Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening

The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Importance

Intimate partner violence and abuse of older or vulnerable adults are common in the United States but often remain undetected. Although estimates vary, IPV (including sexual violence, physical violence, and stalking) is experienced by approximately 36% of US women and 33% of US men during their lifetime. Severe physical violence is experienced by 21% of US women and 15% of US men during their lifetime.¹ Prevalence rates vary by age, race/ethnicity, and income. Estimates also vary for prevalence of elder abuse and abuse of vulnerable adults. A 2008 nationwide survey of US adults 60 years or older found that the prevalence of any abuse or neglect in the past year was 10%.² A 2004 survey of Adult Protective Services (APS) agencies found 40,848 substantiated reports of vulnerable adult abuse (in those aged 18 to 59 years) in 19 states.³

In addition to the immediate effects of IPV, such as injury and death, there are other health consequences, many with long-term effects, including development of mental health conditions such as depression, posttraumatic stress disorder (PTSD), anxiety disorders, substance abuse, and suicidal behavior; sexually transmitted infections; unintended pregnancy; and chronic pain and other disabilities.^4,5 Violence during pregnancy is associated with preterm birth and low birth weight⁶ and adverse effects on maternal and infant health, including postpartum mental health problems⁷ and hospitalization during infancy.⁸

Long-term negative health effects from elder abuse include death,⁹ higher risk of nursing home placement¹⁰ among those referred to APS, and adverse psychological consequences (distress, anxiety, and depression).¹¹

Detection

The USPSTF found adequate evidence that available screening instruments can identify IPV in women. The USPSTF found limited evidence about the performance of IPV screening instruments in men.

The USPSTF found inadequate evidence to assess the accuracy of screening instruments designed to detect elder abuse or abuse of vulnerable adults when there are no recognized signs and symptoms of abuse.

Benefits of Detection and Early Intervention

The USPSTF found adequate evidence that effective interventions that provide or refer women to ongoing support services can reduce violence, abuse, and physical or mental harms in women of reproductive age. However, the USPSTF found inadequate direct evidence that screening for IPV can reduce violence, abuse, and physical or mental harms.

The recommendation on screening for IPV applies to women of reproductive age because the evidence demonstrating benefit of ongoing support services is predominantly found in studies of pregnant or postpartum women. The USPSTF extrapolated the evidence pertaining to interventions with ongoing support services from pregnant and postpartum women to all women of reproductive age.

The USPSTF found no studies on screening or interventions for IPV in men.

The USPSTF found inadequate evidence that screening or early detection of elder abuse or abuse of vulnerable adults reduces exposure to abuse, physical or mental harms, or mortality in older or vulnerable adults.

Harms of Detection and Early Intervention

The USPSTF found inadequate evidence to determine the harms of screening or interventions for IPV. Limited evidence showed no adverse effects of screening or interventions for IPV. The USPSTF determined that the magnitude of the overall harms of screening and interventions for IPV can be bounded as no greater than small. When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.

The USPSTF found inadequate evidence on the harms of screening or interventions for elder abuse or abuse of vulnerable adults.

Patient Population Under Consideration

This recommendation applies to women of reproductive age and older or vulnerable adults without recognized signs and symptoms of abuse. The studies reviewed for IPV included adolescents to women in their 40s.

See below for suggestions for practice regarding men and older and vulnerable adults.

Definitions of IPV and Elder Abuse

The term “intimate partner violence” refers to physical violence, sexual violence, psychological aggression (including coercive tactics, such as limiting access to financial resources), or stalking by a romantic or sexual partner, including spouses, boyfriends, girlfriends, dates, and casual “hookups.” Severe physical violence includes being hit with a fist or something hard, kicked, hurt by pulling hair, slammed against something, hurt by choking or suffocating, beaten, burned on purpose, or threatened with a knife or gun.¹

The term “elder abuse” refers to acts whereby a trusted person (eg, a caregiver) causes or creates risk of harm to an older adult.¹² According to the Centers for Disease Control and Protection (CDC), an older adult is considered to be 60 years or older.¹² The legal definition of “vulnerable adult” varies by state but is generally defined as a person who is or may be mistreated and who, because of age, disability, or both, is unable to protect him or herself.³ Types of abuse that apply to older or vulnerable adults include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial or material exploitation.

Assessment of Risk

Although all women of reproductive age are at potential risk for IPV and should be screened, a variety of factors increase risk of IPV, such as exposure to violence as a child, young age, unemployment, substance abuse, marital difficulties, and economic hardships.¹³ However, the USPSTF did not identify any risk assessment tools that predict greater likelihood of IPV in populations with these risk factors.

Risk factors for elder abuse include isolation and lack of social support, functional impairment, and poor physical health.¹⁴ For older adults, lower income and living in a shared living environment with a large number of household members (other than a spouse) are associated with an increased risk of financial and physical abuse.¹⁵

Screening Tests

Several screening instruments can be used to screen women for IPV. The following instruments accurately detect IPV in the past year among adult women: Humiliation, Afraid, Rape, Kick (HARK); Hurt, Insult, Threaten, Scream (HITS); Extended–Hurt, Insult, Threaten, Scream (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST).

HARK includes 4 questions that assess emotional and physical IPV in the past year. HITS includes 4 items that assess the frequency of IPV, and E-HITS includes an additional question to assess the frequency of sexual violence. PVS includes 3 items that assess physical abuse and safety. WAST includes 8 items that assess physical and emotional IPV.

Most studies only included women who could be separated from their partners during screening, during the intervention, or both, so screening and the intervention could be delivered in private.

State and local reporting requirements vary from one jurisdiction to another, with differences in definitions, whom and what should be reported, who should report, and to whom. Some states require clinicians (including primary care providers) to report abuse to legal authorities, and most require reporting of injuries resulting from guns, knives, or other weapons.¹⁶ For elder abuse, mandatory reporting laws and regulations also vary by state; however, most states require reporting.¹⁷

The USPSTF found no valid, reliable screening tools in the primary care setting to identify IPV in men without recognized signs and symptoms of abuse.

The USPSTF found no valid, reliable screening tools in the primary care setting to identify abuse of older or vulnerable adults without recognized signs and symptoms of abuse.

Screening Interval

The USPSTF found no evidence on appropriate intervals for screening. Randomized clinical trials (RCTs) of screening and interventions for IPV often screen for current IPV or IPV in the past year.

Interventions

No studies definitively identified which intervention components resulted in positive outcomes. However, based on the evidence from 3 studies,^18-20 effective interventions generally included ongoing support services that focused on counseling and home visits, addressed multiple risk factors (not just IPV), or included parenting support for new mothers. See the Box for more information about the components of effective ongoing support services. These studies were conducted in pregnant or postpartum women. Studies that only included brief interventions and provided information about referral options were generally ineffective.

Suggestions for Practice Regarding the I Statement and Other Populations

Potential Preventable Burden

Older or vulnerable adults. Prevalence estimates of elder abuse and abuse of vulnerable adults vary. A 2008 nationwide survey of US adults 60 years or older found that the prevalence of any abuse or potential neglect in the past year was 10%.²¹ Elder abuse has a number of long-term negative health effects, including death,⁹ higher risk of nursing home placement10 among those referred to APS, and adverse psychological consequences (distress, anxiety, and depression).¹¹ A 2004 survey of APS agencies identified 40,848 substantiated reports of vulnerable adult abuse (in those aged 18-59 years) in 19 states.³

Women not of reproductive age. Based on the age categories reported by the CDC, approximately 4% of women aged 45 to 54 years and more than 1% of women 55 years or older have experienced rape, physical violence, or stalking by an intimate partner in the past 12 months.²²

Men. More than 33% of men have experienced sexual violence, physical violence, or stalking by an intimate partner in their lifetime.¹ Approximately 34% of men report any psychological aggression by an intimate partner in their lifetime. Among men who experience sexual violence, physical violence, or stalking, more than 10% experience at least 1 form of an IPV-related adverse effect, such as feeling fearful, feeling concerned for safety, injury, missing days of work or school, and needing medical care.¹

Potential Harms

Some potential harms of screening in older or vulnerable adults, women not of reproductive age, and men are shame, guilt, self-blame, retaliation or abandonment by perpetrators, partner violence, and the repercussions of false-positive results (eg, labeling and stigma).

Current Practice

Older or vulnerable adults. Limited evidence suggests that screening is not commonly occurring in practice; 1 study found that more than 60% of clinicians have never asked their older adult patients about abuse.²³

Women. While not specific to age, evidence suggests that screening for IPV is not commonly occurring in practice. A recent systematic review found that rates of routine screening vary and are typically low, ranging from 2% to 50% of clinicians reporting “always” or “almost always” routinely screening for IPV.²⁴

Men. No data are available on current screening practice in men.

Additional Approaches to Prevention

The Health Resources and Services Administration (HRSA) Strategy to Address Intimate Partner Violence (2017–2020) identifies priorities for reducing IPV, including training the health care and public health workforce to address IPV.²⁵ HRSA also developed a toolkit²⁶ for clinicians and health centers to help implement screening and interventions for IPV. The National Hotline on Domestic Violence has information about local programs and resources across the country.²⁷ The Administration for Children and Families has funded a compendium of state statutes and policies on domestic violence and health care.²⁸

The CDC,²⁹ Substance Abuse and Mental Health Services Administration–HRSA Center for Integrated Health Solutions,³⁰ US Department of Veterans Affairs,³¹ Administration for Community Living,³² and the Administration on Aging’s National Center for Elder Abuse³³ also have additional resources available for clinicians.

Useful Resources

The USPSTF has made recommendations on primary care interventions for child maltreatment;³⁴ screening for depression in adolescents,³⁵ adults, and pregnant women;³⁶ screening for alcohol misuse;³⁷ and screening for drug misuse.³⁸

Research Needs and Gaps

There are several key research gaps related to IPV. The USPSTF recognizes that a significant body of evidence is lacking for men. The CDC has conducted studies demonstrating the prevalence and importance of IPV in men; however, there is a lack of research on screening and interventions to prevent IPV in men. Research is needed in all areas related to the accuracy of screening tools for men, and trials are needed that examine the effectiveness (benefits and harms) of screening and interventions for IPV in the primary care setting in men without recognized signs and symptoms of abuse.

More research is also needed on the most effective characteristics of ongoing support services for reducing IPV. In particular, more RCTs that compare the benefits and harms of screening (plus ongoing support services or referral for women who screen positive) vs no screening are needed, where support services may include more frequent and intensive interventions such as home visits, cognitive behavioral therapy, or other forms that address multiple risk factors. These studies should evaluate the optimal duration, format, and method of delivery.

Trials of ongoing support services should enroll women of all ages, including nonpregnant women and women beyond reproductive age. These trials will help with understanding the types of postscreening, ongoing support services that can be most effective, and the patients for whom they are most effective.

More research is also needed in all areas related to the accuracy of screening tools in the primary care setting for elder abuse and abuse of vulnerable adults when there are no recognized signs and symptoms of abuse. High-quality RCTs are also needed on the effectiveness (benefits and harms) of screening and interventions in the primary care setting to prevent such abuse.

Burden of Disease

Intimate partner violence is a significant public health problem. According to the CDC, 36% of US women and 33% of US men experience sexual violence, physical violence, or stalking by an intimate partner during their lifetime.¹ The prevalence of lifetime psychological aggression is 36.4% in women and 34.3% in men. Lifetime severe physical violence is experienced by 21% of women and 15% of men.¹ The most commonly reported effects of IPV include feeling fearful (61.9% of women and 18.2% of men) and concern for safety (56.6% of women and 16.7% of men).³⁹ Women and men with a history of sexual violence, stalking, or physical violence committed by an intimate partner were more likely to report experiencing asthma, irritable bowel syndrome, frequent headaches, chronic pain, difficulty sleeping, and limitations in their activities than women and men without a history of such violence.³⁹

Intimate partner violence is more common in younger women; thus, women of reproductive age have a higher prevalence of IPV than older women. Approximately 14.8% of women aged 18 to 24 years have experienced rape, physical violence, or stalking by an intimate partner in the past 12 months, compared with 8.7% of women aged 25 to 34 years, 7.3% of women aged 35 to 44 years, 4.1% of women aged 45 to 54 years, and 1.4% of women 55 years or older.²² Intimate partner violence during pregnancy can have significant negative health consequences for women and children, including depression in women, low birth weight and preterm birth, and perinatal death.^6,7

Abuse of older or vulnerable adults is also a significant public health problem. Estimates of prevalence vary. A nationally representative survey (N = 3005) of community-dwelling adults aged 57 to 85 years estimated that 9% had experienced verbal mistreatment, 3.5% financial mistreatment, and 0.2% physical mistreatment by a family member.⁴⁰ Among older adults, intimate partners constitute the minority of perpetrators in substantiated reports of elder abuse. According to data from a national survey of APS agencies, across all substantiated abuse reports involving a known perpetrator among adults older than 60 years (N = 2074), approximately 11% of reports involved a spouse or intimate partner. The most common perpetrators of elder abuse are adult children (about 33% of cases) and other family members (about 22% of cases).³

The USPSTF found few studies reporting on recent estimates of the prevalence of abuse in populations of vulnerable adults. The 1995–1996 National Violence Against Women Survey (N = 6273) found that women with severe disability impairments were 4 times more likely to experience sexual assault in the past year than women without disabilities.⁴¹

Scope of Review

The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on screening for IPV, elder abuse, and abuse of vulnerable adults. The scope of this review is similar to that of the prior systematic review, but in the current review^42,43 the USPSTF also examined the evidence on IPV in men and adolescents. The current review did not examine screening or interventions for perpetration of IPV.

Accuracy of Screening Tests

The review identified 15 fair-quality studies (n = 4460) assessing the accuracy of 12 different IPV screening tools. All studies enrolled adults, and most enrolled only women or a majority of women; 1 study included only men.⁴⁴ The recruitment settings varied; 5 studies recruited from emergency departments, 4 from primary care practices, 1 from urgent care, and 3 by telephone or mail survey. Most studies assessed a tool designed to identify persons experiencing IPV within the past year; however, 4 studies reported on the accuracy of 5 tools for identifying current (ongoing) abuse, 1 assessed the accuracy of detecting lifetime abuse, and 1 assessed the accuracy of a tool for predicting future (within 3 to 5 months) abuse.

Five studies reported on the accuracy of 5 different screening tools (HARK, HITS, E-HITS, PVS, and WAST) for detecting any past-year IPV in adult women. Sensitivity ranged from 64% to 87% and specificity from 80% to 95%. Most screening tools were assessed by only 1 study.

Four studies reported on the accuracy of 5 screening tools for identifying ongoing or current abuse. Across all studies, accuracy varied widely (sensitivity, 46%-94%; specificity, 38%-95%). One tool, the Ongoing Violence Assessment Tool (OVAT), had acceptable sensitivity (86%) and specificity (83%) compared with the Index of Spouse Abuse (ISA).

One study enrolling men only from an emergency department reported on the accuracy of the PVS and HITS for detecting past-year IPV; sensitivity was low for both PVS and HITS for detecting psychological abuse (30% and 35%, respectively) and physical abuse (46% for both).

The review identified 1 fair-quality study assessing the accuracy of screening for abuse in the primary care setting in older adults when abuse is not suspected.⁴⁵ Screening was conducted using the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST), which includes 15 items. Compared with the Conflict Tactics Scale (CTS) (violence/verbal aggression scales combined), the H-S/EAST had a sensitivity of 46% (95% CI, 32%-59%) and specificity of 73.2% (95% CI, 62%-82%).

The review found no studies on the effectiveness of screening questionnaires or tools in identifying abuse and neglect of vulnerable adults.

Effectiveness of Early Detection and Treatment

Overall, 3 RCTs (n = 3759) found no direct benefit of screening for IPV in adult women (mean age range, 34-40 years) when screening was followed by brief counseling or referral. There were no significant differences between screening and control groups over 3 to 18 months for IPV, quality of life, depression, PTSD, or health care utilization outcomes. The RCTs compared universal screening for IPV in a health care setting with no screening; 1 study enrolled participants from 10 US primary care clinics, 1 from a single New Zealand emergency department, and 1 from a variety of Canadian clinical settings (12 primary care sites, 11 emergency departments, and 3 obstetrics-gynecology clinics). No RCTs enrolled men or adolescents, and none focused on pregnant women or reported outcomes separately by pregnancy status. Women who screened positive received brief counseling and referral; the trials did not directly provide ongoing support services, and the proportion of women who received more intensive services after referral was not reported.

Eleven RCTs (n = 6740) evaluated an IPV intervention in adult women with screen-detected IPV or women considered at risk for IPV. Five RCTs enrolled women during the perinatal period; all reported on IPV outcomes. Of these, the studies that were effective generally involved ongoing support services, which included multiple visits with patients, addressed multiple risk factors (not just IPV), and provided a range of emotional support and behavioral and social services. Two home-visit interventions^19,20 found lower rates of IPV in women assigned to the intervention group than in those assigned to the control group; however, the difference between groups was small (standardized mean difference, −0.04 and −0.34, respectively), and only 1 study found a statistically significant difference (standardized mean difference, −0.34 [95% CI, −0.59 to −0.08]).¹⁹

Of the 3 RCTs enrolling pregnant women with screen-detected IPV that evaluated a counseling intervention, 2 found benefit in favor of the intervention.^18,46 One trial only reported on subtypes of violence; the benefit was significant for some subtypes of violence (psychological and minor physical abuse) but not others (severe physical and sexual abuse).⁴⁶

One RCT assessing an integrated behavioral counseling intervention in women with 1 or more risk factors (smoking, environmental tobacco smoke exposure, depression, and IPV) reported on birth outcomes among the subgroup with IPV at baseline; significantly fewer women in the intervention group delivered very preterm neonates (≤33 weeks of gestation).⁴⁷ Many women with IPV at baseline (62%) also screened positive for depression and received counseling for depression in addition to counseling for IPV. Two RCTs reported on depression, and both found benefit in favor of the intervention (only 1 found a statistically significant benefit⁴⁶); 1 of these studies also reported on PTSD symptoms and found similar scores in both groups.⁴⁸

Six RCTs enrolled nonpregnant women; 4 measured changes in overall IPV incidence and found no significant difference between groups in rates of overall IPV exposure^49,50 or combined physical and sexual violence;^51,52 measures of IPV were either similar between groups or slightly higher in the intervention group. Two RCTs measured changes in quality of life after an IPV intervention; in both trials, scores were similar between intervention and control groups and differences were not statistically significant.^49,53 Interventions in nonpregnant women primarily included brief counseling, provision of information, and referrals but did not directly provide ongoing support services, and the proportion of women who received more intensive services after referral was not reported.

The review identified no eligible screening or intervention studies on IPV in men.

The review identified no eligible studies on elder abuse or abuse of vulnerable adults.

Potential Harms of Screening and Treatment

Two fair-quality RCTs reported on harms of screening and identified no adverse effects of screening. One RCT developed a specific tool, the Consequences of Screening Tool (COST), to measure the consequences of IPV screening, such as “Because the questions on partner violence were asked, I feel my home life has become (less difficult… more difficult).” Results indicated that being asked IPV screening questions was not harmful to women immediately after screening. Scores were similar across groups.

Five good- or fair-quality RCTs assessing IPV interventions reported on harms. No study found significant harms associated with the interventions. One RCT⁴⁹ assessing a brief counseling intervention surveyed women at 6 and 12 months about survey participation (including potential harms); there was no difference between groups in the percentage of women who reported potential harms, and the authors concluded no harms were associated with the intervention. Among women who reported that their abusive partner was aware of their participation in the trial, the number of negative partner behaviors (eg, got angry, made her more afraid for herself or her children, or restricted her freedom) was not significantly different between groups.

The review identified no eligible studies on IPV in men.

The review identified no eligible studies on elder abuse or abuse of vulnerable adults.

Estimate of Magnitude of Net Benefit

The USPSTF concludes with moderate certainty that screening for IPV in women of reproductive age and providing or referring women who screen positive to ongoing support services has a moderate net benefit. There is adequate evidence that available screening instruments can identify IPV in women. The evidence does not support the effectiveness of brief interventions or the provision of information about referral options in the absence of ongoing supportive intervention components. The evidence demonstrating benefit of ongoing support services is predominantly found in studies of pregnant or postpartum women. Studies that demonstrated no clear benefit in nonpregnant women, however, did not directly provide ongoing support services. Therefore, the USPSTF extrapolated the evidence pertaining to interventions with ongoing support services in pregnant and postpartum women to all women of reproductive age. More research is needed that includes ongoing support services for women who are not pregnant or postpartum or who are beyond reproductive age.

Because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for elder abuse and abuse of vulnerable adults are uncertain and that the balance of benefits and harms cannot be determined. More research is needed.

Response to Public Comment

A draft version of this recommendation statement was posted for public comment on the USPSTF website from April 24, 2018, to May 21, 2018. The USPSTF reviewed all comments and made revisions to the recommendation as appropriate. Some comments asked for clarification about the patient population, including whether men and older women were included in the recommendation. In response, the USPSTF clarified that it examined the evidence on the benefits and harms of screening for IPV in women of all ages and in men; the recommendation is based on the available evidence. Some comments suggested screening instruments for elder abuse. The USPSTF reviewed the suggested tools; however, none of the suggested screening instruments met the USPSTF’s inclusion criteria (eg, those screening tools were developed or tested in populations with recognized signs or symptoms of abuse). The USPSTF clarified the types of screening instruments that are needed in the Research Needs and Gaps section. Last, the USPSTF added more details on the research gaps and suggested resources for practitioners.

This recommendation replaces the 2013 USPSTF recommendation. It is consistent with the 2013 USPSTF recommendation, which was a B recommendation for women of childbearing age and an I statement for abuse in older or vulnerable adults. This recommendation incorporates new evidence since 2013 and provides additional information about the types of ongoing support services that appear to be associated with positive outcomes.

The American Academy of Family Physicians,⁵⁴ American College of Obstetricians and Gynecologists (ACOG),⁵⁵ American Academy of Neurology,⁵⁶ American Academy of Pediatrics,⁵⁷ Institute of Medicine Committee on Preventive Services for Women,⁵⁸ and the HRSA-supported Women’s Preventive Services Guidelines⁵⁹ are in favor of screening for IPV. The American Academy of Family Physicians recommends screening for IPV in all women of childbearing age and providing interventions for those who screen positive. ACOG recommends screening for IPV in all pregnant women and offering ongoing support services. The American Medical Association Code of Medical Ethics states that clinicians should routinely ask about physical, sexual, and psychological abuse.⁶⁰ The Canadian Task Force on Preventive Health Care⁶¹ and the World Health Organization⁶² indicate that current evidence does not justify universal screening for IPV. The Community Preventive Services Task Force recommends primary prevention interventions that aim to prevent or reduce IPV and sexual violence among youth.⁶³ The American Academy of Neurology⁵⁶ and ACOG⁶⁴ recommend screening for elder abuse. The Canadian Task Force on Preventive Health Care⁶¹ concludes that the current evidence is insufficient to warrant a recommendation for screening.

The US Preventive Services Task Force (USPSTF) members include the following individuals: Susan J. Curry, PhD (University of Iowa, Iowa City); Alex H. Krist, MD, MPH (Fairfax Family Practice Residency, Fairfax, Virginia, and Virginia Commonwealth University, Richmond); Douglas K. Owens, MD, MS (Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Stanford University, Stanford, California); Michael J. Barry, MD (Harvard Medical School, Boston, Massachusetts); Aaron B. Caughey, MD, PhD (Oregon Health & Science University, Portland); Karina W. Davidson, PhD, MASc (Columbia University, New York, New York); Chyke A. Doubeni, MD, MPH (University of Pennsylvania, Philadelphia); John W. Epling Jr, MD, MSEd (Virginia Tech Carilion School of Medicine, Roanoke); David C. Grossman, MD, MPH (Kaiser Permanente Washington Health Research Institute, Seattle); Alex R. Kemper, MD, MPH, MS (Nationwide Children’s Hospital, Columbus, Ohio); Martha Kubik, PhD, RN (Temple University, Philadelphia, Pennsylvania); Ann Kurth, PhD, MPH (Yale University, New Haven, Connecticut); C. Seth Landefeld, MD (University of Alabama at Birmingham); Carol M. Mangione, MD, MSPH (University of California, Los Angeles); Michael Silverstein, MD, MPH (Boston University, Boston, Massachusetts); Melissa A. Simon, MD, MPH (Northwestern University, Evanston, Illinois); Chien-Wen Tseng, MD, MPH, MSEE (University of Hawaii, Honolulu, and Pacific Health Research and Education Institute, Honolulu, Hawaii); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Authors followed the policy regarding conflicts of interest described at https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. No other disclosures were reported.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.

AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.

This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.

1. Smith SG, Zhang X, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data Brief. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2018.
2. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Pub Health. 2010;100(2):292-7.
3. Teaster PB, Dugar TA, Mendiono MS, Abner EL, Cecil KA. The 2004 Survey of State Adult Protective Services: Abuse of Vulnerable Adults 18 Years of Age and Older. Washington, DC: National Committee for the Prevention of Elder Abuse and National Adult Protective Services Association; 2007.
4. Centers for Disease Control and Prevention (CDC). Intimate partner violence: consequences. CDC website. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html. Accessed September 6, 2018.
5. Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med. 2002;23:260-8.
6. Shah PS, Shah J; Knowledge Synthesis Group on Determinants of Preterm/LBW Births. Maternal exposure to domestic violence and pregnancy and birth outcomes: a systematic review and meta-analyses. J Womens Health (Larchmt). 2010;19:2017-31.
7. Desmarais SL, Pritchard A, Lowder EM, Janssen PA. Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems. BMC Pregnancy Childbirth. 2014;14:132.
8. Pavey AR, Gorman GH, Kuehn D, Stokes TA, Hisle-Gorman E. Intimate partner violence increases adverse outcomes at birth and in early infancy. J Pediatr. 2014;165(5):1034-1039.
9. Burnett J, Jackson SL, Sinha AK, et al. Five-year all-cause mortality rates across five categories of substantiated elder abuse occurring in the community. J Elder Abuse Negl. 2016;28(2):59-75.
10. Lachs MS, Williams CS, O'Brien S, Pillemer KA. Adult protective service use and nursing home placement. Gerontologist. 2002;42(6):734-9.
11. Dong X, Chen R, Chang ES, Simon M. Elder abuse and psychological well-being: a systematic review and implications for research and policy—a mini review. Gerontology. 2013;59(2):132-42.
12. Hall JE KD, Crosby AE. Elder Abuse Surveillance: Uniform Definitions and Recommended Core Data Elements for Use in Elder Abuse Surveillance, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention; 2016.
13. Capaldi DM, Knoble NB, Shortt JW, Kim HK. A systematic review of risk factors for intimate partner violence. Partner Abuse. 2012;3(2):231-80.
14. Burnes D, Pillemer K, Caccamise PL, et al. Prevalence of and risk factors for elder abuse and neglect in the community: a population-based study. J Am Geriatr Soc. 2015;63(9):1906-12.
15. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-56.
16. Houry D, Sachs CJ, Feldhaus KM, Linden J. Violence-inflicted injuries: reporting laws in the fifty states. Ann Emerg Med. 2002;39(1):56-60.
17. Institute of Medicine and National Research Council. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: National Academies Press; 2014.
18. El-Mohandes AA, Kiely M, Joseph JG, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstet Gynecol. 2008;112(3):611-20.
19. Sharps PW, Bullock LF, Campbell JC, et al. Domestic violence enhanced perinatal home visits: the DOVE randomized clinical trial. J Womens Health (Larchmt). 2016;25(11):1129-38.
20. Bair-Merritt MH, Jennings JM, Chen R, et al. Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start Home Visitation Program. Arch Pediatr Adolesc Med. 2010;164:16-23.
21. Acierno R, Hernandez-Tejada MA, Anetzberger GJ, Loew D, Muzzy W. The National Elder Mistreatment Study: an 8-year longitudinal study of outcomes. J Elder Abuse Negl. 2017;29(4):254-269.
22. Breiding MJ, Chen J, Black MC. Intimate Partner Violence in the United States—2010.Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2014.
23. Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Fam Med. 2005;37(7):481-5.
24. Alvarez C, Fedock G, Grace KT, Campbell J. Provider screening and counseling for intimate partner violence: a systematic review of practices and influencing factors. Trauma Violence Abuse. 2017;18(5):479-95.
25. Health Resources and Services Administration, Office of Women's Health. The HRSA Strategy to Address Intimate Partner Violence: 2017–2020. Rockville, MD: Health Resources and Services Administration; 2017.
26. Futures Without Violence. Prevent, Assess, and Respond: A Domestic Violence Toolkit for Health Centers & Domestic Violence Programs. IPV Health Partners website. http://ipvhealthpartners.org/wp-content/uploads/2018/08/IPV-Health-Partners-Toolkit-8.18.pdf. Published 2017. Accessed September 11, 2018.
27. National Domestic Violence Hotline. Resources for victims & survivors. https://www.thehotline.org/resources/victims-and-survivors/. Accessed September 11, 2018.
28. Durborow N, Lizdas KC, O’Flaherty A, Marjavi A. Compendium of State Statutes and Policies on Domestic Violence and Health Care. San Francisco, CA: Family Violence Prevention Fund; 2010.
29. Centers for Disease Control and Prevention (CDC). Intimate partner violence. CDC website. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html. Updated June 11, 2018. Accessed September 11, 2018.
30. Substance Abuse and Mental Health Services Administration (SAMHSA)–Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions. Intimate partner violence. SAMHSA website. https://www.integration.samhsa.gov/clinical-practice/intimate-partner-violence. Accessed September 11, 2018.
31. US Department of Veterans Affairs (VA). Intimate partner violence (IPV) assistance program. VA website. https://www.socialwork.va.gov/IPV/Index.asp. Updated March 22, 2018. Accessed September 11, 2018.
32. Administration for Community Living (ACL). Protecting rights and preventing abuse. ACL website. https://www.acl.gov/node/64. Updated September 6, 2017. Accessed September 11, 2018.
33. National Center on Elder Abuse (NCEA) website. https://ncea.acl.gov/. Accessed September 11, 2018.
34. U.S. Preventive Services Task Force. Primary care interventions to prevent child maltreatment: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(4):289-295.
35. U.S. Preventive Services Task Force. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.
36. US Preventive Services Task Force. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.
37. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(3):210-218.
38. U.S. Preventive Services Task Force. Screening for Illicit Drug Use: U.S. Preventive Services Task Force Recommendation Statement. Rockville, MD: US Preventive Services Task Force; 2008.
39. Smith SG, Chen J, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017.
40. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254.
41. Casteel C, Martin SL, Smith JB, Gurka KK, Kupper LL. National study of physical and sexual assault among women with disabilities. Inj Prev. 2008;14(2):87-90.
42. Feltner C, Berkman N, Kistler C, et al. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 169. AHRQ Publication No. 18-05240-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2018.
43. Feltner C, Wallace I, Berkman N, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320(16):1688-1701.
44. Mills TJ, Avegno JL, Haydel MJ. Male victims of partner violence: prevalence and accuracy of screening tools. J Emerg Med. 2006;31(4):447-452.
45. Fulmer T, Strauss S, Russell SL, et al. Screening for elder mistreatment in dental and medical clinics. Gerodontology. 2012;29(2):96-105.
46. Tiwari A, Leung WC, Leung TW, Humphreys J, Parker B, Ho PC. A randomised controlled trial of empowerment training for Chinese abused pregnant women in Hong Kong. BJOG. 2005;112(9):1249-1256.
47. Kiely M, El-Mohandes AA, El-Khorazaty MN, Blake SM, Gantz MG. An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial [published correction appears in Obstet Gynecol. 2011;117(5):1232]. Obstet Gynecol. 2010;115(2, pt 1):273-283.
48. Zlotnick C, Capezza NM, Parker D. An interpersonally based intervention for low-income pregnant women with intimate partner violence: a pilot study. Arch Womens Ment Health. 2011;14(1):55-65.
49. Hegarty K, O'Doherty L, Taft A, et al. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet. 2013;382(9888):249-58.
50. Rhodes KV, Rodgers M, Sommers M, et al. Brief motivational intervention for intimate partner violence and heavy drinking in the emergency department: a randomized clinical trial. JAMA. 2015;314(5):466-77.
51. Miller E, Tancredi DJ, Decker MR, et al. A family planning clinic-based intervention to address reproductive coercion: a cluster randomized controlled trial. Contraception. 2016;94(1):58-67.
52. Miller E, Decker MR, McCauley HL, et al. A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion. Contraception. 2011;83(3):274-80.
53. Tiwari A, Fong DY, Yuen KH, et al. Effect of an advocacy intervention on mental health in Chinese women survivors of intimate partner violence: a randomized controlled trial. JAMA. 2010;304(5):536-43.
54. Dicola D, Spaar E. Intimate partner violence. Am Fam Physician. 2016;94(8):646-51.
55. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 518: intimate partner violence. Obstet Gynecol. 2012;119(2 Pt 1):412-7.
56. Schulman EA, Hohler AD. The American Academy of Neurology position statement on abuse and violence. Neurology. 2012;78:433-5.
57. Thackeray JD, Hibbard R, Dowd MD; Committee on Child Abuse and Neglect; Committee on Injury, Violence, and Poison Prevention. Intimate partner violence: the role of the pediatrician. Pediatrics. 2010;125(5):1094-1100.
58. Institute of Medicine. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: National Academies Press; 2011.
59. Health Resources and Services Administration (HRSA). Women’s preventive services guidelines. HRSA website. https://www.hrsa.gov/womens-guidelines-2016/index.html. October 2017. Accessed September 11, 2018.
60. American Medical Assocation (AMA). Code of Medical Ethics Opinion 8.10: preventing, identifying, and treating violence and abuse. AMA website. https://www.ama-assn.org/delivering-care/preventing-identifying-treating-violence-abuse. Accessed September 11, 2018.
61. Canadian Task Force for Preventive Health Care. Domestic abuse. Canadian Task Force for Preventive Health Care website. https://canadiantaskforce.ca/guidelines/appraised-guidelines/domestic-abuse/. Published 2013. Accessed September 11, 2018.
62. World Health Organization. Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines. Geneva, Switzerland: World Health Organization; 2013.
63. Community Preventive Services Task Force. Primary prevention reduces intimate partner violence and sexual violence among youth. Community Preventive Services Task Force website. https://www.thecommunityguide.org/content/primary-prevention-reduces-intimate-partner-violence-and-sexual-violence-among-youth. Accessed September 11, 2018.
64. American College of Obstetricians and Gynecologists. Committee Opinion No. 568: elder abuse and women's health. Obstet Gynecol. 2013;122(1):187-91.

Format and Content

• Home visits and counseling that address multiple risk factors (beyond just IPV)
• Some examples of the home visit component include:
  • Tailored IPV-related information based on the individual’s expressed needs and level of danger at each visit (eg, information addressing the cycle of violence, risk factors for homicide, choices available to the woman, safety planning, and other IPV resources in the community)
  • Services related to parenting, problem-solving skills, and emotional support; linking families to community services; and prevention of child abuse
• Some examples of the counseling component include:
  • Cognitive behavioral therapy aimed at reducing behavioral risks, including depression, IPV (emphasizing safety behaviors), smoking, and tobacco exposure; cognitive behavioral therapy aimed at risks specific to the individual

Duration, Frequency, and No. of Visits

• Average duration ranged from 31 wk to 3 y; ongoing support services spanned the prenatal and postnatal periods
• Frequency of ongoing support services varied and were often tailored to the individual or coincided with routine perinatal care visits (eg, weekly, biweekly, monthly, or quarterly)
• Total average No. of sessions ranged from 4 to 14
• Ongoing support services were delivered either at home or in perinatal care sites

Provider

• Delivery of ongoing support services often required dedicated training and was performed by paraprofessionals; master’s-level, trained social workers or psychologists; community health workers; and nurses

Abbreviation: IPV=intimate partner violence.