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A mother recently visited pediatrician Kathy Franchek with complaints that her son's attention deficit hyperactivity disorder was out of control.

The elementary school student was acting aggressively at home, proof to the mother that his medication wasn't working.

But to Franchek, that was the first clue that the boy may have been exposed to violence.

Upon probing, she learned he was scared at night. She privately asked the mother if there was domestic violence in the home. There was.

No wonder his medication wasn't working — his aggression wasn't caused by ADHD. Franchek referred him to a psychologist to be screened for post-traumatic stress disorder.

To Franchek, a childhood exam is a chance to not only check on the youngster's health but also the mother's — to see if she is being abused. The Primary Children's Medical Center doctor and University of Utah pediatrics assistant professor is training U. medical residents and other doctors and nurses to ask parents about violence in their homes.

New research by her and others examining Utah children living in domestic-violence shelters indicates there is good reason: They are more likely to have chronic diseases that are exacerbated after they witness or hear their mothers being abused.

Other research shows children exposed to domestic violence are also more likely to be victims of abuse; to become violent themselves, and to have serious emotional distress and behavioral problems.

"Many [pediatricians] think we shouldn't be asking parents about this ... because the parent isn't our patient. Really, it is our business," Franchek said. "If we're not asking, we're missing a very important component of managing [a child's] illness."

Parents need to be referred to domestic-violence advocates and their children should see a mental-health specialist, she said.

"Children are intimately involved" • The abuse of women is a pediatric issue, the American Academy of Pediatrics said in a policy statement last year that urged pediatricians to recognize signs of abuse and intervene. One-third to three-quarters of children whose mothers are assaulted are also abused, it said, so helping moms can also help prevent child abuse. Children who aren't physically harmed are still hurt: "Witnessing violence in the home can be as traumatic for children as being the victim of physical or sexual abuse," it said.

Franchek was once skeptical. As a medical student and resident at Baylor College of Medicine in the 1990s, she didn't learn about domestic violence. Later, in private practice, she initially balked at the opportunity to listen to a domestic-violence advocate, thinking, "This isn't my problem."

But the talk was powerful enough to persuade her to volunteer to give free medical care at a shelter.

As an assistant professor at Baylor University, she developed clinical guidelines for pediatricians to assess for maternal domestic violence and refer mothers to help.

In 2006, she moved to Utah, where she serves on the YWCA's board of directors, helps advise the Peace House in Park City, and raises awareness among health care providers for the Utah Domestic Violence Council.

At a recent three-hour training for U. pediatric residents at the YWCA, Franchek played a 911 tape for two medical residents. A hysterical child calls to report her parents are having a fight.

Before the girl abruptly hangs up, she cries out for her mother and screams, "Oh, my God!"

"Children are intimately involved in the violence in the home," Franchek said, "even if they aren't the direct recipients of that violence."

"Start asking" • Under Utah law, a child being present during domestic violence is considered child abuse. Doctors should warn parents that they must report child abuse to police or child protective services, Franchek said. That may stop a mother from talking, but she can still be referred to a shelter for help.

At wellness visits, Franchek mentions that domestic violence is common — one in four women have been assaulted at some point by a partner — and tells parents they can come to her for help.

Then, when a child comes with complaints that don't add up — abdominal pain without evidence of a physical problem or asthma that isn't under control despite the best efforts — she asks direct questions about what is happening in the home.

Children may also come with aggression or sleep problems or struggles at school. She saw a 2-year-old who was kicked out of day care for aggression and learned that the mother was hit by her husband. A toddler who woke up screaming at night also witnessed or heard violence.

"When you get these common complaints that seem really outside of the normal, you better start asking," she said.

Franchek's guidelines aren't just based on anecdotes.

From December 2008 to July 2009, she and pediatrics professor Paul C. Young and then-graduate student Carrie Sillito oversaw a study to anonymously survey 116 mothers living at domestic violence-shelters across Utah. The survey asked about the mothers' abuse, their children's exposure to the violence and the children's health.

The mothers were eight times more likely to say their children had poor or fair health than the general Utah population, according to unpublished results presented at a pediatric conference this spring and now being submitted to a peer-reviewed journal.

The children were sick even if the violence was less severe or frequent, suggesting any amount of domestic violence is bad for children's health.

Chronic problems • Slightly more than 40 percent of the children had been diagnosed with a chronic disease. That's about double the rate for the general Utah and U.S. pediatric population. The diseases ranged from physical ailments such as asthma to mental illnesses, including post-traumatic stress disorder and anxiety.

In particular, they were more likely than Utah children in general to have depression and ADHD. Children being diagnosed with the disorder must be asked about violence, Franchek said.

"If you're going to go home every night and you don't know who's going to get hurt, you might be distracted at school. You might not finish your homework because you're forced to sit in your room and hear screaming," she said.

The study also suggested that one-third of the mothers said their children's chronic condition worsened after a violent episode.

Franchek gives the example of a doctor seeing a child after an asthma attack.

"You might assume there was air pollution in the air that day, but it may have been because the child saw his mother beat up. You don't know that because you didn't ask," she said.

A pain that lingers • The health problems don't stop in childhood.

"Adverse childhood experiences" — including witnessing domestic violence — are linked to lifelong physical and mental problems, other research suggests.

A 2010 Centers for Disease Control and Prevention report says exposure to abuse and serious family dysfunction can alter children's developing nervous, immune and metabolic systems by activating the stress response. Those negative experiences have been linked to cardiovascular disease, chronic obstructive pulmonary disease, autoimmune diseases, substance abuse and depression.

According to new data from the Utah Department of Health, Utah adults who experienced adverse childhood events were more likely to smoke, to be overweight or obese and to be in fair or poor health. About 12 percent, or one in eight adults, had witnessed domestic violence as a child.

At the training at the YWCA, survivor Brandy Farmer told the residents that women want to be asked specific questions about violence. She didn't want anyone to know "the person who claimed to love me" was beating her and verbally abusing her, she said.

But if her obstetrician "had ever asked me about domestic violence, I would have told him. I felt my doctor cared about me," she said.

First-year pediatric resident Sara Scranton said the training was a "revelation." She plans to include domestic violence in her list of possible causes when children are struggling. "I would feel like it was a positive experience if I was able to uncover something like that, rather that just giving them Albuterol [for asthma]," she said.

Franchek told the residents they may not be able to end the violence, but they must try. "We've got to find these families and help them," she said.

Domestic violence in Utah

Among the 116 women who participated in the study on violence and health:

• Average age: 34.

• 62 percent reported a family income of less than $10,000.

• 92 percent reported a history of emotional abuse.

• 80 percent reported a history of physical abuse.

• 66 percent had been hit, slapped or kicked in the past year.

• 45.5 percent had been physically abused while pregnant.

• 42 percent said they were abused at least weekly.

• 15 percent had suffered a head injury, permanent injury or internal injury from the violence.

Among their children:

• Nearly all had been exposed to violence nearly half their lives.

• 54 percent had witnessed their mother's abuse.

• 18 percent had also been victims of physical or sexual abuse.

During their mother's abuse:

• 12 percent of the children had been intentionally harmed.

• 12 percent had been unintentionally harmed.

• 4 percent were injured when they tried to intervene.

Source: Unpublished University of Utah report on intimate partner violence and children's health outcomes —

Chronic illness and violence

Among the children in the Utah study:

• 43 percent had a chronic illness, about twice the percentage of children in the general Utah and U.S. population.

• 17 percent had fair or poor health as rated by their mothers — eight times the amount of Utah and U.S. populations.

• 17 percent had been diagnosed with ADHD, about twice the Utah and U.S. pediatric populations.

• 11 percent had been diagnosed with depression, about three times the Utah and U.S. pediatric populations.

• 10 percent were overweight — half the amount of the general pediatric population.

• 14 percent had asthma.

• 8 percent had anxiety or a mood disorder.

• 7 percent had post-traumatic stress disorder.

Source: Unpublished University of Utah report on intimate partner violence and children's health outcomes