Understanding Teen Dating Violence: Practical screening and intervention strategies for pediatric and adolescent healthcare providers

Abstract

Purpose of Review

Teen Dating Violence (TDV) is a serious and potentially lethal form of relationship violence in adolescence. TDV is highly correlated with several outcomes related to poor physical and mental health. Although incidence and prevalence data indicates high rates of exposure to TDV among adolescents throughout the United States, significant confusion remains in healthcare communities concerning the definition and implications of TDV. Additionally, healthcare providers are uncertain about effective screening and intervention methods. The article will review the definition and epidemiology of TDV and discuss possible screening and intervention strategies.

Recent Findings

TDV research is a relatively new addition to the field of relationship violence. Although some confusion remains, the definition and epidemiology of TDV is better understood which has greatly lead to effective ways in which to screen and intervene when such violence is detected. Universal screening with a focus on high risk subgroups combined with referrals to local and national support services are key steps in reducing both primary and secondary exposure.

Summary

TDV is a widespread public health crisis with serious short and long-term implications. It is necessary for pediatric and adolescent healthcare providers to be aware of TDV, its potential repercussions, as well as possible methods for screening and intervention. More research is needed to better understand TDV as well as to further define effective screening and intervention protocol for the clinical environment.

Introduction

Dating violence in teen relationships is widespread; over 10% of all high school adolescents report some form of physical violence in their dating relationships [1,2**].Teen dating violence (TDV)--defined as psychological, physical, and sexual aggression within the dating relationship of an adolescent aged 13–19 by a member of either a heterosexual or same sex couple is highly prevalent among all adolescents [1,2**,3**]. However, TDV is more prevalent in populations engaging in other high-risk behaviors including alcohol use, drug use, suicidal ideation, and high-risk sexual behaviors [3**,4].Yet, despite its prevalence many medical providers do not screen for dating or interpersonal violence in adolescents.

Similarities and Differences between adult relationship violence and teen relationship violence

IPV(Intimate Partner Violence) in adulthood and TDV share many common qualities including exposure to physical, sexual, and psychological abuse. However, the significant differences in psychological, physical, and intellectual development between adolescents and adults make comparisons between IPV in adulthood and TDV problematic [5]. Because of their developmental stage, a typical adolescent may be less capable of utilizing positive relationship skills and more likely to use anger, physical aggression, and emotional abuse in conflicts [6]. Disparities between adolescent and adult relationships extend beyond developmental differences. Unlike adults, adolescents rarely co-habitate, share finances, or co-parent. The traditional power dynamic, related to reliance and control, which is often present in adult domestic violence, is less present in teen relationships [6,7]. Qualitative research studies have examined the ways in which teens conceptualize relationships and the reasons they choose to remain in relationships. Teens discuss the ways in which material and sexual benefits encourage remaining in a relationships despite the presence of TDV but indicate peer pressure and the social environment are more likely to drive their decisions about relationships [8].

Epidemiology

Though there is general agreement that TDV differs from IPV in adulthood, there is a lack of consensus regarding the definition of TDV and thus its incidence and prevalence. The lack of consensus in definition also leads to confusion in assessing the long and short-term effects of TDV as well as appropriate screening and prevention strategies [9]. In studies utilizing the Youth Risk Behavior Survey where researchers often strictly define TDV as exposure to physical abuse, lower percentages of adolescents screen positive for TDV [2**,4]. When the definition of TDV is expanded to include multiple forms of sexual violence, controlling behaviors, and other forms of emotional abuse, significantly higher percentages of adolescents screen positively [8,10]. Clearly, the lack of a formal definition of TDV has implications in both research and clinical practice.

While research regarding incidence and prevalence is limited and constrained by the lack of a universal definition, the available research finds that adolescents experience relationship violence at alarmingly high rates. The 2009 Youth Risk Behavior Surveillance data revealed that nearly 10% of the students surveyed reported some form of physical violence by a dating partner in the past 12 months [2**]. Studies examining other aspects of TDV report high rates of exposure to sexual and psychological TDV [**3,10,11].Young women, ages 16–20, have been consistently found to experience the highest rates of relationship violence, even when compared to adult women [10].

TDV, like IPV in adulthood, impacts adolescents from all races, ethnicities, religions, and socioeconomic backgrounds [5]. Not surprisingly, the prevalence of TDV among specific populations is also debated. Exposure to TDV appears to be most highly correlated with socioeconomic status, and high risk behaviors including: unprotected sex and unintended pregnancy, riding in a car with a partner under the influence of alcohol or drugs, alcohol and drug use, history of self harm, lack of seatbelt and helmet use, difficulties in school and disordered eating habits [5,9,11,12,*13].

Short and Long-term impacts of TDV

Adolescents exposed to TDV suffer significant short and long-term consequences. The short-term consequences linked to TDV include, but are not limited to depression, suicidal ideation, anxiety, alcohol abuse, cigarette and drug use, unintended pregnancies and other sexual health risk behaviors [4,9,14]. Long-term consequences associated with TDV include decreased self-esteem, poorer academic performance, disordered eating behaviors, substance dependence, and poor mental health measures [11,15].

Much of the literature has focused on the bidirectional nature of TDV within the context of heterosexual relationships. Studies indicate that male and female adolescents, in heterosexual relationships, report perpetrating violence equally and that they also report comparable exposure to victimization [10,16]. Though young women and men have been shown to be both perpetrators and victims of TDV, they perpetrate and experience the violence differently. Studies have shown that young men tend to perpetrate more severe and more physical violence and suffer fewer psychological consequences [15,17,18]. Young women tend to perpetrate less significant forms of physical violence and suffer more profound psychological consequences [15,17,18,19]. A study published in 2007 examined TDV and mental health outcomes in a sample of older adolescents (men=671, female=720) utilizing a longitudinal research design [15]. The sample, based in Minnesota, was taken from 31 public middle and high schools throughout the Minneapolis and Saint Paul areas. The researchers collected data in two waves, five years apart, and measured TDV exposure and several indicators of mental health. The results of the study revealed women who were exposed to TDV reported considerably higher rates of depression, body dissatisfaction, and low self-esteem when compared to men with similar TDV exposure [15]. Young men exposed to TDV, either as perpetrators or victims, struggled to a lesser degree with depression, anxiety, poor self-esteem, and substance use 15]. The reasons for these differences between young men and women are complex and are not well understood; more research is needed not only to understand gender differences in response to TDV but also to better understand the dynamics in heterosexual and same sex relationships.

Though further research on mental health impacts of relationship violence is needed, the current literature demonstrates that exposure to relationship violence has significant impact on mental health outcomes. The research indicates that IPV exposure significantly increases poor mental health outcomes and that the frequency and severity of the violence is linked with an increase in the severity and associated impairment of mental illness [4,7,14,19]. IPV is associated with both the development and worsening of many mental health conditions including depression, Post Traumatic Stress Disorder (PTSD), anxiety, obsessive compulsive disorders, substance abuse, and severe and persistent mental illnesses including schizophrenia and bipolar disorder in adults [20].

Relationship violence begun in adolescence has been shown to continue into adulthood. While few studies have examined the associations between TDV and IPV in adulthood, the limited data indicates that TDV exposure increases risk for IPV in adulthood [21]. It appears that studies that have tested the association between TDV and IPV have not examined exposure to screening or safe dating curricula [21,22]. Therefore little is known about the ways in which these forms of intervention and prevention influence TDV in already at-risk adolescents.

Screening

Despite the high prevalence of TDV, few teens report having been asked by healthcare providers about safety in their dating relationship [**3,4]. However, in surveys adolescents endorse the need for healthcare providers to screen all adolescents for TDV exposure and indicate a belief that screening by a healthcare provider is necessary [**3]. And the literature overwhelmingly supports universal and regular screening of all adolescents, aged 13 and older, regardless of chief complaint [**3,4,13,16].

Researchers use several different screening measures to assess TDV and the decision regarding the appropriate tool is largely dependent on the way in which the researcher conceptualizes TDV. Researchers who define TDV as primarily physical violence often use questions similar to those found in the Youth Risk Behavior Survey which asks participants to report on physical violence including hitting, scratching, punching, kicking, and the use of weapons to threaten or injure [4]. While many agree that research using this tool provides the prevalence of the most serious forms of dating violence, it misses those exposed to other forms of TDV. More comprehensive tools such as Braiker and Kelly’s (1979) relationship questionnaire focus on additional aspects of relationships such as stress within the relationship and overall perception of health of the relationship [23]. There are additional more comprehensive tools such as the Revised Conflicts Tactics Scale (CTS2) [24]. However care must be taken when choosing a screening tool as many screening tools were originally developed for adult populations and may require significant adaptations for use with adolescents [9].

The most effective and reliable method for screening for TDV appears to be screening measures which utilize the Audio Computer Assisted Survey Instruments (ACASI) with follow up interviews conducted by a healthcare professional [**3,9,25]. However, this screening method may not be realistic for many pediatric and adolescent clinic settings. Alternatively, screening utilizing a few precise questions regarding safety, experiences with physical violence and feelings of fear in past and current relationships has been shown to positively identify TDV exposure in the majority of adolescent patients [*13]. Additionally, the literature indicates that adolescents are more likely to disclose TDV if the healthcare provider acknowledges the ubiquitous nature of TDV and offers prevention and intervention information to the adolescent regardless of a positive or negative screen [**2,16]. The clinical environment is also important. Adolescents report greater comfort in disclosing TDV when the clinical environment suggests safety and confidentiality [**3,16,**26]. Posters, brochures, and cards with information about TDV, risks, prevention, and intervention programs should be placed throughout the clinic and healthcare providers should frequently discuss confidentiality and the limitations of confidentiality during routine medical exams to increase adolescents’ confidence in providers ability to both help and protect confidentiality [*3,16, **26].

Though universal screening for TDV is the gold standard, there are certain subgroups that should definitely be targeted. Adolescent subgroups known to be at increased risk of TDV include:

• Those with past TDV exposure

• Those with alcohol/drug use

• Those with symptoms of depression or anxiety

• Those with irregular medical care histories

• Those with high risk sexual behaviors

• Those with concerning responses to HEADSSS (Home, Education/Employment, Activities. Drugs, Sexuality, Suicide/Depression) assessment [**3,5,11,13]

Intervention

While school based TDV intervention programs have shown the most promising results for reduction of both primary and secondary exposure, the role of healthcare providers and medical clinics cannot be overlooked [16, 22]. The majority of adolescents believe medical providers should screen for TDV likely because they believe healthcare providers will be helpful [**3,13]. Healthcare providers may shy away from screening for TDV because many pediatric and adolescent clinics lack the mental health or social work resources necessary to support patients following a positive screen for TDV. While adding such services may not be possible, healthcare providers can provide excellent and reliable resources to patients who report positive TDV exposure by becoming familiar with both local and national organizations dedicated to providing supportive care for adolescents experiencing TDV[*3,13,16]. While connecting adolescents with clinic-based mental health and other social work services has been found to be most effective, interventions which provide adolescents with information about local and national resources have also yielded positive results [*3,11,16]. Healthcare providers in pediatric and adolescent clinics without mental health and other social work services should increase awareness among staff about local resources as well as reliable, well-respected websites such as:

• http://www.loveisrespect.org/

• http://www.cdc.gov/chooserespect/

• http://www.breakthecycle.org/

• http://www.thatsnotcool.com/

• http://www.thesafespace.org/

These websites are featured on the website of the Office of Violence Against Women and provide accurate and accessible information to adolescents [**27]. In addition to these adolescent friendly websites, healthcare providers should also be aware of both local and national 24-hour crisis support lines. National crisis lines including the National Teen Dating Abuse Helpline at 1-866-331-9474 not only provide supportive services but can also provide referrals to local resources. Pediatric and adolescent healthcare clinics should create protocols to address TDV. Interventions might include information about these websites and hotline information along with referrals to local supportive mental health and social services organization.

Conclusion

TDV is a growing public health problem with serious short and long-term consequences. The high incidence and prevalence rates discussed in this article demand those healthcare providers who treat adolescent patients to become familiar with TDV, the way in which it presents in adolescent populations, and ways to screen adolescent patients. Although universal screening utilizing computer based screening methods may be ideal, lack of access to such screening methods should not preclude screening efforts. Integrating questions regarding relationship safety into each medical examination with an adolescent regardless of gender or sexual orientation is an excellent way to increase the rate of disclosure and connections to positive mental health and social service supports.

Key Points.

• Teen dating violence is highly prevalent in adolescent populations.

• Teen dating violence has serious short and long-term implications on adolescent health.

• Healthcare providers can play a critical role in screening and intervention.

• Universal screening is optimum but healthcare providers should pay special attention to adolescents involved in other high risk behaviors including alcohol and drug use and high risk sexual behaviors.

Abbreviations

TDV

Teen Dating Violence

IPV

Intimate Partner Violence

ACSAI

Audio Computer Assisted Survey Instruments

HEADSS

Home, Education and Employment, Activities, Drugs, Sexuality, and Suicide/Depression