Danger Assessment Tool for Domestic Abuse

Why use it

Intimate partner violence is the leading cause of homicide in women ages 16–44 in many countries. Identifying women at highest lethality risk enables targeted safety planning, emergency protection orders, and specialized resource referral. The DA helps clinicians structure conversations about danger and empowers women to understand their own risk level objectively. Research shows that most women who were killed by partners had presented to health care settings before their death.

About

The Danger Assessment (DA) is a clinician-administered tool developed by Dr. Jacquelyn Campbell at Johns Hopkins University to assess the risk of intimate partner femicide (killing of a woman by a male partner) or near-lethal abuse in women experiencing domestic violence. Originally published in 1986 and revised in 2004, the DA consists of two parts: (1) a 12-month calendar on which the woman marks the approximate dates of past abuse incidents and rates the severity of each on a 1–5 scale, and (2) a 20-item yes/no weighted questionnaire assessing known lethality risk factors derived from case-control studies of intimate partner femicide. The DA has been validated in the United States, Canada, and internationally across multiple racial/ethnic groups. It is one of the most widely used intimate partner violence (IPV) lethality assessment tools in clinical, forensic, and law enforcement settings.

When to use

• Any woman presenting with intimate partner violence or disclosing ongoing abuse
• Emergency department presentations for assault, injury, or attempted strangulation
• Prenatal care visits when domestic violence screening is positive
• Mental health evaluations where domestic violence is identified as a stressor
• Social work assessments and discharge planning for abuse victims
• Forensic nursing evaluations (SANE/SAE examinations)
• Law enforcement victim advocacy and lethality assessment protocols

Formula

Pearls & pitfalls

• Strangulation (item 9) is one of the strongest predictors of future homicide in IPV relationships — any history of strangulation should prompt immediate safety intervention regardless of total score.
• Access to a gun (item 8) dramatically increases femicide risk — a gun in the home with an abusive partner increases femicide risk by approximately 5-fold.
• Threats to kill (item 3) are highly specific to future lethal violence — take all such threats seriously even if the patient minimizes them.
• Abuse during pregnancy (item 15) is associated with particularly severe IPV trajectories — screen at every prenatal visit.
• Forced sex (item 7) is associated with severe controlling behavior patterns and increased lethality risk.
• Many women at Extreme Danger level do not perceive their situation as extremely dangerous — the DA helps bridge this gap with objective risk framing.
• The calendar component (part 1 of original tool) helps women recognize escalating severity and frequency of violence — important for insight and safety planning.
• The DA should be administered in private — never with the partner present. Offer it in the patient's preferred language.
• A negative screen does not rule out danger — all women in violent relationships should receive basic safety information regardless of score.

Next steps

Variable Danger (Score 0–7): Provide safety resources, hotline numbers, and safety planning information. Document findings. Low-to-moderate increased risk. Increased Danger (Score 8–13): Safety planning essential. Refer to domestic violence advocate. Discuss protective orders, shelter options. Danger is real and increasing. Severe Danger (Score 14–17): Immediate safety planning required. Strong recommendation for emergency shelter. Involve domestic violence advocate in current visit. Consider mandated reporting if children are in the home and at risk. Extreme Danger (Score ≥ 18): Highest lethality risk — this woman is in extreme danger of being killed. Urgent safety intervention required. Emergency protection order should be considered. Do not allow abuser in clinical setting. Immediate domestic violence advocacy consultation.

Evidence

Campbell JC. Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers. 1995. Campbell JC et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003;93(7):1089-1097. PMID:12835191. (n=220 femicide cases, 343 controls) — AUROC 0.90 for extreme danger group. The DA has been validated in over 30 studies across multiple countries and languages.

References

1. Campbell JC et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003;93(7):1089-1097. — link
2. Campbell JC. Nursing assessment for risk of homicide with battered women. ANS Adv Nurs Sci. 1986;8(4):36-51. — link
3. Messing JT, Thaller J. The average risk of homicide in domestic violence: exploring variations. Violence Against Women. 2013;19(9):1108-1125. — link