Intimate partner violence (IPV) is a prevalent pediatric public health concern, as one in four U.S. children is exposed to parental or caregiver IPV (Hamby et al., 2011). Childhood IPV exposure is considered an adverse childhood experience and has numerous negative child health impacts, including developmental delays, low uptake of vaccinations, poor lung function, and poor nutrition (Gilbert et al., 2013; Holmes et al., 2022; Levendosky et al., 2013). Caregivers who are IPV survivors may experience a range of physical and mental health problems, such as anxiety, depression, chronic pain, and traumatic brain injuries, which may also impact their parenting and their child’s health (Campbell, 2002).

IPV survivors may interact with healthcare for acute and preventive services, including those for their children. Primary care settings may be particularly well suited to support survivors and their children because of long-lasting relationships and trust with providers (Feder et al., 2009). Survivors often speak to a primary care provider first, before they talk to others about IPV (Feder et al., 2009). Several interventions have been established to support survivors within primary care settings. One example of an approach to supporting survivors in healthcare settings is Confidentiality, Universal Education, Empowerment, and Support (CUES; Miller et al., 2017). This approach includes brief information about healthy relationships and the health impacts of violence, sharing national and local resources, and referral to local advocacy programs if a disclosure occurs (Miller et al., 2017). When used in school and college health centers and family planning clinics, CUES improved the knowledge of the patient on community resources and the confidence of the provider in discussing IPV (Miller et al., 2017).

Pediatricians have an important role in supporting IPV survivors, which may be heightened during large-scale disruptions to usual mechanisms for resource access, such as the COVID-19 pandemic (Risser et al., 2022). Pediatric healthcare settings offer unique opportunities to support IPV survivors and their children, as adults often will not seek medical care themselves but will bring their children to the doctor (Martin et al., 2001; Thackeray et al., 2023). Additionally, the impacts of IPV on their children are a common motivation for help-seeking, and most caregivers find it acceptable for pediatricians to address IPV (Dowd et al., 2002; Newman et al., 2005; Randell et al., 2012). The American Academy of Pediatrics (AAP) has long recognized pediatricians’ role in supporting IPV survivors; the recommended means include universal IPV education and resource provision, clinic- or hospital-based IPV advocates, and connecting survivors to local IPV agencies and other community-based organizations (American Academy of Pediatrics, n.d.; Thackeray et al., 2023). However, little is known about current practices used by pediatricians to address IPV. Prior research identified a lack of training, time, resources, and funding, as well as pediatrician discomfort, as limiting pediatricians’ capacity to address IPV (Borowsky & Ireland, 2002; Erickson et al., 2001; McColgan et al., 2010; Randell et al., 2015). Intervention and advocacy efforts have attempted to address these barriers with resources and clinical programs developed to help healthcare providers better support IPV survivors and their children (AAP, 2022; Cruz et al., 2013; Litzau et al., 2020; Loza-Avalos et al., 2022; Mancheno et al., 2021; McColgan et al., 2010; Randell et al., 2018). For example, some children’s hospitals have implemented hospital-based IPV advocacy initiatives that include universal screening and/or education, community agency partnership, and/or multidisciplinary staff education (Cruz et al., 2013; Litzau et al., 2020; Mancheno et al., 2021; McColgan et al., 2010). Concurrently, multiple changes within the healthcare landscape have potentially impacted pediatrician practices around IPV and the factors impacting the implementation of such practices (Colbert et al., 2020; Evans, 2016; Schapiro & Mihaly, 2021; The Joint Commission, 2022). These changes include the advent of the electronic health record (EHR), increased use of telehealth catalyzed by the COVID-19 pandemic, and the increased focus on identifying and supporting patients and families with health-related social needs (e.g., current Joint Commission and Centers for Medicare and Medicaid Services requirements to screen for health-related social needs; Colbert et al., 2020; Evans, 2016; Schapiro & Mihaly, 2021; The Joint Commission, 2022). Recent evidence suggests that some of these changes may have exacerbated previously known barriers or resulted in additional barriers and facilitators to addressing IPV in pediatric healthcare settings (Ragavan et al., 2020; Rahman et al., 2022; Randell et al., 2022; Shum et al., 2022).

The aim of this study was to better understand pediatricians’ current practices around IPV and desired IPV resources, as well as barriers and facilitators around the use of currently available practices and resources to support caregivers who are IPV survivors. This study addressed a key gap in understanding individual pediatrician practices around IPV, given the paucity of recent studies addressing this topic, and may facilitate the development and dissemination of resources that can enable pediatricians to better support IPV survivors.

Twenty-three pediatricians participated in five single interviews and nine dyadic interviews; we reached thematic saturation. Table 1 describes pediatricians’ demographics.

We identified four themes: (a) pediatricians’ approach to IPV focused primarily on resource provision and consideration for child protective services (CPS) referral in the context of IPV disclosure; (b) multilevel barriers inhibit pediatrician’s support for IPV survivors; (c) pediatricians want caregiver-facing and provider-facing resources to enhance their capacity to address IPV; and (d) sustained, responsive, systems-level facilitators can enhance pediatricians’ capacity to support IPV survivors. Representative quotations are given below and in Table 2.

This study revealed that pediatrician practices to support IPV survivors center on the identification of IPV and resource provision primarily in response to disclosure. In alignment with previous work, participants identified multilevel barriers to effective support for IPV survivors (Borowsky & Ireland, 2002; Evans et al., 2021; McColgan et al., 2010; Randell et al., 2015; Tarzia et al., 2021). The participants described resources that could enable pediatricians to better support survivors; some were unaware that such resources (e.g., national domestic violence hotline and scripts to discuss IPV with caregivers) were currently available (The National Domestic Violence Hotline, n.d.). Findings suggest that coordinated, sustained efforts across multiple dissemination channels may increase pediatricians’ knowledge of best practices and available resources to support caregivers who are IPV survivors.

Participants’ current strategies to support IPV survivors focused largely on IPV identification through caregiver disclosure. Participants noted the need for screening tools to detect caregivers experiencing IPV and described resource provision primarily within the context of IPV disclosure, that is, disclosure-based resource provision. However, screening- and disclosure-based resource provision reaches a limited number of survivors. Previous research has elucidated numerous barriers to IPV disclosure, including survivor concern for increased violence, loss of resources such as housing or income, or loss of child custody (Amel Barez et al., 2022; Heron & Eisma, 2021; Wright et al., 2022). Furthermore, when relying on disclosure-based resource provision, survivors who may not feel comfortable or safe disclosing IPV to their clinicians consequently do not receive information or support (Heron & Eisma, 2021). In one study, almost four of five survivors did not seek help from a medical professional (Black et al., 2011). Within a universal IPV screening program in a pediatric emergency department, only 0.3% of screens were positive (Litzau et al., 2020). Focusing on disclosure as the mechanism to facilitate resource provision may unintentionally place a greater emphasis on disclosure rather than survivor-centered resource provision. This paradigm may contribute to barriers that inhibit robust support for IPV survivors in pediatric and other healthcare settings.

Some participants’ perspectives and knowledge were not aligned with survivor-centered processes. A few participants shared that survivors who did not disclose were themselves creating barriers to intervention and resource provision. In contrast, a survivor-centered approach recognizes that survivors should disclose only if they choose. Additionally, some participants shared that they file CPS reports for all families experiencing IPV, which is not mandated by most state laws and may increase the risk for harm (Child Welfare Information Gateway, 2019; Lippy et al., 2020). A Delphi study around best practices for CPS reporting in the context of IPV found that experts were in consensus that a CPS report is not indicated universally for child exposure IPV and noted that nuanced consideration is required to determine the need for reporting (Ragavan et al., 2022).

Study findings align with prior research on barriers to healthcare-based IPV intervention and resource provision. More than 20 years ago, pediatricians perceived a lack of knowledge, standard practices, time, and support staff as barriers to addressing IPV (Erickson et al., 2001). More recently, a 2021 meta-synthesis of provider-level barriers described similar barriers, as well as the uncertainty of the provider on their role (Tarzia et al., 2021). Our study demonstrates the continued knowledge deficits of the provider. Some participants suggested the development of resources that are already available (e.g., national domestic violence hotline and IPV-related clinical scripts), highlighting a critical gap between resource availability and resource knowledge and utilization. Dissemination of evidence-based information is a well-documented challenge requiring multilevel solutions, including diverse learning opportunities, IPV champions to highlight best practices, collaboration with IPV agencies, and a multipronged strategy for information sharing (Dowd et al., 2002; Schubert et al., 2023). Our study, which was conducted in the latter half of the COVID-19 pandemic, also elucidated newer barriers such as increasing training challenges due to staff turnover. Additionally, participants noted concerns about confidentiality after IPV disclosure. Although confidentiality has previously been described as a barrier to addressing IPV in healthcare settings, the context of such concerns has shifted (Vranda et al., 2018). EHR implementation, including online patient portals, the 21st Century Cures Act, and telehealth, creates new challenges to ensuring confidentiality when addressing IPV in pediatric health settings (Manning, 2021; Shum et al., 2022; Simon, 2021). Pediatricians can mitigate risk by using coded documentation or a “secure” note, denying health record release (allowed under the 21st Century Cures Act “preventing harm exception”), or discussing documentation with survivors to facilitate survivor-informed documentation (Manning, 2021; Randell et al., 2022). Universal education on resources for IPV and other psychosocial determinants of health offers an opportunity to provide IPV resource information during telehealth visits (Ragavan et al., 2020).

Our study has several implications for clinical practice, research, and public policy. In clinical practice, the use of healing-centered engagement, which prioritizes relationships as central to healing, survivor strengths, and connection to resources, may facilitate improved support for survivors regardless of disclosure during the health visit (Ginwright, 2018). The CUES intervention, a healing-centered, universal education approach, has been shown to increase provider knowledge and improve outcomes for survivors (Miller et al., 2015,2016, 2017). Developing standard practices to maintain confidentiality during telehealth visits and EHR documentation may reduce the risk related to confidentiality (Randell et al., 2022). Our findings suggest the need for improved dissemination of existing resources. Future research should identify effective dissemination and implementation strategies for IPV practices. Professional and healthcare institutions can work to raise awareness of existing resources, such as the National Domestic Violence Hotline and the AAP’s IPV web page. Aligned with previous work, our findings also suggest the benefit of clinical practice guidelines and institutional policies that promote standard practices to support IPV survivors (Risser et al., 2022). While outside the scope of this study, participants also recommended policy changes beyond the healthcare system to better support IPV survivors, such as early childhood education, housing and financial support, and legal protections.

This study had several limitations. Most participants worked in urban, academic settings and were predominantly female, White, and in early career. Participants may have had greater interest and expertise in IPV than pediatricians as a whole. Due to missing appointments, we used a mix of dyadic and individual interviews; individual interviews do not generate the same type of conversation as dyadic pairings, although we did reach data saturation.

Our study suggests that pediatricians center strategies to support IPV survivors on IPV identification and may be unaware of available IPV resources. Findings underscore the continued challenge of longstanding barriers related to time, knowledge, and funding that inhibit the capacity of pediatricians and the health system to support IPV survivors, as well as identify newer challenges related to the EHR and telehealth. This study also highlights the need for effective dissemination and implementation efforts around currently available IPV resources, as well as institutional, technological, and policy changes that may increase the capacity to support families experiencing IPV.