Table 3:

Themes and Representative Quotes

Theme		Quotations
	1) an opportunity to assess children at highest risk	Pediatric ED Physician – “To find the one that might go home and be killed by the violence, to try to prevent any significant harm”
Theme 1: Benefits of routine medical evaluation of IPV-exposed children	2) reassurance about the physical well-being of a child	CPS investigator – “She was feeding the baby. She questioned the dad about selling formula and dad kicked her in the back when she was breastfeeding. It was reassuring to the mom and me that there was no physical injuries because of the IPV. For the mom, it was nice to know that the baby who can’t speak was okay and for me. I was like, “Oh my God. I found out through this investigation that the baby fell a week prior.” Although there’s no visible injuries, I’m not a doctor.”
	3) possibility to engage a caregiver in resources through the child’s evaluation	ED Social Worker – “The benefits are also making sure that the family’s treated as a unit. You’re not just focusing on the child’s needs.”
	1) lack of robust evidence about the risk of child abuse in the context of IPV	Child Abuse Pediatrician – “If one [IPV-exposed child] was brought to me, I wouldn’t [obtain occult injury testing] right now. We need to know more information on that. Right now, a witness, a kid in another room, I wouldn’t do any of those tests. I don’t have a great argument, I just don’t have any data to really tell me what to do.”
	2) burden on a resourcelimited system	Child Abuse Pediatrician – “If you think about the number of women who are victims, the number of women who have kids… what’s the system’s capacity?”
Theme 2: Barriers to evaluating children after exposure to IPV	3) parental refusal of an evaluation	CPS Investigator – “I get a lot of pushback from family sometimes when they feel, okay, children weren’t present. They were in another room, or they would say they weren’t—basically, they weren’t present. They would push back and say that there’s no need for them to have them bein’ seen by the doctor or somethin’ like that. They would say, ‘Oh, the incident, it’s the first time they were physical with each other.’“
	4) complexity of IPV cases	Child Abuse Pediatrician – “Also you’re in a volatile, violent situation and the more interventions you have—now you’re getting the kid evaluated, and that might make it more volatile, because more stuff starts flowing out and it becomes harder and more unwieldy for anyone to control. I think that’s why when you start doing these things, you have to have the systems in place and you have to know how to handle what you find, to not escalate something that’s already bad for somebody.”
Theme 3: Facilitators of evaluating children after exposure to IPV	1) collaboration	CPS Investigator – “I wanna say just the ability to communicate with the workers, staff involved in this process from the doctors to the nurses to the people facilitating this study. The ability to communicate with them has been good.”
	2) training for providers on IPV and providing caregiver-centered support	Child Abuse Pediatrician – “pediatricians, they feel uncomfortable. They don’t know how to have those conversations with families to be asking the appropriate questions to even know if it’s [IPV] an issue, and so I think across the board that tends to be a challenge and leading to under recognition or delayed recognition. Victim willingness to talk, trust…go hand-in-hand?”
Theme 4: A trauma- and violence-informed care strategy for IPV		ED Nurse – “I think if there’s any obvious injury, really bruising or bleeding… of course, if they have anything that looks like a fracture…they should [be seen in an emergency department]. If they look well-appearing children, nourished and fed well and not with any bruises, those might be the kids that might be able to go to a different set up, like a clinic or primary care provider…” Child abuse pediatrician – “I think that an ideal process would be for these families to get evaluated in a different setting. Perhaps the child abuse clinic where we can offer services to both the mom and the child in a friendly, calm environment and really offer the support that the mom needs and have follow-through.” Parent – “Going through the ER seemed like it was scary for x (son). He doesn’t understand what was going on. The pediatrician’s office is—the walls have pictures. They have stuff over there that, just a little bit more, it makes the kids feel comfortable. I will say that, when you handed him the toys, though, he was so much happier. He looked like he was, actually, enjoying it.”