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Table 1.  
Data on the Individual Risk Factors Present
Data on the Individual Risk Factors Present
Table 2.  
Data on High Risk of IPH by Subgroupa
Data on High Risk of IPH by Subgroupa
1.
Thackeray  JD, Hibbard  R, Dowd  MD; Committee on Child Abuse and Neglect; Committee on Injury, Violence, and Poison Prevention.  Intimate partner violence: the role of the pediatrician.  Pediatrics. 2010;125(5):1094-1100. doi:10.1542/peds.2010-0451PubMedGoogle ScholarCrossref
2.
Campbell  JC, Webster  D, Koziol-McLain  J,  et al.  Risk factors for femicide in abusive relationships: results from a multisite case control study.  Am J Public Health. 2003;93(7):1089-1097. doi:10.2105/AJPH.93.7.1089PubMedGoogle ScholarCrossref
3.
Smith  SG, Fowler  KA, Niolon  PH.  Intimate partner homicide and corollary victims in 16 states: National Violent Death Reporting System, 2003-2009.  Am J Public Health. 2014;104(3):461-466. doi:10.2105/AJPH.2013.301582PubMedGoogle ScholarCrossref
4.
Brignone  L, Gomez  AM.  Double jeopardy: predictors of elevated lethality risk among intimate partner violence victims seen in emergency departments.  Prev Med. 2017;103:20-25. doi:10.1016/j.ypmed.2017.06.035PubMedGoogle ScholarCrossref
5.
Maryland Network Against Domestic Violence. Development of the Lethality Assessment Program (LAP). https://lethalityassessmentprogramdotorg.files.wordpress.com/2016/09/development-of-the-lap1.pdf. Accessed February 13, 2018.
6.
Litzau  M, Dowd  MD, Miller  MK, Stallbaumer-Rouyer  J, Randell  KA.  Universal intimate partner violence in the pediatric emergency department and urgent care setting: a retrospective review.  Pediatr Emerg Care. In press.Google Scholar
7.
Randell  KA, Bledsoe  LK, Shroff  PL, Pierce  MC.  Mothers’ motivations for intimate partner violence help-seeking.  J Fam Violence. 2012;27(1):55-62. doi:10.1007/s10896-011-9401-5Google ScholarCrossref
Research Letter
January 2019

Risk of Intimate Partner Homicide Among Caregivers in an Urban Children’s Hospital

Author Affiliations
  • 1Division of Emergency Medicine, Children’s Mercy, Kansas City, Missouri
  • 2Department of Social Work, Children’s Mercy, Kansas City, Missouri
  • 3School of Social Work, University of Missouri–Kansas City
  • 4Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City
JAMA Pediatr. 2019;173(1):97-98. doi:10.1001/jamapediatrics.2018.3222

Given the high prevalence and lifelong negative outcomes of childhood exposure to intimate partner violence (IPV), the American Academy of Pediatrics recommends that pediatricians assess and provide intervention for IPV.1 Clinicians must ensure that methods for IPV screening and intervention maximize safety. Leaving an abusive partner increases the risk for intimate partner homicide (IPH)2; children are also at significant risk for homicide in this context.3 Among patients disclosing IPV at an adult emergency department, 61% were at high risk for IPH; children in the home were associated with increased risk.4 To our knowledge, no studies to date examine risk of IPH among adults in pediatric health care settings.

Methods

Caregivers disclosing IPV at our Midwestern urban children’s hospital (Children’s Mercy, Kansas City, Missouri) are offered referral to an IPV advocate. We analyzed deidentified data provided by our community IPV agency partner for caregivers meeting with an advocate from July 1, 2016, to June 30, 2017. Advocate assessment includes the 11-item Maryland Lethality Assessment Program (LAP)5 and 4 additional questions about risk; caregiver responses assist safety planning. Clients are categorized as high risk for lethal IPV if they meet validated LAP scoring parameters (answering yes to any of items 1-3; ≥4 yes answers to items 4-11; Table 1). Basic demographics were provided. We used χ2 and Fisher exact tests for exploratory analysis between subgroups. All P values were from 2-sided tests and results were deemed statistically significant at P < .05. The Children’s Mercy Institutional Review Board determined this study to be exempt from review as non–human participants research owing to the use of deidentified data.

Results

Among the 150 participants, the mean (SD) age was 32.1 (9.5) years and 149 were women. Of the 106 participants who provided information on race, 63 were white (59.4%) and 36 were African American (34.0%); of the 117 participants who provided information on ethnicity, 36 were Hispanic (30.8%). Among the 127 participants completing the LAP, 109 (85.8%) scored as having a high risk of IPH. The most common risk factors reported were separation from the abuser (101 of 127 [79.5%]), the abuser was violently or constantly jealous or controlled most decisions (98 of 127 [77.2%]), and the abuser followed or spied on the participant or left threatening messages (84 of 127 [66.1%]) (Table 1). Approximately half of participants reported their abuser might try to kill them (76 of 127 [59.8%]), has or could easily access a gun (74 of 127 [58.3%]), tried to choke them (69 of 127 [54.3%]), or threatened to kill them or their children (66 of 127 [52.0%]). Risk of IHP as assessed by the LAP was not associated with race, ethnicity, campus, or patient care unit (Table 2).

Discussion

Most individuals completing LAP assessment were determined to be at high risk for IPH. Lethality risk was not associated with demographics, campus location, or patient care unit. Pediatric health care practices should not limit opportunity to identify IPV or provide resources based on patient demographics, location, or type of care provided.

Data were not available on caregivers declining the advocate referral or not disclosing IPV. Owing to data limitations, we cannot report the number of advocate referrals during the study period; previous work found 42% of referrals were accepted.6 It is possible that caregivers accepting advocate referral are at increased risk compared with others who are experiencing IPV. Escalation of abuse is a risk factor for IPH and a motivating factor for seeking help for IPV.2,7

More than half of the participants reported that their abuser had or could easily access a gun, highlighting the importance of legislation to prevent IPV abusers from legally obtaining or maintaining firearms as a means to decrease risk of IPH.

Although limited by lack of pediatric patient data, our findings highlight the significant risk for IPH among these families. Children often experience unintended effects of IPH.3 Pediatric health care settings offer a unique opportunity to provide IPV resources. Parents experiencing IPV may seek health care for their children when they would not see a clinician for their own health care needs. Children are also a motivating factor for seeking help for IPV.7 It is critical that efforts to address IPV in pediatric settings provide opportunities for all families to access IPV resources, as well as optimize safety practices around screening and response to disclosure. Future studies should examine the risk of IPH among more diverse populations and explore use of the LAP to facilitate resource provision and clinical management.

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Article Information

Accepted for Publication: July 25, 2018.

Corresponding Author: Kimberly A. Randell, MD, MSc, Division of Emergency Medicine, Children’s Mercy, 2401 Gillham Rd, Kansas City, MO 64108 (karandell@cmh.edu).

Published Online: November 19, 2018. doi:10.1001/jamapediatrics.2018.3222

Author Contributions: Dr Randell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Randell, Stallbaumer-Rouyer, Dowd.

Acquisition, analysis, or interpretation of data: Randell, Adams, Ramaswamy.

Drafting of the manuscript: Randell, Adams.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Randell, Adams.

Administrative, technical, or material support: Dowd.

Supervision: Stallbaumer-Rouyer, Ramaswamy.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Tanya Draper-Douthit, MSW, LSCSW, and Annie Struby, JD, Rose Brooks Center, provided assistance with data acquisition. They were not compensated for their contribution. We are also grateful to Rose Brooks Center.

References
1.
Thackeray  JD, Hibbard  R, Dowd  MD; Committee on Child Abuse and Neglect; Committee on Injury, Violence, and Poison Prevention.  Intimate partner violence: the role of the pediatrician.  Pediatrics. 2010;125(5):1094-1100. doi:10.1542/peds.2010-0451PubMedGoogle ScholarCrossref
2.
Campbell  JC, Webster  D, Koziol-McLain  J,  et al.  Risk factors for femicide in abusive relationships: results from a multisite case control study.  Am J Public Health. 2003;93(7):1089-1097. doi:10.2105/AJPH.93.7.1089PubMedGoogle ScholarCrossref
3.
Smith  SG, Fowler  KA, Niolon  PH.  Intimate partner homicide and corollary victims in 16 states: National Violent Death Reporting System, 2003-2009.  Am J Public Health. 2014;104(3):461-466. doi:10.2105/AJPH.2013.301582PubMedGoogle ScholarCrossref
4.
Brignone  L, Gomez  AM.  Double jeopardy: predictors of elevated lethality risk among intimate partner violence victims seen in emergency departments.  Prev Med. 2017;103:20-25. doi:10.1016/j.ypmed.2017.06.035PubMedGoogle ScholarCrossref
5.
Maryland Network Against Domestic Violence. Development of the Lethality Assessment Program (LAP). https://lethalityassessmentprogramdotorg.files.wordpress.com/2016/09/development-of-the-lap1.pdf. Accessed February 13, 2018.
6.
Litzau  M, Dowd  MD, Miller  MK, Stallbaumer-Rouyer  J, Randell  KA.  Universal intimate partner violence in the pediatric emergency department and urgent care setting: a retrospective review.  Pediatr Emerg Care. In press.Google Scholar
7.
Randell  KA, Bledsoe  LK, Shroff  PL, Pierce  MC.  Mothers’ motivations for intimate partner violence help-seeking.  J Fam Violence. 2012;27(1):55-62. doi:10.1007/s10896-011-9401-5Google ScholarCrossref
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