic violence service programs are emerging based on a common goal of safety from violence for all family members. Innovative strategies include the use of domestic violence specialists in a variety of child protection settings for case consultation and for support to the battered women, direct referrals of battered women from domestic violence programs to family preservation services, and cross-training of CPS workers and domestic violence service providers. A survey of state CPS administrators and domestic violence coalition directors conducted for this article revealed that although there is mutual interest in greater collaboration, such efforts remain limited. New forums, such as CPS citizen review panels and community-based CPS partnerships, hold promise for further collaboration. Critical to successful strategies are supportive agency leadership, greater trust and understanding across systems, a recognition of common goals, and a willingness to change policies and practice.

Responses to domestic violence have focused, to date, primarily on intervention after the problem has already been identified and harm has occurred. There are, however, new domestic violence prevention strategies emerging, and prevention approaches from the public health field can serve as models for further development of these strategies. This article describes two such models. The first involves public health campaigns that identify and address the underlying causes of a problem. Although identifying the underlying causes of domestic violence is difficult--experts do not agree on causation, and several different theories exist--these theories share some common beliefs that can serve as a foundation for prevention strategies. The second public health model can be used to identify opportunities for domestic violence prevention along a continuum of possible harm: (1) primary prevention to reduce the incidence of the problem before it occurs; (2) secondary prevention to decrease the prevalence after early signs of the problem; and (3) tertiary prevention to intervene once the problem is already clearly evident and causing harm. Examples of primary prevention include school-based programs that teach students about domestic violence and alternative conflict-resolution skills, and public education campaigns to increase awareness of the harms of domestic violence and of services available to victims. Secondary prevention programs could include home visiting for high-risk families and community-based programs on dating violence for adolescents referred through child protective services (CPS). Tertiary prevention includes the many targeted intervention programs already in place (and described in other articles in this journal issue). Early evaluations of existing prevention programs show promise, but results are still preliminary and programs remain small, locally based, and scattered throughout the United States and Canada. What is needed is a broadly based, comprehensive prevention strategy that is supported by sound research and evaluation, receives adequate public backing, and is based on a policy of zero tolerance for domestic violence.

Historically, the legal system has not responded adequately, if at all, to cases involving domestic violence. In the past two decades, U.S. courts and law enforcement agencies have increasingly acknowledged the seriousness of domestic violence and have developed responses to it. Unfortunately, the legal system has been slower to recognize the impact of domestic violence on children. This article highlights four key areas of case law in which the courts have begun, in varying degrees, to examine the effects of domestic violence on children: child custody and visitation, restraining orders, failure to protect a child from harm, and termination of parental rights. A survey of appellate cases since 1990, though not representative of all cases, shows an ongoing need for mandatory judicial training on domestic violence and its effects on children, greater clarity about how to interpret relevant laws, changes in the laws to better serve children, and the renewal of national funding for legal aid programs. Courts and law enforcement agencies in some locales have implemented innovative programs to improve their interventions with children exposed to domestic violence. These programs include coordinated court responses, child development training for police officers, multidisciplinary team approaches, and supervised visitation centers. However, few of these programs have been evaluated for overall effectiveness in improving outcomes for children. Better evaluation is needed, as is ongoing funding for the replication of successful programs nationwide. A companion article by Matthews in this journal issue examines federal laws and policies with regard to domestic violence and children, and reviews many of the state statutes on which the court decisions discussed here are based.

Until recently, few federal and state laws specifically addressed the needs of children in families in which there is domestic violence. Yet, many laws, particularly in the areas of domestic violence, family law, child welfare, welfare reform, and immigration, can have profound effects on the well-being of these children. The growing understanding by legislators and policymakers of the potential harms of domestic violence to children has resulted in recent years in statutory changes, particularly at the state level. However, laws that are enacted and implemented with inadequate knowledge of the complex dynamics of domestic violence and the unique issues battered parents and their children face may have unintended negative consequences for the children these laws are designed to protect. Collaboration across public and private social service agencies and domestic violence training for court personnel are examples of efforts that can bridge this knowledge gap and increase the likelihood that the protective intent of the laws is carried out in practice. This article analyzes current and proposed federal and state civil laws to better understand their potential impact on children affected by domestic violence. A companion article by Lemon in this journal issue examines court decisions related to these laws.

Study Objective: As of March 1994, 45 states had laws that, to varying extents, required health practitioners to report cases of domestic violence (DV). Colorado passed a mandatory DV reporting law in 1995. Laws that mandate police involvement in cases of DV injuries have been criticized because of concerns that these laws deter victims from seeking medical care. We hypothesized that these laws would deter DV victims from seeking medical care., Methods: A questionnaire was administered in 3 stages: stage 1, convenience time blocks at 2 emergency departments and a primary care clinic; stage 2, prospective randomized blocks at an inner-city ED; and stage 3, a targeted population of women at risk for DV. All English-speaking, noncritical adult patients who presented during the time blocks were eligible to participate., Results: Five hundred seventy-seven patients participated; 55% of the patients were aware of the mandatory DV reporting law. Twenty-seven percent of the patients would be more likely to seek medical care because of this law. Only 12% of patients stated that they would be less likely to seek medical care for a DV-related injury because of this law (15% of men and 9% of women; P =.001). There was no difference between ED patients and targeted female patients at risk for DV in seeking medical care ( P =.833)., Conclusion: Only rarely did mandatory reporting laws appear to adversely affect a patient's decisions to seek medical care in this study. The benefits of mandatory reporting must be measured to assure that they justify deterrence to a small minority of patients.

Objective: Women with histories of interpersonal violence are poorly identified because of barriers in self-disclosure. This study identified differences on maternal health and child behavior between women who report filing a restraining order (RO) and those who do not among a nonreferred sample of women living in high-crime neighborhoods., Methods: During a maternal interview mothers were asked whether they ever filed a RO, the victim/defendant relationship, the number of times, and the year of the filing. Four types of violence were coded independently based on maternal narratives: verbal harassment, verbal threats or intimidation, physical assault, and destruction of property. We controlled for differences between RO and non-RO groups regarding demographic background, partner characteristics, other types of maternal past victimization, and use of alcohol and illicit drugs. Outcomes for mothers include partner aggression (Conflict Tactics Scale-R), perception of health and bodily pain (SF-36 Health Survey), distress symptoms (SCL90-R), posttraumatic stress (PTS)-related symptoms, and partial posttraumatic stress disorder (PTSD) diagnosis (modified Diagnostic Interview Schedule PTSD-Module). Outcomes for the child include partner aggression (Conflict Tactic Scale-R), behavior problems (CBC 2-3 or Child Behavior Checklist), and PTS-related symptoms (PTS-related symptom checklist)., Patients: One hundred sixty patients between 3.0 to 6.1 years who resided within five residential ZIP codes with a high rate of local crime in the City of Boston were drawn from a pediatric care clinic practice. Patients were participants of a larger study about the impact of community violence on mother-child relations., Results: Sixty-four (40%) of 160 mothers reported a history of filing a RO against a current boyfriend or husband (39%), ex-boyfriend or husband (44%), someone known (8%), or other (9%), with a mean of 3.9 years (standard deviation = 3.5 years) since RO filing. After controlling for covariates of marital status, immigrant status, public assistance, and lifetime sexual victimization, we found a significant multivariate analysis of covariance group effect on maternal outcomes. Analysis of covariance analyses indicated that mothers in the RO group experienced higher current partner verbal aggression and physical violence to mother, poorer health, and higher PTS-related symptoms, compared with mothers in the non-RO group. More mothers in the RO group met partial lifetime PTSD diagnosis. Unadjusted for maternal covariates, the multivariate analysis of variance analyses on child outcomes (partner aggression to child, behavior problems, and PTS-related symptoms) indicated a nonsignificant group effect., Conclusions: Among dyads residing in high-risk crime areas, the incidence of RO histories is substantive considering this was a nonshelter, nonreferred sample. The inquiry about the history of a RO may provide a new and efficient marker to quality of current partner relationship, maternal health, and maternal stress-related symptomatology.

Psychiatric home healthcare nurses (PHHNs) work directly with clients and their families in the community and serve as consultants to other home health nurses when concerns of mental health arise. They must be able to identify areas of possible or actual family violence or abuse and intervene appropriately. They must be cognizant of the laws regarding abuse reporting in their states. Decisions to report abuse are practical and moral and, when combined with legal imperatives, create ethical dilemmas for healthcare professionals. Guidelines are presented to help PHHNs understand the complex issues associated with mandatory reporting of abuse.

This study was undertaken to learn whether law enforcement agencies in California ("agencies") have standard policies and procedures in place for responding to reports of domestic violence injuries from health practitioners ("HP reports"), and to describe the variation in policies and procedures across agencies. Using a structured interviewing tool with closed- and open-ended questions, a survey was taken of domestic violence experts from 39 agencies throughout California. Forty-one agencies were asked to participate in the study. Interviews were completed with 39. Almost all agencies reported that they have standard procedures in place for responding to HP reports when the reports are made by telephone. Agencies handle written HP reports differently than telephone HP reports. HP reports constitute a very small proportion of agencies' overall domestic violence caseloads. Emergency departments are the usual source of HP reports. Although the law requires both an immediate telephone report and a written report, fewer than one quarter of sampled agencies always received both types of HP reports. Most agencies use standard response protocols when reports of domestic violence incidents are made by telephone, whether the reporting party is a health practitioner or someone else. Written HP reports do not fit into the agencies' usual response protocol for domestic violence situations. Because agencies' protocols are best suited to situations requiring prompt dispatch of an investigating officer, only reports made by telephone have the opportunity to promote an effective law enforcement response.

Violence between partners in dating and live-in relationships is high. Using standardized questions, a clinician can assess for, and determine the seriousness of, partner violence. This article includes a comprehensive assessment for partner violence, plans for primary prevention of violence in the office setting, and comprehensive plans for various degrees of domestic violence.

Laws are clear when it comes to reporting child abuse, elder abuse, or maltreatment of the disabeled; however, the fuzzy area of domestic violence, or injury to women by their husbands or intimates, puzzles the system ethically and legally. Experts are divided on the issue of mandatory reporting of domestic violence by health care professionals. As exemplified by the Florida law, the crux of the problem may be twofold. First, the law requires reporting of certain incidents that are ambiguously defined. Second, reporting may be mandatory without the patient's consent. Many experts in the field of domestic violence suggest that mandated reporting by health care workers is not in the best interests of the victims; it may lead to more violence and increase the victim's reluctance to get needed health care. This victim vulnerability creates ethical dilemmas in the emergency department, often the first outside contact after a violent incident. This paper examines the implications of reporting applied to emergency practice in the context of basic ethical standards. The application of mandatory reporting laws to competent adult victims presents questions related to nonmaleficence, beneficence, autonomy, confidentiality, and a variety of contextual issues that arise from these main ethical domains.

As of January 1994, California physicians are required to report to police all patients who are suspected to be victims of domestic violence. This article describes the results from a focus group study of abused women (n = 51) that explored their experiences with and perspectives on medical care. The eight focus groups included two Latina (total n = 14), two Asian (total n = 14), two African-American (total n = 9), and two Caucasian (total n = 14) groups of women who had been the victims of domestic abuse within the previous 2 years. The women were recruited through community-based organizations in the San Francisco Bay Area. With regard to physician reporting of domestic violence to police, five themes were identified: fear of retaliation by the abuser, fear of family separation, mistrust of the legal system, desire for police protection, and preference for confidentiality and autonomy in the patient-health professional relationship. Our results indicate that mandatory reporting may pose a threat to the safety and well-being of abused women and may create barriers to their seeking help and communicating with health care professionals about domestic violence.

Objective: This paper is the second of 2 parts reviewing the topic of stalking. It focuses on victims difficulties with the legal system and the psychotherapeutic tasks for victims and therapists., Method: Computerized literature searches were used to identify relevant papers from psychiatric and legal journals. Publications by victims' and women's organizations provided additional information., Results: Victims suffer emotional consequences from being stalked. Additional stress is caused by the legal system's lack of understanding of the causes and consequences of stalking and inadequate and unenforced laws. The treatment of victims requires a comprehensive approach, including education, supportive psychotherapy, and discussion of practical measures. Therapists may overidentify with the patient's powerlessness or hesitate to take on a case out of fear of the stalker. Female therapists may protect themselves against the realization of their own vulnerability by blaming the victim, while male therapists may feel defensive or overprotective., Conclusion: Stalking is a crime with major mental health consequences which is often poorly understood by society. Therapists need to be aware of the victim's emotional reactions, the types of legal and practical supports available, and the possible biases of society. Further education and research should be encouraged.

Domestic violence is a recognized and growing public health concern in the United States. Health care professionals have a duty to improve the identification of victims of domestic violence, intervene effectively, and advocate for better education to break the cycle of abuse.

Experts have argued that there are significant barriers to recent immigrants' use of the criminal justice system. This exploratory study, using convenience samples, is among the first to look empirically at the experiences of recent immigrant victims with the criminal justice system in the United States. Contrary to expectations, we found that immigrants reported relatively few problems unique to foreign-born persons in dealing with the police and the courts, and that their satisfaction with the justice system was comparable to levels reported in studies of native-born victims. The results suggest that although recent immigrants' expectations of the criminal justice system may be different from those of native born, the experiences of immigrant victims and their satisfaction with the justice system are similar in many respects to those of native-born victims.

Advanced practice nurses have many career alternatives. The role of the advanced practice nurse in the judicial system is as a cross-jurisdictional advocate--a case manager, a court advocate, and a legal nurse consultant. This article explores these roles with specific emphasis to the problem of family violence.

Public concern with societal violence is intensified when persons who have been found not guilty by reason of insanity (NGRI) of having committed a homicide or serious assault are returned to the community. Successful management of such acquittees in the community requires a sophisticated understanding of the person and the illness within the larger context of the violent incident, the family, the community, and the culture. In this article, we present an analysis of psychotic violence within a family context. A qualitative study of 64 subjects who were found NGRI of killing or seriously injuring a family member resulted in four prototypes of intrafamilial homicide/assault: Till Death Us Do Part; Overwhelming Burden, Elimination of the Limit Setter; and Family-Focused Delusional Killing. The prototypes are presented as a model for developing management strategies both for future risk assessment and for successful transition of the insanity acquittee into the community.

Background: Although domestic violence (DV) is recognized as a serious crime, only recently has it been acknowledged as a critical public health problem., Methods: To develop appropriate medical intervention methods to stop abuse, we interviewed 406 female patients in the ambulatory clinics at the Miami Veterans Affairs Medical Center, using a standardized questionnaire. We assessed their experiences with DV and their expectations of physicians in treating victims., Results: Of the 406 women, 40% have had emotional/physical abuse by a partner, 7% were currently in abusive relationships, and 3% had forced sex within the past year. Although 68% of the women could tell their doctors they were abuse victims, only 12% have been asked about abuse. Even when told of abuse, the doctors did nothing for 20% of the patients. The majority of the respondents believe that doctors should routinely screen for abuse. As part of treatment, all women strongly recommended that doctors provide information on community and legal resources and assistance in seeking protective services., Conclusions: Domestic violence is a significant problem for female patients in the ambulatory care setting. Women expect physicians to act as their advocates and, in partnership with other community professionals, to assist abuse victims and stop the violence.