Intimate partner violence and its impact on children — formative SAQs

SAQ 1 (10 marks)

A seven-year-old boy is referred to the general paediatric clinic by his teacher for "behavioural problems and possible ADHD." His mother describes worsening aggression, distractibility, and emotional outbursts over the past six months, poor sleep, and frequent unexplained stomach aches. When you interview the boy alone, he asks quietly whether you can "make the shouting stop at night." You separately interview the mother, who appears tense and avoids eye contact, and discloses that her partner has been "pushing her around" and frightening her for over a year. There is a licensed firearm in the home. [2] [3]

1. State how this presentation distinguishes trauma exposure from primary ADHD, and why taking a trauma history is the discriminator. (3) [2]
2. Outline your immediate safety assessment and the time-critical actions you must take before the family leaves the encounter. (4) [4]
3. Describe your child-protection response and your referral of the non-offending parent, including the principle of not setting leaving as a condition of your support. (3) [2] [6]

Model answer — SAQ 1

(1) Trauma versus ADHD (3). Primary ADHD is persistent across all settings from early childhood, with no temporal link to family stress and no trauma history. Trauma-driven inattention and aggression emerged or worsened after family stress, are episodic and situational, and coexist with hypervigilance, exaggerated startle, sleep disturbance, somatic complaints, and regression. The temporal relationship to the family stress, the trauma-specific features, and the boy's own disclosure ("make the shouting stop at night") are the discriminators. The two can coexist, so taking a trauma history does not exclude ADHD — but failing to take one means treating the symptom while the cause continues. The most common exam-stem error is attributing a trauma-exposed child's symptoms to primary ADHD without taking a trauma history. [2] [3]

(2) Immediate safety assessment (4). The priority is physical safety for the child and the non-offending parent, run in parallel with the assessment. First, because the perpetrator is not the patient and the mother has disclosed privately, confirm the family is not leaving to an immediate threat and that she has a safe place to go. Second, the firearm is the single most time-critical risk: the presence of firearms in a home with IPV is the strongest predictor of intimate partner homicide, and the risk extends to the children. Ask about access, and work with the family, social work, and where necessary law enforcement to remove or secure the weapon before the family leaves — lethal-means restriction is a clinical act, not a deferred social-work referral. Third, ask whether the violence is escalating, whether the child has been directly threatened or harmed, and whether an escape plan exists. Fourth, agree a written safety plan — where they will go if violence escalates, who they will call, and a code word the child can use — and provide the local and national IPV helpline in a form the perpetrator cannot see. [4] [2]

(3) Child-protection response and parent referral (3). Exposure to IPV is itself a form of child harm — the toxic-stress cascade is the mechanism — so make the child-protection report on a reasonable belief of risk, not on diagnostic certainty. In most ANZ jurisdictions the threshold is met when a child lives in a home with ongoing IPV with coercive control, escalation, weapons, or direct threats to the child. Document in the child's record, mark it sensitive, and coordinate with social work before any information reaches the family — never document a disclosure in a record the perpetrator can access, as it can trigger retaliation. Refer the non-offending parent to IPV advocacy services (1800 RESPECT in Australia, Shine or Are You OK in Aotearoa New Zealand) without blame and without requiring her to leave the relationship: leaving is the period of highest danger, and the decision is hers. Supporting the non-offending parent is supporting the child, because she is usually the child's strongest buffer. Arrange trauma-focused cognitive behavioural therapy (TF-CBT) for the boy, developmental and mental-health follow-up, and a fixed review date. [2] [6]

SAQ 2 (10 marks)

A 16-year-old girl presents to her general practitioner with frequent headaches, anxiety, and declining school attendance. She discloses that her father is violent toward her mother at home, and that her boyfriend has recently begun controlling her movements and pressured her into sex. She is tearful and asks you not to tell anyone. [2] [8]

1. Explain the epidemiological link between childhood IPV exposure and the adolescent's own risk of dating violence and re-victimization, and the biological mechanism (toxic stress and the HPA axis) that makes exposure harmful even when the child is never hit. (4) [5] [2]
2. Outline how you would balance this adolescent's confidentiality with your duty to protect, and the consent and reporting principles that apply. (3) [6]
3. Describe the management plan for this adolescent, including her own relationship safety, mental-health follow-up, and the wider family response. (3) [2] [8]

Model answer — SAQ 2

(1) Epidemiology and mechanism (4). Children exposed to IPV are at elevated risk of multiple forms of victimisation, and adolescent girls exposed to IPV are at elevated risk of experiencing violence in their own relationships — the poly-victimisation literature shows that IPV exposure rarely occurs in isolation, and cumulative adversity compounds the dose. The biological mechanism is toxic stress: a child's stress response is healthy when it is brief and buffered by a responsive adult, but IPV removes the buffer because the threat comes from within the caregiving environment and the adult the child would turn to for comfort is the victim. The sustained activation recalibrates the developing hypothalamic-pituitary-adrenal (HPA) axis, produces chronically elevated or dysregulated cortisol, dysregulates the immune system, and alters the architecture of the limbic and prefrontal circuits governing fear, emotion, attention and impulse control. The Adverse Childhood Experiences study showed a graded dose-response between the ACE score — which counts witnessing a mother being treated violently — and the leading adult causes of death, including ischaemic heart disease, mental illness, substance use and suicide. The child does not need to be hit to be harmed. [5] [2]

(2) Confidentiality and duty to protect (3). A mature minor who demonstrates capacity may consent to her own health care, and confidentiality builds the trust that enables disclosure — but confidentiality is not absolute. The duty to protect a child or young person at risk of significant harm overrides confidentiality when there is a reasonable belief of risk, and the clinician should explain this boundary honestly and in advance wherever possible. Here, two harms are in play: the ongoing IPV in her home (a risk to her and her mother) and the sexual coercion by her boyfriend (a risk to her directly). Discuss what will be shared, with whom, and why; offer to involve her in the reporting conversation; and use professional interpreters if language is a barrier. Record her disclosures verbatim, do not interrogate, and document the reasoning for any breach of confidentiality. Where the risk is immediate, act first and explain in parallel. [6] [2]

(3) Management plan (3). Address her own relationship safety directly: name the sexual coercion as abuse, offer STI screening and emergency contraception where relevant, and refer her to adolescent IPV and sexual-assault services. Arrange trauma-focused therapy and mental-health follow-up for her anxiety and headache (a somatic presentation of distress), and engage school welfare to address attendance. For the wider family, make the child-protection report regarding the ongoing IPV in the home, screen for direct co-victimisation of the adolescent and any siblings, and refer the non-offending parent to advocacy services without blame. Provide the national IPV helpline and a written safety plan, agree a fixed follow-up date, and ensure a named professional carries each element of the plan forward. [2] [8]