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Suggested Citation:"Front Matter." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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PREFACE i CONFRONTING CHRONIC NEGLECT The Education and Training of Health Professionals on Family Violence Committee on the Training Needs of Health Professionals to Respond to Family Violence Felicia Cohn, Marla E. Salmon, and John D. Stobo, Editors Board on Children, Youth, and Families INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, DC

NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Board on Children, Youth, and Families is a joint effort of the Institute of Medicine and the Division of Behavioral and Social Sciences and Education. Support for this project was provided by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. The views presented in this report are those of the Institute of Medicine’s Committee on the Training Needs of Health Professionals to Respond to Family Violence and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Board on Children, Youth, and Families (U.S.). Committee on the Training Needs of Health Professionals to Respond to Family Violence. Confronting chronic neglect : the education and training of health professionals on family violence / Committee on the Training Needs of Health Professionals to Respond to Family Violence, Board on Children, Youth, and Families, Institute of Medicine ; Felicia Cohn, Marla E. Salmon, and John D. Stobo, editors. p. ; cm. Includes bibliographical references and index. ISBN 0-309-07431-2 (hardcover) 1. Family violence. 2. Medical personnel—Training of—United States. [DNLM: 1. Domestic Violence—prevention & control—United States. 2. Health Personnel—education—United States. HV 6626.2 B662 2002] I. Cohn, Felicia. II. Salmon, Marla E. III. Stobo, John D. IV. Title. RC569.5.F3 B63 2002 616.85'822—dc21 2002000875 Additional copies of this report are available for sale from the National Academy Press, 2101 Consti- tution Avenue, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP’s home page at www.nap.edu. The full text of this report is available at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2002 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

COMMITTEE ON THE TRAINING NEEDS OF HEALTH PROFESSIONALS TO RESPOND TO FAMILY VIOLENCE JOHN D. STOBO (Chair), University of Texas Medical Branch at Galveston MARLA E. SALMON (Vice Chair), The Nell Hodgson Woodruff School of Nursing, Emory University ELAINE J. ALPERT, Boston University School of Public Health JACQUELYN C. CAMPBELL, Johns Hopkins University School of Nursing MICHAEL I. COHEN, Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine DEBORAH EPSTEIN, Georgetown University Law Center SHERYL HERON, Department of Emergency Medicine, Emory School of Medicine SUSAN R. JOHNSON, University of Iowa College of Medicine RICHARD D. KRUGMAN, University of Colorado School of Medicine MARK S. LACHS, Division of Geriatrics and Gerontology, Weill Medical College of Cornell University GARY B. MELTON, Institute on Family and Neighborhood Life, Clemson University GREGORY J. PAVEZA, School of Social Work, University of South Florida GEORGINE M. PION, Vanderbilt Institute for Public Policy Studies, Vanderbilt University MICHAEL A. RODRIGUEZ, Department of Family and Community Medicine, University of California, San Francisco ROBERT S. THOMPSON, Department of Preventive Care, Group Health of Puget Sound Study Staff FELICIA COHN, Study Director MAURA SHEA, Senior Project Assistant Scholar-in-Residence ELENA NIGHTINGALE v

BOARD ON CHILDREN, YOUTH, AND FAMILIES EVAN CHARNEY (Chair), Department of Pediatrics, University of Massachusetts Medical Center JAMES A. BANKS, Center for Multicultural Education, University of Washington DONALD COHEN, Child Study Center, Yale University THOMAS DEWITT, Children’s Hospital Medical Center of Cincinnati MARY JANE ENGLAND, President, Regis College MINDY FULLILOVE, School of Public Health and Department of Psychiatry, Columbia University PATRICIA GREENFIELD, Department of Psychology, University of California, Los Angeles RUTH T. GROSS, Professor of Pediatrics (emerita), Stanford University KEVIN GRUMBACH, Department of Family and Community Medicine, University of California, San Francisco/San Francisco General Hospital NEAL HALFON, School of Public Health, University of California, Los Angeles MAXINE HAYES, Washington State Department of Health, Olympia MARGARET HEAGARTY, Department of Pediatrics, Harlem Hospital Center, Columbia University RENEE JENKINS, Department of Pediatrics and Child Health, Howard University HARRIET KITZMAN, School of Nursing, University of Rochester SANDERS KORENMAN, School of Public Affairs, Baruch College CINDY LEDERMAN, Juvenile Justice Center, Dade County, Florida VONNIE MCLOYD, Center for Human Growth and Development, University of Michigan GARY SANDEFUR, University of Wisconsin-Madison ELIZABETH SPELKE, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology RUTH STEIN, Department of Pediatrics, Montefiore Medical Center, New York ELEANOR E. MACCOBY (Liaison, Division of Behavioral and Social Sciences and Education), Department of Psychology (emerita), Stanford University WILLIAM ROPER (Liaison, Institute of Medicine), School of Public Health, University of North Carolina, Chapel Hill Staff MICHELE D. KIPKE, Director SONJA WOLFE, Administrative Associate Scholar-in-Residence ELENA NIGHTINGALE vi

REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures ap- proved by the National Research Council’s Report Review Committee. The pur- pose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Robert A. Burt, Yale University Linda Chamberlain, Alaska Family Violence Prevention Project Lynn Mouden, Arkansas Department of Health Barbara Parker, University of Virginia Desmond K. Runyan, University of North Carolina, Chapel Hill Pat Salber, Kaiser Permanente LuAnn Wilkerson, UCLA School of Medicine Rosalie Wolf, The Medical Center of Central Massachusetts Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recom- mendations nor did they see the final draft of the report before its release. The review of this report was overseen by Neal A. Vanselow, Tulane University, appointed by the Institute of Medicine and Luella Klein, Emory University School of Medicine, appointed by the National Research Council’s Report Review Com- mittee, both of whom were responsible for making certain that an independent examination of this report was carried out in accordance with institutional proce- dures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. vii

Preface This report is not the first recent National Academies’ report to focus on the issue of family violence. It is the third and, regrettably, it may not be the last. Family violence continues to plague society and we have not yet developed either the practical interventions or evidence base to address this important social issue. When Congress passed the Health Professions and Education Partnerships Act of 1998, it issued an important challenge to government and the health professions. The bill’s language suggested that education of health professionals is an important first step in mitigating the problem of family violence. The Board on Children, Youth, and Families of the Institute of Medicine and the Division of Behavioral and Social Sciences and Education of the National Research Council responded to this challenge by establishing the Committee on the Training Needs of Health Professionals to Respond to Family Violence. The committee’s point of departure for its work was to adopt three funda- mental principles: (1) family violence is a health issue; (2) education of health professionals about the issue is therefore important; and (3) while education of health professionals about family violence is necessary to address the problem, it is not by itself sufficient. Other individuals and entities outside the health profes- sions are involved in addressing issues related to family violence, and this larger societal context must not be forgotten. As the committee began its deliberations, we quickly became aware that education of health professionals in family violence is not a consistent priority across or within health professions education curricula. The challenge of even identifying curricular content or strategies was compounded by the almost com- plete absence of either educational research or evaluation relating to family vio- ix

x PREFACE lence education and training for health professionals. In short, while family vio- lence exacts a tremendous cost from its victims and society, it is not viewed as sufficiently important for society to invest the resources and expertise critical for developing the research and demonstrations necessary to improve the response of health professionals and others to this serious social and health problem. That must change. The charge to our committee reflected a desire by Congress to encourage health professionals in education and practice to assume more responsibility for addressing this difficult, devastating issue. While the committee is sympathetic with this view, we also recognize that the complexity and breadth of this issue call for the involvement of professionals whose work lies outside the health arena. Responding to victims of family violence, and ultimately preventing its occurrence, is a societal responsibility. As such it must be shared. The committee has chosen to limit the number of our recommendations in the hope that offering a few specific priorities will increase the likelihood of implementation. In our view, family violence should be treated like other public scourges such as heart disease, cancer, diabetes, and AIDS. Resources equiva- lent to those used to address these problems should be applied to address the problem of family violence. We recommend the creation of education and re- search centers that will not only generate significant new information with a beneficial impact on family violence but will also be useful in coordinating, integrating, and evaluating educational and intervention activities related to fam- ily violence. The work of such centers will benefit the development of sound, evidence-based curricula, contributing to the development of research and schol- ars around this issue. Such centers will provide focus to activities related to this very serious health problem. Our recommendations reflect our consideration of the evidence and input that we worked diligently to uncover throughout the study process. It is impor- tant to note, however, that the committee members were both troubled and frus- trated by the lack of scholarship in this area. We note here a finding that is not explicitly discussed elsewhere: the failure to make progress on education and practice in the area of family violence is in itself clear evidence that society has paid too little attention to what will remain a national shame and tragedy. For too long family violence has indeed been a case of chronic neglect. John D. Stobo, Chair Marla E. Salmon, Vice Chair Committee on the Training Needs of Health Professionals to Respond to Family Violence

Acknowledgments No report is possible without the assistance of many people. The Committee on the Training Needs of Health Professionals to Respond to Family Violence would like to acknowledge the efforts of many who contributed to this report. The study conducted by this committee was funded by the National Center for Injury Prevention and Control of the Centers for Disease Control and Preven- tion (CDC). CDC staff members Rodney Hammond, director for the Division of Violence Prevention, and Lynn Short, previously with the CDC and now execu- tive director for Analytic Systems Associates, Inc., among others, provided use- ful background material and ongoing support. Joyce McCurdy, public health advisor in the Division of Violence Prevention, served as the project officer for this study and continuously provided invaluable assistance. This study, the result of federal legislation, also benefited from the support of Anne Marie Murphy, legislative assistant in the Office of the Honorable Richard J. Durbin, sponsor of the authorizing legislation. Several consultants provided important background information, assisted in data collection, and contributed text for use in the report. Jane Koziol-Mclain of Johns Hopkins University prepared materials on issues related to funding and core competencies. Gina Espinosa Salcedo of Boston University assisted in the collection and organization of existing curricula for health professionals on fam- ily violence. Paul Mazmanian of the Medical College of Virginia provided back- ground materials on clinician behavior change research. In addition to these formally appointed consultants, a number of other individuals offered background information and contributed text for this report. Kim Bullock of the Georgetown University Medical Center Department of Family Medicine prepared a compre- xi

xii ACKNOWLEDGMENTS hensive description and bibliography on cultural competencies for health profes- sionals. William Rudman of the University of Mississippi provided extensive background materials on health care utilization data related to intimate partner violence. Deborah Horan of the American College of Obstetricians and Gyne- cologists (ACOG) developed the flowchart describing ACOG’s work on family violence, and Donna Vivio of the American College of Nurse-Midwives (ACNM) developed the timeline of ACNM’s family violence activities for inclu- sion in this report. Frank Putnam, director of the Mayerson Center for Safe and Healthy Children, provided helpful data and references. Bernice Parlak and Joan Weiss of the Health Resources and Services Administration and Diane Hanner of the Substance Abuse and Mental Health Services Administration provided essential information on the Geriatric Education Centers evaluation. Richard Hodis and Tony Phelps of the National Institute on Aging assisted with informa- tion on the Alzheimer’s disease program. David Hemenway of the Harvard In- jury Control Research Center provided useful information on the impact of that center. The committee is indebted to each of these individuals for their hard work and cooperation. The committee’s progress was possible, in part, due to the regular assistance of a number of speakers at committee meetings and other experts on family violence, health professional education, and related topics. Wanda Jones, deputy assistant secretary for health (women’s health) of the U.S. Department of Health and Human Services; Denice Cora-Bramble, special advisor to the director of primary health care of the Health Resources and Services Administration; Lisa James, senior program specialist for the Family Violence Prevention Fund; Lori Stiegel, American Bar Association, Commission on the Problems of the Elderly; and David Cordray, professor of public policy and psychology and co-director, Center for Evaluation Research and Methodology, Institute for Public Policy Studies, Vanderbilt University, provided thoughtful presentations regarding cur- rent efforts to educate health professionals as well as frequent insights relevant to the committee’s work. A number of others also served as resources for the committee, including Marcy Gross, Kate Rickard, and Carolina Reyes of the Agency for Healthcare Research and Quality; Angela Gonzalez-Willis of the Bureau of Health Professions; Debbie Lee of the Family Violence Prevention Fund; Hal Arkes and Ann Bostran of the National Science Foundation; Anita Rosen and Joan Zlotnick of the Council on Social Work Education; Rosalie Wolf of the Institute on Aging at the University of Massachusetts; Lynn Moudin of Prevent Abuse and Neglect Through Dental Awareness and the Arkansas Department of Health; Catherine Judd of the University of Texas Southwestern Medical Center at Dallas; Brian Rafferty of Talaria; and Calvin Hewitt of the University of Mississippi. A number of other individuals provided helpful presentations and back- ground materials on topics related to the committee’s work. The committee ap- preciates the time and resources offered by the following individuals: Sidney

ACKNOWLEDGMENTS xiii Stahl, chief, Health Care Organization and Older People in Society, National Institute on Aging; Mark Rosenberg, executive director, Task Force for Child Survival and Development; Brigid McCaw, director of the Family Violence Pre- vention Project, Kaiser Permanente Richmond and clinical lead for domestic violence prevention, Northern California Kaiser Permanente; Connie Mitchell, medical director for domestic violence, California Medical Training Center; Marilyn Peterson, director, California Medical Training Center, and director, University of California-Davis Child Protection Center; Ellen Taliaferro, medi- cal director, Violence Intervention Prevention Center, Parkland Health and Hos- pital System, and co-founder, Physicians for a Violence Free Society; Bonnie Brandl, project coordinator, National Clearinghouse on Abuse in Later Life and Wisconsin Coalition Against Domestic Violence; Robert Spagnoletti, chief, Sex Offense and Domestic Violence Section, U.S. Attorney’s Office; Billie Weiss, Injury and Violence Prevention Program, Los Angeles County Public Health and Program Service; Joanne Marlott Otto, program administrator, Adult Protection/ Elder Rights Services, Colorado State Department of Human Services; John Umhau, Laboratory of Clinical Studies, National Institutes for Alcohol Abuse and Alcoholism; Christopher Murphy, Department of Psychology, University of Maryland, Baltimore County; Larry Cohen, executive director, Prevention Insti- tute; Suzanne Donovan, senior program officer, National Research Council; Deborah Danoff, assistant vice president for medical education, Association of American Medical Colleges; and Jeffrey Rachlinski, professor, Cornell Law School. The committee conducted a public forum in Washington, DC, to inform its deliberations. The forum was designed to elicit the expertise of health profes- sionals, policy makers, family violence advocates, and educators on the content and design of training programs for health professionals on family violence and information on existing guidelines and organizational positions. Representatives from over 20 organizations presented their policies, positions, educational initia- tives, and research. The committee appreciates the insights these presentations provided into existing and potential educational approaches and is thankful to each participant and to all of those who submitted written materials. Finally, the committee benefited tremendously from the support and assis- tance of several members of the Division on Behavioral and Social Sciences and Education and Institute of Medicine staff, as well as the administrative and re- search assistants of several committee members. A special thanks goes to Maura Shea, who provided administrative and research support to the committee, as- sisted in drafting pieces of the report, and helped prepare the report for publica- tion. Drusilla Barnes, Amy Gawad, Rebekah Pinto, Michael Rosst, Mary Strigari, Kerry Williams, and Sonja Wolfe deserve much appreciation for their assistance with committee and meeting organization. The research needs of this report could not have been met without the able assistance of Adrienne Davis, Georgeann Higgins, James Igoe, and others in the National Research Council

xiv ACKNOWLEDGMENTS Library. The substantive contributions and ongoing support of Nancy Crowell and Rosemary Chalk were inestimable. Bronwyn Schrecker was invaluable to the report review process. Christine McShane edited the report and Yvonne Wise was especially helpful in preparing the report for publication. The public release and dissemination of this report would not have been possible without the hard work of Mary Graham, Jennifer Otten, and Vanee Vines. Several assistants to specific committee members, including Eve Adams, Jandee Christensen, Sandy Froslan, Pat Knox, Latisha Lord, Drew Smith, JoEllen Stinchcomb, and Dianne Winsett, deserve thanks for facilitating the committee process, as do Samantha Coulombe, Caroline Han, Stacey Vaccaro Milonas, and Carla VandeWeerd. Fi- nally, a heartfelt thanks to our study director, Felicia Cohn, who kept us orga- nized and on time while guiding us through the entire process and who made significant contributions to the substance of the report.

Contents EXECUTIVE SUMMARY 1 1 INTRODUCTION 13 The Charge to the Committee, 15 The Committee’s Approach, 15 Definitional Issues, 17 Organization of the Report, 20 2 DEFINING THE PROBLEM 21 Definitions and Magnitude, 21 Health Professionals’ Roles, 27 Conclusions, 33 3 CURRENT EDUCATIONAL ACTIVITIES IN THE HEALTH PROFESSIONS 35 Physician Education, 35 Physician Assistants, 38 Dentistry, 38 Nursing, 39 Psychology, 40 Social Work, 42 Conclusions, 43 xv

xvi CONTENTS 4 FORCES INFLUENCING HEALTH PROFESSIONALS’ EDUCATION 45 Intrinsic Influences on the Training Environment, 46 Accreditation, Licensure, and Certification Requirements, 54 Individual Issues: Professional and Personal Factors, 56 Professional Organizations and Stakeholder Groups, 60 Laws Mandating Reporting and Education, 68 Resource Issues, 74 Conclusions, 81 5 EVALUATION OF TRAINING EFFORTS 84 Search Strategy, 85 Types of Training Efforts Evaluated, 88 Assessing the Available Evidence, 90 Characteristics of the Evaluation and Research Base, 92 Training Outcomes and Effectiveness, 97 Quality of the Evidence Base, 105 Conclusions, 107 6 TRAINING BEYOND THE STATE OF THE ART 108 Training Content: Core Competencies, 109 Achieving Competency Through Education and Training, 122 Influencing Family Violence Education in the Future, 134 Conclusions, 138 7 PRIORITIES FOR HEALTH PROFESSIONAL TRAINING ON FAMILY VIOLENCE 141 Building a Field, 141 Conclusions, 145 Recommendations, 152 Final Thoughts, 160 REFERENCES 161 APPENDIXES A Accreditation Requirements 193 B Policy Statements of Health Professional Organizations 197 C Mandatory Reporting Laws for Family Violence 205 D Mandatory Education Laws for Family Violence 229 E Existing Curricula on Family Violence 233

CONTENTS xvii F Summary of Evaluation Studies on Training of Health Care Professionals on Intimate Partner Violence 269 G Summary of Evaluation Studies on Training Health Care Professionals on Child Abuse and Neglect 317 H Core Competencies for Family Violence 327 I Biographical Sketches of Committee Members and Staff 331 INDEX 337

CONFRONTING CHRONIC NEGLECT

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As many as 20 to 25 percent of American adults—or one in every four people—have been victimized by, witnesses of, or perpetrators of family violence in their lifetimes. Family violence affects more people than cancer, yet it's an issue that receives far less attention. Surprisingly, many assume that health professionals are deliberately turning a blind eye to this traumatic social problem.

The fact is, very little is being done to educate health professionals about family violence. Health professionals are often the first to encounter victims of abuse and neglect, and therefore they play a critical role in ensuring that victims—as well as perpetrators—get the help they need. Yet, despite their critical role, studies continue to describe a lack of education for health professionals about how to identify and treat family violence. And those that have been trained often say that, despite their education, they feel ill-equipped or lack support from by their employers to deal with a family violence victim, sometimes resulting in a failure to screen for abuse during a clinical encounter.

Equally problematic, the few curricula in existence often lack systematic and rigorous evaluation. This makes it difficult to say whether or not the existing curricula even works.

Confronting Chronic Neglect offers recommendations, such as creating education and research centers, that would help raise awareness of the problem on all levels. In addition, it recommends ways to involve health care professionals in taking some responsibility for responding to this difficult and devastating issue.

Perhaps even more importantly, Confronting Chronic Neglect encourages society as a whole to share responsibility. Health professionals alone cannot solve this complex problem. Responding to victims of family violence and ultimately preventing its occurrence is a societal responsibility

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