What You Don’t Know Can Hurt You: The importance of family violence screening tools for family law practitioners


Family Violence Screening Tools Literature Review


This literature review outlines some of the most common and recommended practices related to FVFootnote 9 screening to inform the development of a FVST for FLPs in Canada. The literature reviewed includes the tools themselves and their accompanying research articles and/or administration instructions (if either was available). This review serves as a supplement to the screening tool analysis by summarizing key research findings and common organizational practices relevant to FV screening. This is not intended to be a comprehensive review of all relevant and available literature. For additional information on FVSTs see: Costa & Barros (2016); Haggerty, et al. (2011); Hussain, et al. (2015); Paterno & Draughon (2016); Rabin, Jennings, Campbell, & Bair-Merritt (2009).

Importantly, how a screening tool for family law lawyers is designed and implemented will be largely determined by the context as well as the purpose and goal(s) of the screening tool. For example, in health care settings (such as emergency departments), the purpose of FV screening is quite different from the purpose of FV screening in mediation. In health care settings, screening is often used to make a quick determination of abuse that will inform the plan of care, impact duty to report requirements (in cases of suspected child abuse) and affect the provision of referrals. In mediation, screening is primarily used to determine whether or not mediation is appropriate. These differences in the context and purpose of screening influence the optimal structure and design of the tools (e.g., length of tool, breadth and depth of questions, administration format). A screening tool for use in an emergency room, where patients have only a few minutes with the physician or nurse, will likely be much shorter than a screening tool used by a mediator who has significantly more time to spend with a client. Given this, an important preliminary step in developing a new FV screening tool for family law lawyers is to identify the specific context and objectives of the tool.

Background on FV Screening

There are a significant number of screening tools that have been created to identify FV. The majority of these tools were developed for research purposes and for screening in health care settings. However, there are a number of FV screening tools and protocols/frameworks developed for the legal sector (e.g., Davis, Frederick & Ver Steegh, 2015), most of which have been developed specifically for mediation.

Research on FV screening in the context of family law and mediation has identified several limitations within existing FV screening tools (e.g., DOVE, Ellis & Stuckless, 2006; MASIC, Holtzworth-Munroe, Beck, & Applegate, 2010; Conflicts Tactics Scale-2 (CTS-2), Straus, Hamby, Boney-McCloy, & Sugarman, 1996; CAP, Girdner, 1990). Taken together, these limitations include:

  1. A focus on certain types of abuse, such as physical abuse
  2. Narrow definitions of what constitutes risk (both with respect to definition of risk and risk for victimization and perpetration)
  3. A failure to screen for coercive controlling behaviours
  4. A lack of behaviourally-specific questions (i.e., they assess subjective experience)
  5. Not being specific to separating couples
  6. A failure to address issues of comorbidity (e.g, substance abuse, mental illness) or contextual factors (e.g., lack of social support, religious significance)
  7. Not being designed for universal screening (i.e., not broad or inclusive enough)
  8. Not screening for both victims and perpetrators
  9. Requirement for intensive training (Beck, Menke, & Figuerdo, 2013; McIntosh, Wells, & Lee, 2016)

Similarly, in clinical contexts such as health care settings, FV screening tools have been critiqued for emphasizing severe physical violence without giving adequate attention to emotional abuse, sexual abuse, and less severe forms of physical maltreatment (Todahl & Walters, 2009).

Despite these limitations, the use of standard protocols for FV screening is recommended, particularly in the health care sector, by major medical associations and organizations (e.g., Canadian Nurses Association, US Department of Health and Human Services, American College of Nurse-Midwives, American Academic of Family Physicians, Family Violence Prevention Fund, among others). In fact, routine screening for FV by health care providers is legally mandated in some US states. For example, the California State screening law (Business and Professions Code 2091.2, Health & Safety Code sections 1233.5 and 1259.5) requires: i) doctors, nurses, and mental health professionals to document training in detection and treatment of domestic violence; and ii) licensed clinics and hospitals to have written policies and procedures for screening, documentation and referral of domestic violence (Contra County Health Services, 1995; Stanford Medicine, 2018).

There is some literature on FV screening practices among law practitioners. A common research finding is that family law lawyers (as well as other legal personnel) do not tend to be knowledgeable about FV. This lack of awareness may result in women’s experiences of FV being ignored in family law cases. This, in turn, can have negative effects for women and their children in determining custody, relocation, parenting time, distribution of assets, whether or not to participate in mediation or other forms of alternative dispute resolution, and the type of parent education that is needed (Araji, 2012; Abshoff and Lanthier, 2008; Bemiller, 2008; Davis et al., 2015; Laing, 2017). Screening every client for FV helps lawyers provide competent and effective representation (Chewter, 2003; Minnesota State Bar, 2013; Sussman & Carter, 2007).

Particularly relevant to family law, research consistently shows that post-separation is one of the most dangerous times for victims of FV (Brownridge, 2006; Campbell et al., 2009; Hardesty, 2002). This is recognized in some FV screening protocols and tools developed for a legal context (e.g., McIntosh et al., 2016; Minnesota State Bar, 2013; Sussman & Carter, 2007). In one study of the efficacy of FV screening in the child welfare sector, practitioners saw a 300% increase in the number of abused women identified during the intake process with the introduction of FV screening questions (Magen, Conroy, & Del Tufo, 1997). The authors of this study concluded that asking about FV clearly leads to clients disclosing FV.

Women are unlikely to voluntarily disclose abuse in health care settings, such as emergency departments or clinical therapeutic settings, unless asked directly (Sohal, Eldridge, & Felder, 2007). Chewter suggests that women who are subjected to abuse may be reluctant to disclose this to their family law lawyer unless asked directly (2003). Parker and McFarlane (1991) found that routine FV screening increases the probability of identifying FV when the screening is conducted privately and face-to-face. Reasons for women’s reluctance to disclose abuse may include a belief that the violence is not relevant or they may feel unsafe about disclosing (Stith, Rosen, Barasch, & Wilson, 1991). The impacts of trauma may influence how much a woman initially discloses, her capacity to recall events, the consistency in the details of her disclosure, and her affect (Neilson, 2013). In addition, interpretation and application of family law and divorce legislation often appears to assume that shared parenting is always in the best interest of the child. Mothers may be discouraged from bringing up allegations of violence because it can be interpreted by judges and lawyers as trying to limit fathers’ access to their children (Dragiewicz, 2014).

In the legal sector, there is further evidence to support the use of screening measures for detection of FV in mediation. Ballard, et al. (2011) found that 66.7% of the mediation cases reported physical partner abuse on the behaviourally-specific screen (asked about specific behaviours indicative of abuse, such as “has the other partner ever hit or kicked you?”) while mediators using the standard screening tool used by the clinic (which examined court records and asked about history of conflict and comfort with mediating) reported IPV in only 21.3% of the cases. While screening for FV is a secondary intervention for women experiencing abuse, it can also be considered a primary intervention because it creates a space for discussing and creating awareness about FV (Jory, 2004; McFarlane, Greenberg, Weltge, & Watson, 1995; Thurston, Tutty, & Eisener, 2004) and, as a result, may have positive, unintended consequences (e.g., women using the referral and resource information they received in the future or to help another woman) (Contra County Health Services, 1995; Sherman et al., 2017).Footnote 10

Discussed in greater detail below, there exist a number of screening protocols that describe procedures for conducting FV screening in both the health care and legal sectors. These protocols provide pertinent instruction about how to think about and approach screening that goes beyond the mere provision of questions to ask a client. For example, the Domestic Abuse Committee of the Family Law Section of the Minnesota State Bar (2013) provides a list of tips for family law lawyers to “apply the lens of domestic violence to existing interviewing processes.”

Research on FV screening consistently shows that practitioners (in the health, child welfare, and legal sectors) are concerned that asking questions about FV may be interpreted as intrusive or offensive. However, research on women’s experiences being screened for FV shows that most women supported FV screening (Magen et al., 1997; Sethi, Watts, Zwi, Watson, McCarthy, 2004; Todahl & Walters, 2011) and reported feeling better able to protect themselves and their children as a result of being asked questions about their abuse experiences (Magen et al., 1997). A lack of knowledge about and comfort discussing FV and/or using a screening tool, as well as a lack of understanding about the importance of screening for FV, are commonly cited barriers to routinely FV screening, particularly in the health care sector (e.g., Furbee et al., 1997; Sherman et al., 2017; Thurston et al., 2004).

The purpose of the information provided below is to inform the development of a screening tool for FLPs by highlighting key issues and important considerations found in the FV screening literature.

1. Purpose of the Screening Tool

Different screening tools provide practitioners with different types of information. While, by their nature, they universally seek to understand more about a client’s history of FV, the specific purpose of the tools varies as a function of the types of information it solicits from a client. For example, tools developed for research and surveillance purposes (e.g., CTS-2, Straus et al., 1996; CAS, Hegarty et al., 1999; SES, Koss et al., 2007) were not developed specifically for use as clinical tools, although they are often used in clinical practice. Other tools, such as the HARK (Sohal et al., 2007), HITS (Sherin et al., 1998), AAS (Parker & McFarlane, 1991), OAS (Weiss et al., 2003), and DOVE (Ellis & Stuckless, 2006), among many others, were developed specifically for the purpose of identifying FV in individual patients/clients. As a result, the tools’ questions and accompanying instructions and procedures may differ.

Existence of Abuse/Violence

Some tools, particularly those that are brief, typically seek to answer the question, “Is my client experiencing abuse by an intimate partner?” (e.g., AAS, Parker & McFarlane, 1991; HARK, Sohal et al., 2007; Intimate Justice Scale, Jory, 2004; Multi-Door Screen, Rossi et al., 2015). Other tools, particularly those that are in-depth and include open-ended questions, can answer additional questions such as: “Is the abuse current or in the past?”, “How long has the abuse been happening?”, “How often does the abuse occur?”, “What specific types of abuse has my client experienced?”, and “What are the impacts of the abuse?” (e.g., DOORS, McIntosh et al., 2016; HITS, Sherin et al., 1998; IPV-SAT, Todahl & Walters, 2005; all tools developed for mediation).

Context and Impact of Abuse/Violence

Some tools, such as the IPV-SAT (Todahl & Walters, 2009), include a multi-stage assessment that first screens for the existence of FV in the client’s life (i.e., “Has my client experienced abuse?”) and then engages in a more detailed assessment to determine if violence may be a factor. This assessment stage seeks to answer questions including: “What occurred or is occurring?”, “When did this occur?”, “What is the impact of this behaviour?”, and “Where does the violence fall on a continuum of coercion and control?”

The Battered Women’s Justice Project (Davis et al., 2015) offers another example of a multi-stage screening assessment through a framework for identifying, understanding, and accounting for abuse, developed specifically for the family law/court context. Similar to Todahl and Walters (2009), the first step of the framework is to identify if abuse may be an issue in the case. Davis and colleagues argue that identifying abuse is an important first step, but that it is necessary to understand the nature and context of abuse in order to make informed decisions and action. In family law, understanding how the abuse is related to parenting, the wellbeing and safety of children, and the parent experiencing abuse is particularly important.

2. Screening Tool Structure and Form
Verbal or Written (i.e., practitioner versus self-administered)

Previous research has compared verbal format (i.e., practitioner-administered questions) to written formats (i.e., patient or client self-report measures), and in general, research on FV screening in the context of health care settings shows mixed findings on the efficacy of self-administered tools to detect FV (Decker et al., 2017; Sherman et al., 2017). For example, verbal screening resulted in higher disclosure rates among pregnant woman administered the AAS (29% compared to 7%) (Trabold, 2007). However, written self-administered screens have been shown to lead to fewer missing data than verbal (i.e, face-to-face) screens (MacMillan et al., 2006). MacMillan and colleagues (2006) also reported that the face-to-face approach was least preferred by clients in a health care setting compared to self-administered approaches, such as written or computer-administered. Studies have shown that patient self-administered or computerized screenings are as effective as clinician interviewing in terms of disclosure, comfort and time spent screening (Chen et al., 2007; Glass, Dearwater, & Campbell, 2001).

There does not appear to be any research studying the effectiveness of practitioner versus self-administered FV screening in a family law setting. However, of the screening tools and protocols included in this review that were developed specifically for use in the legal sector, many are practitioner-administered because they are integrated into the interview/intake process. The BC Family Justice Services Centre (BC Ministry of Justice, 2013) takes a hybrid approach whereby the intake/assessment process is facilitated by the Family Justice Counsellor but the client is responsible for completing the assessment form, which includes questions about family dynamics and violence, prior to the intake meeting.

Length of Screening Tool

In general, single-question tools may not be adequate for identifying FV (Sohal et al., 2007). Abuse is complex and multi-dimensional, and a single question may not be sensitive enough to detect it. For example, if the question asks about physical violence but a woman has experienced emotional violence, her experience with abuse may not be detected by the tool. However, a balance must be struck between the length of the tool and its ability to effectively identify FV. Shorter screening tools (e.g., tools with few questions) may not capture a wide enough range of abusive behaviours to detect FV. While longer, more comprehensive tools may have greater validity, reliability and efficacy, they may also be less useful in time-constrained settings (e.g., Straus et al., 1996; Hinsliff-Smith & McGarry, 2017). As discussed above, the purpose of the tool will ultimately influence the length of the tool. Tools and protocols that seek to gain an in-depth and nuanced understanding of a client’s abuse experience will ultimately be longer and more complex than tools that more simply seek to determine whether or not violence is a factor in a client’s life.

Degree of Standardization

The extent to which FV screening tools and protocols are standardized varies. “Standardization” refers to the presence of uniform instructions and scoring procedures and the inclusion of statistical analysis that test the reliability and validity of the tool to adequately detect FV. Our review of screening tools and relevant literature suggests that FV screening protocols, which include screening questions but offer a more comprehensive approach, are more often found in the mediation and legal sectors compared to the health care sector and are typically less standardized than brief screening questionnaires. For example, the BC Family Justice Services Centre’s protocol says that counsellors conducting the assessment (which includes but is not limited to FV screening):

[W]ill rely on their professional judgement, analytical skills and critical thinking as well as observation of non-verbal cues. For example, it is possible that the client might answer in the low end of the scale on the family violence questions, but you detect a discomfort either through comments made or body language that makes you think otherwise. Naturally you are going to probe more deeply at this point (BC Ministry of Justice, 2013).

The Consumer Rights for Domestic Violence Survivors Initiative for Consumer Lawyers (Sussman & Carter, 2007) provides a list of possible screening questions, but reiterates that it is not intended to be a script and does not recommend asking all of the questions on the list. Rather, lawyers are encouraged to use their “interviewing acumen and judgement to determine how to inject these screening questions in [their] practice”.

In contrast, FVSTs developed primarily for research purposes (e.g., CTS-2, Straus et al., 1996; CAS, Hegarty et al., 1999; SES, Koss et al., 2007) and brief screening tools typically used in health care settings (e.g., HARK, Sohal et al., 2007) typically include cut-off criteria to help practitioners categorize women as victims of FV. Cut-off criteria are most relevant for screening tools that are standardized and have been assessed for reliability and validity.

Gender-Neutral Language

There is some indication that gender-neutral language, such as “intimate partner violence” (IPV), is used during screening to ensure that individuals in non-heterosexual relationships do not feel marginalized during screening (e.g., Contra County Health Services, 1995). Some scales, such as the Intimate Justice Scale (Jory, 2004), intentionally use gender-neutral language to ensure that the tool can be appropriately used with same-sex couples. Of course, the use of gender-neutral language also allows the tool to be used with male victims of abuse in heterosexual relationships. The American Bar Association (n.d.) recommends that lawyers conducting FV screening have an awareness that, while women make up the majority of FV victims, men can also be victims and that FV can occur in all types of relationships.

Conceptualization of Family Violence

Research shows that behaviourally-specific, detailed screening tools with more items inquiring about different violent behaviours uncover higher rates of violence than broader screens with fewer items (Rossi et al., 2015). Behaviourally-specific items can be useful in educating clients about the behavioural aspects of abuse and may help them to reconceptualize their own experiences (Jory, 2004). Documenting specific behaviours may also be useful for police records or court proceedings (Jory, 2004). However, specific acts of physical violence do not exclusively define FV and do not identify patterns of abuse (Hegarty, Bush, & Sheehan, 2005). Furthermore, research on FV demonstrates that physical violence is often the least damaging to women and it is, instead, the psychological abuse and coercive control that are most harmful (Hegarty et al., 2005).

While violence in intimate relationships may be mutual, there is overwhelming evidence that FV is a gendered phenomenon. Research suggests that, at least in a clinical setting, questioning women about their own aggressive behaviour (as is done with the CTS-2) or suggesting that the abuse may be mutual in any way may result in women remaining in violent situations (Jory & Anderson, 2000; Jory, 2004). There is currently little that is known about mutual violence in the context of family law (Kelly & Johnson, 2008) or the impact that questioning about mutual violence may have for women working with family law practitioners. From the practitioner’s viewpoint, it has been suggested that there may be disagreement among clients about the degree of mutuality in the violence and that this must be taken into consideration when deciding on a course of action (Bickerdike, 2007).

3. Practitioners’ Approach to Screening
a) The Importance of Attending to Context and Knowledge of Abuse Dynamics

Screening for FV is a more complex process than simply asking a list of questions. In the legal sector, it has been recommended that screening occur in the context of a conversation with the client (Minnesota State Bar, 2013; Sussman & Carter, 2007). A number of in-depth protocolsfor FV screening exist (within which the screening questions are included) that outline additional considerations for the screening process. For example, the Contra Costa County Health Services Department (1995) protocol includes a section on working with diverse populations that encourages physicians to consider, among other factors, issues of racial oppression, language barriers, family and community values, the role of shame, a woman’s body language and her age, disability status, sexual orientation and history of substance abuse as factors in her experience of abuse and disclosure.

Failure to attend to contextual factors such as these or to develop a rapport with the patient/client may reduce screening efficacy by making women feel unsafe and unwilling to disclose (Contra County Health Services, 1995; Minnesota State Bar, 2013). Research conducted by the Transition House Association of Nova Scotia (2000) demonstrated that women frequently did not disclose abuse to mediators because they were uncomfortable.

The Domestic Abuse Committee of the Family Law Section of the Minnesota State Bar (2013) and the BC Family Justice Services Centre (BC Ministry of Justice, 2013) further acknowledge the importance of attending to context when considering acts of violence within intimate relationships, including: i) the intent of the offender; ii) the meaning of the violence to the victim; and iii) the effect of the violence on the victim (from the research of Frederick and Tilley, 2001).

They also highlight the importance of considering other relevant factors including the “particulars of the incident, and how much violence, coercion, or intimidation accompanied the violent event” because this will influence the course of action for the lawyer and the case. Sussman and Carter (2007), in their screening protocol for consumer law lawyers, similarly suggest that “context is key” and lawyers must attend to their client’s individual situation and social location (e.g., age, economic class, sexuality). Thus, it is necessary for practitioners, particularly in the legal sector, to have sufficient awareness and knowledge about FV in order to effectively carry out screening procedures. The importance of practitioner knowledge about abuse (e.g., different types of abuse including coercion, control, and emotional abuse) was demonstrated in a study on abuse screening among mediators undertaken in 2000 by the Transition House Association of Nova Scotia (THANS, 2000). 

b) Framing Screening as Routine and Universal

In the health care sector, emphasis is placed on the routine and universalnature of FV screening. Many of the screening protocols and tools reviewed included an opening statement to inform women that FV screening was a routine measure carried out with all female patients (e.g., ACOG, 2012; Contra County Health Services, 1995).

c) Practitioners’ Use of Language

The language used in screening tools is important. In the health care sector, the American College of Gynecologists (ACOG, 2012) recommends providers avoid questions that have the potential to be stigmatizing, such as “abuse,” “rape,” “battered,” or “violence.” The Minnesota State Bar (2013) similarly recommends to refrain from using the term “domestic violence” because clients may not identify with it. In a legal context, it is also important to avoid legal acronyms and jargon (Minnesota State Bar, 2013). Furthermore, the ACOG (2012) recommends the use of culturally relevant language.

d) Approaching Screening in a Direct, Sensitive, and Safe Way

The manner in which the topic of FV is approached and the screening questions are delivered is important. It has been recommended that screening be approached in a straightforward, or “matter of fact,” way (King County, 2015).  For example, the screening protocol outlined by the Contra County Health Services recommends that health care practitioners ask direct questions about FV in a non-threatening way and that they maintain direct eye contact when speaking to the patient about abuse (when culturally appropriate). It is further recommended by researchers and professional health organizations that providers approach screening in a way that does not convey judgement or disbelief in any way (ACOG, 2012; Furbee et al., 1999). Practitioners are also instructed to “encourage but do not badger” the patient/client to respond to screening questions, recognizing that victims of abuse will share their experiences in their own time and terms and that a level of trust and rapport must first be established (Contra County Health Services, 1995; Minnesota State Bar, 2013; Sussman & Carter, 2007).

In further recognition that women may not disclose FV in the first meeting or interview, several organizations recommend that service providers across different sectors screen women for FV periodically (e.g., ACOG, 2012; Davis et al., 2015; King County, 2015; Michigan Supreme Court, 2006; Minnesota State Bar, 2013; North Dakota Supreme Court, 2017). Additionally, women who have received services from the same agency in the past should be rescreened so that the practitioner has the most up-to-date and accurate information about the client’s situation (King County, 2015).

Some screening tools use a graduated approach to asking about violence. For example, the Domestic Violence Questionnaire (Magen et al., 1997) moves from asking questions about “normal” relationship conflict to questions about abusive behaviour. The Family Civil Intake Screen (Salem, Kulak, & Deutsch, 2007) begins with the most factual -- and therefore least likely to give rise to defensiveness -- questions (e.g., information about parties).

It has been recommended that practitioners ensure they are promoting “safe and informed disclosures of domestic abuse” (Davis et al., 2015). FLPs should explain the purpose of FV screening (i.e., why you are asking questions about abuse), how the information they provide will be used, who will have access to it, and how it may be used in the family court process (Davis et al., 2015). Similar recommendations have been made for FV screening in the health care context (e.g., Todahl & Walters, 2009).

4. Recommended Practices for Positive Screens

The literature points to three recommended practices following a positive screen: i) risk assessment and/or safety planning; ii) provision of resources and referrals; and iii) affirmation and validation.

If FV has been identified, much of the literature recommends that practitioners immediately assess the client’s level of risk and/or develop a safety plan for her and her children (e.g., CDC, 2007; Futures without Violence, 2004).

Providing informational resources and referrals to relevant services, including domestic violence agencies and shelters, legal centres and mental health services, is a frequently recommended practice. Some agencies and organizations, such as Contra County Health Services (1995), recommend that health care providers offer to connect the woman directly with domestic violence services and, should she refuse, provide her with informational resources. Other organizations, such as the ACOG (2012), emphasize the importance of not forcing a woman to accept resources and referrals. 

In addition to assessing risk, safety planning, and providing resources and referrals to women, some FVSTs recommend affirming and validating women’s disclosures. For example, following a positive screen, the Conflict Assessment Protocol recommends that mediators use statements such as, “I know it has been difficult to talk about this. I am glad you were able to tell me, because now I am better able to help you” and “I want to say that this should not have happened to you and it is not your fault” (Girdner, 1999, p. 3). Relatedly, and somewhat unique to a legal context, the American Bar Association (n.d.) emphasizes the importance of having all of the pertinent information, so that lawyers are in the best position to effectively represent their clients and recommends that practitioners emphasize this during screening to encourage disclosure.

5. Developing a Screening Tool

A common practice in the literature reviewed was to develop a FVST in consultation with interprofessional experts, including local, national, and international practitioners, researchers, and consultants (Brief Inpatient Screen, Laurie et al., 2012; New South Wales Dept. of Health Survey, Ramdsen & Bonner, 2002; DOORS, McIntosh et al., 2016). FVSTs developed in the legal sector have also included specific consultation with family court lawyers, judges, and other legal professionals (e.g., Salem et al., 2007; Minnesota State Bar, 2003). Women with and without a history of abuse represent another group of key stakeholders that can be included in the process of developing FVSTs (e.g., Relationship Chart, Wasson et al., 2000; New South Wales Dept. of Health Survey, Ramdsen & Bonner, 2002).

Piloting and evaluating a newly developed tool is important for ensuring an appropriate, reliable, valid and effective screening tool. For example, the tool developers for the Intimate Justice Scale (Jory, 2004) conducted an exploratory study with marriage and family therapists from which the screening questions were developed. The therapists then rated the items developed out of the interviews based on whether the item would be a good predictor of physical violence and/or psychological abuse, and whether the item would apply to all, some, or none of their clients.