Children who are raised in violent homes are also in danger. These children are at high risk for abuse and for emotional damage that may affect them as they grow older. Slightly more than half of female victims/survivors of domestic violence live in a household with at least one child younger than 12 years of age, and between 3.3 million and 10 million children witness domestic violence annually [24,26]. Studies demonstrate that children who witness domestic violence are more likely to grow into a perpetrator or victim of domestic violence than a child who was himself or herself abused, thereby creating a cycle of violence. For example, in one study, adolescent witnesses of abuse were also more likely to report having perpetrated abuse (42%) compared to non-witnesses (15%)[27]. Research regarding the psychosocial outcomes of children exposed to domestic violence has found that child witnesses exhibit more aggression, anxiety, difficulties with peers, and academic problems than the average child[26,28]. An estimated 47% of children who have witnessed IPV at home are younger than 6 years of age, and these preschool-age children are more likely to show evidence of internalizing behavior problems (e.g., anxiety, depression, somatic complaints) compared to older children, who show more signs of externalizing behavior problems (e.g., bullying, aggression, misconduct)[29]. In addition to witnessing violence, these children may also become direct victims/survivors of violence, as child maltreatment occurs in 30% to 60% of families in which IPV is reported[30]. Moreover, statistics demonstrate that 85% of domestic violence victims/survivors abuse or neglect their children.

As with domestic violence in the civilian population, military victims/survivors face a host of barriers in disclosing abuse. In addition to shame and embarrassment, fear of reprisals, feelings of isolation, and lack of available services, many military victims/survivors found when they did report abuse, military personnel were not sensitive to their needs [39]. Given these barriers to disclosure, it is difficult to assess the prevalence of domestic violence among military families. According to the U.S. Department of Defense, there were a total of 18,208 reported incidents of domestic abuse in 2009[40]. However, it should be noted that a 2010 report released by the U.S. General Accounting Office (GAO) indicated that the U.S. Department of Defense's use of multiple registries and inclusion of only those reports made to the Family Advocacy Program (excluding cases handled by civilian law enforcement, identified by nonmilitary medical staff, and reported to commanders) make calculating the actual number of domestic violence cases impossible[40]. Reports from the Congressional Research Service indicate that among the active-duty population, there were 16,912 reported incidents of spouse and intimate partner abuse in 2018[33]. Among these, 8,039 reports (6,372 victims/survivors) met the Department of Defense definitions. Physical abuse accounted for the highest number of reports (73.7%), followed by emotional abuse (22.6%), sexual abuse (3.6%), and neglect (0.06%)[33].

It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims/survivors. In a 2016 study of 288 healthcare facilities in Florida, 78% understood the importance of IPV screening and had some type of IPV screening policy institute in their setting[82]. However, many of the respondents did not know which screening tool was used or the types of screening questions asked. These guidelines should review appropriate interview techniques and should also include the utilization of screening tools, such as intake questionnaires. The following is a review of certain signs and symptoms that may indicate the presence of abuse. Although victims/survivors of domestic violence do not display typical signs and symptoms when they present to healthcare providers, there are certain cues that may be attributable to abuse. The obvious cues are the physical ones. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen. These are often distinguishable from accidental injuries, which are more likely to involve the periphery of the body. In one hospital-based study, domestic violence victims/survivors were 13 times more likely to sustain injury to breast, chest, or abdomen than accident victims/survivors. Abuse victims/survivors are also more likely to have multiple injuries than accident victims/survivors. When this pattern of injuries is seen in a patient, particularly in combination with evidence of old injury, physical abuse should be suspected[19].

In addition to physical signs and symptoms, domestic violence victims/survivors also exhibit psychologic cues that resemble an agitated depression. As a result of prolonged stress, victims/survivors often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches, and digestive problems. Often, they will complain of fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical[19,52]. In many women, this constellation of symptoms has been labeled "Battered Women's Syndrome." Unfortunately, healthcare professionals may respond to these women by diagnosing the patient to be neurotic or irrational[36]. Healthcare professionals should cast aside these misperceptions of abused victims/survivors and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms. In addition, it is important to recognize that vulnerable populations, including LGBT+ individuals, those with HIV, individuals with disabilities, and veterans are also at risk and should be screened for IPV[83].

In addition to physical signs and symptoms, domestic violence victims/survivors also exhibit psychologic cues that resemble an agitated depression. As a result of prolonged stress, victims/survivors often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches, and digestive problems. Often, they will complain of fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical[19,52]. In many women, this constellation of symptoms has been labeled "Battered Women's Syndrome." Unfortunately, healthcare professionals may respond to these women by diagnosing the patient to be neurotic or irrational[36]. Healthcare professionals should cast aside these misperceptions of abused victims/survivors and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms. In addition, it is important to recognize that vulnerable populations, including LGBT+ individuals, those with HIV, individuals with disabilities, and veterans are also at risk and should be screened for IPV[83].

Other studies demonstrate that abusive mates are generally possessive and jealous. Another characteristic related to the batterer's dependency and jealousy is extreme suspiciousness, also referred to as intrusiveness (i.e., overdependence on controlling behaviors)[84]. In a study of 342 lesbian women, high levels of intrusiveness were correlated with higher incidences of perpetrating physical violence[84]. This characteristic may be so extreme as to border on paranoia[53]. In addition, domestic violence victims/survivors have frequently reported that abusers are extremely controlling of the everyday activities of the family. This domination is generally all encompassing. One battered woman gave the following examples of her controlling husband: "He insisted that no one (including guests and their toddler children) wear shoes in the house, that the furniture be in the same indentations in the carpet, that the vacuum marks in the carpet be parallel, and that any sand that spilled from the children's sandbox during their play be removed from the surrounding grass"[55]. In addition, healthcare professionals should be on the lookout for perpetrators who have low self-esteem, are frequently angry and depressed, and are "very dependent on their partners as the sole source of love, support, intimacy, and problem solving"[52].

Of female trauma patients, 16% to 30% will report that they have been battered when asked directly about how the injury occurred. Obviously, however, some victims/survivors will not admit to a history of battering. Any trauma or burn that seems incompatible with a history of the injury is suggestive of battering and indicative of the need for gentle probing regarding how things are at home. Information must also be collected to facilitate a comprehensive assessment of the victim's/survivor's needs, resources, and priorities in order to develop immediate and long-range plans designed to minimize and eliminate future abusive episodes. A structured interview can be used to obtain the necessary information for treatment planning (Table 2)[22].

All practitioners who deal with domestic violence should periodically review safety planning with victims/survivors. Homicide is of high risk for victims/survivors; therefore, safety planning is crucial. When advocating a safety plan, it is important to:

After identifying victims/survivors and their abusers, healthcare professionals should immediately implement a plan of action that includes providing a referral to a local domestic violence shelter to assist the victim/survivor and their family. The acute situation should be referred immediately to local law enforcement officials. Other resources in an acute situation include crisis hotlines and rape relief centers.