Domestic Violence-Florida

Question 1

Fast Facts: Domestic Violence – Florida

Answer

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Question 2

Domestic Violence – Florida Pretest

Answer

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Question 3

Definitions

Answer

Child Abuse	Involves the emotional, sexual, physical, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm.
Domestic Violence	The victimization of an individual with whom the abuser has an intimate or romantic relationship. It includes physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner.
Economic Abuse	Occurs when one is forced to become dependent through improper use of money by a person in a trusting relationship through coercion to surrender property, forgery, theft of possessions, and improper use of guardianship or power of attorney.
Elder Abuse	Is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an elder.
Emotional or Psychologic Domestic Violence	Includes verbal and non-verbal communication which inflicts emotional or mental harm. Emotional or psychologic violence may be subtle, but it is often very harmful to the victim, resulting in depression and suicide. Abuse may involve convincing the victim that the violence is their fault, there is no way out of their situation, and the victim is worthless and needs the abuser to exist. Many abusers will isolate their victims from friends, family, school, and work. Examples include: – Child Relationship Control: Deliberately damaging relationship with a child – Coercive: Limiting resource access, possessiveness, and constant monitoring – Exploitation: Use of consequence to control choices, for example, “If you call the protective service, I could go to jail, and you will have no financial support.” – Expressive: Name-calling, degradation, and threats – Gaslighting: Presenting false information making the victim doubt his or her memory and perception; making victims question their sanity – Reproductive Control: Refusing birth control or forced pregnancy terminations – Threats: Use of gestures, words, or weapons that future harm may occur
Intimate Partner Violence	Includes sexual or physical violence, psychological aggression, and stalking. This may include former or current intimate partners.
Munchausen by Proxy Syndrome	Factitious disorder where an individual fabricates or exaggerates mental or physical health problems in the person for whom he or she cares. The primary motive is to gain attention or sympathy for themselves.
Neglect	Failure of an individual who is responsible for the well-being of a child or elder to provide for the dependent’s emotional, physical, or social needs which includes hygiene, nutrition, clothing, shelter, and access to health care rendering them in a harmful situation. Abandonment is also a form of neglect.
Physical Abuse	The use of physical power which results in injury, disability, or death. Other forms include coercion, administering drugs or alcohol without permission, and denying medical care. Examples include: – Assault – Biting – Burning – Choking – Gagging – Grabbing – Kicking – Punching – Pulling hair – Restraining – Scratching – Shaking – Shoving – Slapping
Sexual Violence	Using physical coercion to force participation in unwanted sex acts. Perpetrators often incapacitate victims with alcohol or drugs. Categories include: – Forced anal, oral, or vaginal penetration of a victim – Forced penetration of someone else – Sexual coercion involving intimidation to pressure consent – Unwanted exposure to pornography, harassment, sexual violence, filming, taking, or disseminating sexual photograph or video – Unwanted sexual contact
Stalking	Repeated, unwanted attention that causes fear or concern for safety. The actions include unwanted letters, emails, texts, or phone calls; watching, following, or spying; showing up repeatedly in the same place as the victim; damaging the victim’s property; making threats of harm
The Cycle of Abuse and Violence	Begins with verbal threats that escalate to physical violence. Violent events are often unpredictable, and the triggers are unclear to the victims. The victims live in constant fear of the next violent attack. Violence and abuse are perpetrated in an endless cycle involving three phases: tension-building, explosive, and honeymoon. – Tension-building: In the tension-building phase, the abuser becomes more judgmental, temperamental, and upset; the victim may feel she is “walking on eggshells.” Eventually, the tension builds to the point that the abuser explodes. During this phase, the victim may try to calm, stay away, or reason with the abuser, often to no avail. The abuser is often moody, unpredictable, screams, threatens, and intimidates. They may use children as tools to intimidate the victim and family. They often engage in alcohol and illicit drug use. – Explosive: The explosive phase involves the victim attempting to protect themselves and the family, possibly by contacting authorities. This phase may result in injuries to the victim. The abuser may start with breaking items that progress to striking, choking, and rape. The victim may be imprisoned. Emotional, verbal, physical, financial, and sexual abuse is common. – Honeymoon: During the honeymoon phase, the victim may set up counseling, seek medical attention, and agree to stop legal proceedings. They may hold the mistaken belief and hope that the situation will not happen again. Unfortunately, this is rarely the case. The abuser may apologize, agree to counseling, beg forgiveness, and give presents. They may declare love for the victim and family and promise to “never do it again.”

Question 4

Introduction

Answer

Family and Domestic violence are a common problem in the United States and affects approximately 10 million people every year. They are abusive behaviors in which one individual gains power over another individual. In the United States, it is estimated that as much as 25% of women and 11% of men are victims of family and domestic violence. Domestic and family violence occurs in all ages, races, and sexes. It knows no cultural, educational, geographic, religious, or socioeconomic limitation. Persons with different sexual orientations may also be affected. Domestic and family violence includes child abuse, intimate partner abuse, and elder abuse and encompasses economic, physical, sexual, emotional, and psychological abuse toward children, adults, and elders.⁴˒⁵ It causes diminished psychological and physical health, and decreases the quality of life.

The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The numbers of individuals affected is expected to rise over the next 20 years with the increase in the elderly population. ⁶˒⁷˒⁸ Domestic violence is difficult to identify, and many cases go unreported. Due to the prevalence of family and domestic violence, all healthcare should be able to identify the risk factors, signs, and available resources for victims.

Question 5

Causes of Domestic and Family Violence

Answer

Domestic and family violence, including child abuse, intimate partner violence, and elder abuse often starts when a caretaker, parent, or partner feels the need to dominate or control another person. This can occur because of several reasons, such as:

Alcohol and drugs use, as an impaired individual may be less likely to control violent impulses
Anger management issues
Cultural believing that they have the right to control their partner
Feeling inferior due to less education
Feeling inferior due to poor socioeconomic status
Jealousy
Learned behavior from growing up in a family where domestic violence was accepted
Low self-esteem
Personality disorder or psychological disorder
While the research is not definitive, several characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:
Have a higher consumption of alcohol and illicit drugs and assessment should include questions that explore drinking habits and violence
Be possessive, jealous, suspicious, and paranoid
Be controlling of everyday family activity including control of finances and social activities
Suffer low self-esteem
Have emotional dependence which tends to occur in both partners, but more so in the abuser.

There are several risk factors for domestic and family violence, which are inclusive of individual, relationship, community, and societal issues. For instance, there is an inverse relationship between education and domestic violence. The less education one has, the more likely they will be involved in domestic violence. Exposure to domestic abuse and family violence as a child is commonly associated with becoming a perpetrator of domestic violence as an adult. This cycle occurs because children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. As a child grows to become an adult, they may solve conflicts in a manner that is familiar to them, often resulting in a repeated cycle of domestic violence. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, the gender roles can be reversed. Perpetrators of domestic violence commonly repeat acts of violence with new partners, and drug and alcohol abuse greatly increase these risks. ¹⁴ Common risk factors for domestic violence include:

A family history of violence
Aggressive behavior as a youth
Antisocial personality disorder
Corporal punishment in the household
Domination may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.
Economic stress/families with low annual incomes
Females whose educational or occupational level is high relative to their spouse’s educational or occupational level
History of abuse as children
Individuals with disabilities
Low education
Low self-esteem
Marital discord
Marital infidelity
Multiple children
New cases of HIV infection are linked to intimate partner violence.
Poor legal sanctions or enforcement of laws
Poor parenting
Pregnancy
Psychiatric history
The use and abuse of alcohol and drugs are strongly associated with a high probability of violence. Alcohol abuse is known to be a strong predictor of acute injury. Approximately half of the domestic violence victims indicate their partner was intoxicated at the time of the assault.
Unemployment

Abuse usually begins with emotional or verbal threats and may escalate to physical violence. Victims of domestic and family violence live in a constant state of fear. Often, the perpetrator can become explosively violent. After the violent event, the perpetrator may apologize. This cycle usually repeats in domestic and family violence. ¹¹˒¹²˒¹³ No matter the underlying circumstances, nothing justifies domestic and family violence. Understanding the causes assists us in understanding the behavior of an abuser. The abuser must be separated from the potential victim and treated for destructive behavior before a major event negatively impacts the lives of all involved.

Question 6

Statistical Data

Answer

Domestic violence is a serious and challenging public health problem. Approximately 33% of women and 10% of men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1,500 deaths in the United States and as many as 200 deaths in the state of Florida. In Florida, more than 33% of women and 25% of men experience physical violence, stalking, or rape. ¹²˒¹⁵˒¹⁶

Domestic violence victims typically experience physical injuries that require care at a hospital or clinic. The cost to individuals and society is significant. The national annual cost of medical and mental health care services related to acute domestic violence is estimated to be over $8 billion. If the injury results in a long-term or chronic condition, the cost is significantly higher. Fortunately, the national rate of nonfatal domestic violence is declining. This is thought to be due to a decline in the marriage rate, decreased domesticity, better access to domestic violence shelters, improvements in female economic status, and an increase in the average age of the population. Financial hardship and unemployment are contributors to domestic violence. An economic downturn is associated with increased calls to the National Domestic Violence Hotline.

Question 7

National Statutes

Answer

Federal Child Abuse Prevention and Treatment Act (CAPTA):

Each state has specific child abuse statues. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure recent act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation.

Elder Justice Act:

The Elder Justice Act provides strategies to decrease the likelihood of elder abuse, neglect, and exploitation. The Act utilizes three significant approaches:

Creation of a Coordinating Council and an Advisory Board which are charged with recommending multidisciplinary tactics for reducing elder abuse at the local, state, and federal levels.
Allotment of grant money and monetary incentives to improve staffing, quality of care, and technology in long-term care facilities and increase states, adult, protective services departments.
A provision of the EJA that requires facilities receiving federal funding to adhere to a strict reporting requirement.

Patient Safety and Abuse Act

The Violence Against Woman Act makes it a federal crime to cross state lines to stalk, harass, or physically injure a partner; or enter or leave the country violating a protective order. It is a violation to possess a firearm or ammunition while subject to a protective order or if convicted of a qualifying crime of domestic violence. The victim also has a right to:

Restitution
Information about the offender
Notification and presence at court proceedings
Dignity and privacy
Protect from the accused offender
Conference with an attorney

Question 8

Florida Considerations

Answer

Domestic violence is the victimization of an individual with whom the abuser has an intimate or romantic relationship. According to Chapter 741in the state of Florida, domestic violence is well defined with the statutes to protect the victim. For instance, domestic violence under Florida law is defined as “any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.” Family members must “reside in the same single dwelling unit, with the exception of persons who have a child in common.” Similarly, Florida Department of Children and Families defines domestic violence as “a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and controls. It may include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation, and power over one’s partner.” And the Centers for Disease Control and Prevention defines domestic violence as “physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner.”

Domestic and family violence has no boundaries. It occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referrals.

In Florida, a state task force has recommended standards to accurately measure the extent of domestic violence and develop strategies for education and increasing public awareness. The results include:

A statute that includes dating relationships of six months or more.
A statute that requires judges to inform victims of their rights, such as the right to appear, be notified, seek restitution, and make a victim-impact statement.
Domestic Violence Data Resource Center (DVDRC) Domestic Violence Fatality Review Teams have been established to examine cases of domestic violence that result in a fatality and to identify potential changes in policy that might prevent future deaths.
Legislation requiring all healthcare providers to obtain two hours of domestic violence education every third licensure renewal period.
The Family Protection Act, which requires a five-day jail term for any domestic battery crime in which the perpetrator deliberately injures the victim. The law makes a second battery crime a felony offense.
The Domestic Violence Leave Act which requires employers with 50 or more employees to provide guaranteed leave for domestic violence issues.

Question 9

Florida Statutes

Answer

Florida Statute 415.502 requires anyone “who knows, or has reasonable cause to suspect, that a child is an abused or neglected child, shall report such knowledge or suspicion.” Thus, healthcare providers must report when there is suspicion. Healthcare providers do not need confirmatory proof. Healthcare providers must report all cases of reasonable cause to believe that a child or adolescent has been abused or neglected or is in danger of being abused. ¹⁷˒³⁵˒³⁶
In Florida, the reporting requirement is not limited to the first-person reporting. In other words, a healthcare provider cannot assume that the report has been made. Healthcare providers must always make a report if they suspect a child is or has been abused.
Florida Statute 456.031 mandates a two-hour continuing education course on domestic violence as part of every third biennial re-licensure or recertification for health care providers.
Florida. Statute 626.9541 (1)(g)(3) applies to health, life, disability, and property insurance. Florida insurance carriers cannot refuse to issue, reissue, or renew a policy, refuse to pay a claim, cancel or otherwise terminate a policy, or increase rates based upon the fact that the proposed insured has made a claim or sought or should have sought medical or psychological treatment in the past for abuse.
Florida Statute 741.316 allows for the establishment of domestic violence fatality review teams at a local, regional, or state level to review fatal and near-fatal incidents of domestic violence, related domestic violence matters, and suicides. Membership must include a representative from the Office of the Medical Examiner and other victim’s services.
Florida Statute 790.24 requires any physician, nurse, or employee thereof and any employee of a hospital, sanitarium, clinic, or nursing home who knowingly treats or is requested to treat any person suffering from a gunshot wound or life-threatening injury indicating an act of violence to report immediately to the sheriff’s department. Willful failure to report is punishable as a misdemeanor.
Florida Statute 877.155 requires any person who treats, or is requested to treat, second or third degree burns affecting 10% or more of the body, to report such treatment to the sheriff’s department if the burns were caused by a flammable substance and if the injury could be the result of violence or other unlawful activity.
Domestic violence offenses result in approximately 200 deaths in Florida annually. The perpetrators of domestic violence are usually male, and victims are usually female. One-third of the perpetrators of domestic violence in Florida have a known “do not contact” order filed against them and one-fifth of the perpetrators had a permanent injunction for protection against them filed by someone other than the victim. Also, one-third of the perpetrators were diagnosed with mental health disorders and one-half have a substance abuse history. ¹⁷˒¹⁸˒¹⁹

Domestic violence offenses result in approximately 200 deaths in Florida annually. The perpetrators of domestic violence are usually male, and victims are usually female. One-third of the perpetrators of domestic violence in Florida have a known “do not contact” order filed against them and one-fifth of the perpetrators had a permanent injunction for protection against them filed by someone other than the victim. Also, one-third of the perpetrators were diagnosed with mental health disorders and one-half have a substance abuse history. ¹⁷˒¹⁸˒¹⁹

Question 10

Joint Commission on Accreditation of Healthcare Organizations Requirements

Answer

Victims of alleged abuse or neglect have specialized needs during the assessment process. The Joint Commission requires hospitals to have policies for the identification, evaluation, management, and referral of victims. This includes:

Safeguarding information and potential evidence that may be used in future actions as part of the legal process.
Having policies and procedures that define responsibility for collecting these materials.
Having policies that define activities and specify who is responsible for their implementation.
Provide an opportunity for victims of domestic violence to obtain help.

Question 11

Legal Implications

Answer

It is important to be aware of federal and state statutes governing domestic and family abuse. Reporting domestic and family violence to law enforcement does not obviate detailed documentation in the medical record.

Battering is a crime, and the victim should be made aware that help is available. In some jurisdictions, domestic violence reporting is mandated. The legal obligation to report abuse should be explained to the victim. If the victim desires legal help, the local police should be called. The victim should also be informed how local authorities typically respond to such reports and provide follow-up procedures. The healthcare provider and victim should address the risk of reprisal, need for shelter, and possibly an emergency protective order (available in every state and the District of Columbia). If there is a possibility that the victim’s safety will be jeopardized, the healthcare provider should work with the victim and authorities to best protect the victim while meeting legal reporting obligations.

The clinical role in managing a victim of abuse goes beyond obeying the laws that mandate reporting; there is a primary obligation to protect the life of the patient.

The clinician must help mitigate the potential harm that results from reporting, to provide appropriate ongoing care and preserve the safety of the patient.
If the patient desires, and it is acceptable to the police, a health professional should remain during the interview.
The medical record should reflect the incident as described by the patient and any physical exam findings. Include the date and time the report was taken and the officer’s name and badge number.

Question 12

Child Abuse

Answer

Each year there are over three million referrals submitted to child protective services nationally. Maltreatment of children is found in every race, culture, ethnicity, and socioeconomic status. According to Florida law, witnessing domestic violence is defined as “violence in the presence of a child if an offender is convicted of a primary offense of domestic violence, and that offense was committed in the presence of a child under age 16 who is a family or household member with the victim or perpetrator.”

The fatality rate from domestic and family violence is approximately two deaths per 100,000 children, and women account for a little over half of the perpetrators. In Florida, approximately seven percent of domestic homicide victims were children killed by a parent. Age, family income, and ethnicity are all risk factors for both sexual abuse and physical abuse of a child. Gender is also a risk factor for sexual abuse as young girls are more likely to be abused sexually than boys, however, the increased risk as it relates to gender is less likely to occur with physical abuse.

Children who have been abused may experience fear, humiliation, injury, loss of self-esteem, and pain. The physical damage may range from minor injuries to disfigurement, and in severe cases, physical damage may lead to brain trauma and death. Long-term consequences of child abuse may result in chronic mental health problems, criminal behavior, depression, increased anxiety, premature mortality, self-mutilation, substance abuse, and suicide. Mortality increases with multiple episodes of trauma. Homicide is a leading cause of death in children aged one to four years, and over 80% of fatalities from child abuse are in children younger than four.

Despite often being the first to examine the victims of child abuse, only about 10% of the referrals are from healthcare providers. Those who treat children and adolescents should understand the signs and symptoms of domestic violence and intervene quickly to protect young children and adolescents from further abuse. The history and physical exam should be tailored to the age of the victim. 

To diagnose a child of suspected abuse is difficult because the child may be nonverbal or too frightened or severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Healthcare providers will see children of abuse in a range of ways that include:

An adult or mandated reporter may bring the child in when they are concerned for abuse
A child or adolescent may come in disclosing the abuse
The perpetrators may be concerned that the abuse is severe and bring in the patient for medical care
The child may present for care unrelated to the abuse, and the abuse may be found incidentally.

Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include the interview of each caretaker separately and the verbal child, as well. The parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the healthcare provider’s questions or interpretations.

Question 13

Types of Abuse Seen in Children

Answer

Abusive Head Trauma:	Abusive head trauma (AHT), also known as the shaken baby syndrome (SBS), is a preventable, severe form of physical child abuse resulting from violently shaking an infant or toddler by the shoulders, arms, or legs. Shaken baby syndrome and the resultant head injury is the leading cause of death related to child abuse; nearly 25%. Symptoms may be as subtle as vomiting, or as severe as lethargy, seizures, apnea, or coma. Findings suggestive of AHT are retinal hemorrhages, subdural hematomas, and diffuse axonal injury. An infant with abusive head trauma may have no neurologic symptoms and may be diagnosed instead with acute gastroenteritis, otitis media, GERD, colic, and other non-related entities. Often, a head ultrasound is used as the initial evaluation in young infants. However, it is not the test of choice in the emergency setting. In the assessment of AHT, the ophthalmologic examination should be performed, preferably by a pediatric ophthalmologist.
Abdominal Trauma:	Abdominal trauma is a significant cause of morbidity and mortality in abused children. It is the second most common cause of death from physical abuse and is mostly seen in infants and toddlers. Many of these children will not display overt findings, and there may be no abdominal bruising on physical exam. Therefore, screening should include liver function tests, amylase, lipase, and testing for hematuria. Any positive result can indicate the need for imaging studies, particularly an abdominal CT scan.
Skeletal Trauma:	The second most common type of child abuse after neglect is physical abuse. Eighty percent of abusive fractures occur in non-ambulatory children, particularly in children younger than 18 months of age. The most important risk factor for abusive skeletal injury is age. There is no fracture pathognomonic for abuse, but there are some fractures that are more suggestive of abuse.  These include posterior or lateral rib fractures and “corner” or “bucket handle” fractures, which occur at the ends of long bones and which result from a twisting mechanism. Other highly suspicious fractures are sternal, spinal, and scapular fractures.
Neglect:	Physical examination may not only demonstrate signs of physical abuse but may show signs of neglect. The general examination may show poor oral hygiene with extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds. All healthcare providers are mandated reporters, and, as such, they are required to make a report to child welfare when there is a reasonable suspicion of abuse or neglect. One does not need to be certain, but one does need to have a reasonable suspicion of the abuse. This mandated report may be lifesaving for many children. an interprofessional approach with the inclusion of a child-abuse specialist is optimal.
Physical Abuse:	Child physical abuse should be considered in each of the following: · A non-ambulatory infant with any injury · Injury in a nonverbal child · Injury inconsistent with child’s physical abilities and a statement of harm from the verbal child · Mechanism of injury not plausible; multiple injuries, particularly at varying ages · Bruises on the torso, ear, or neck in a child younger than 4 years of age · Burns to genitalia · Stocking or glove distributions or patterns · Caregiver is unconcerned about injury · An unexplained delay in seeking care or inconsistencies or discrepancies in the histories provided.  “TEN 4” is a useful mnemonic device used to recall which bruising locations are of concern in cases involving physical abuse: Torso, Ear, Neck and 4 (less than four years of age or any bruising in a child less than four months of age). A few injuries that are highly suggestive of abuse include retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions. Bruising is the most common sign of physical abuse but is missed as a sentinel injury in ambulatory children. Bruising in non-ambulatory children is rare and should raise suspicion for abuse. The most common areas of bruising in non-abused children are the knees and shins as well as bony prominences including the forehead. The most common area of bruising for the abused children includes the head and face. Burns are a common form of a childhood injury that is usually not associated with abuse. Immersion burns have characteristic sharp lines of demarcation that often involves the genitals and lower extremities in a symmetric pattern, and this is highly suspicious for abuse.
Sexual Abuse:	If a child demonstrates behavior such as undressing in front of others, touching others’ genitals, as well as trying to look at others underdressing, there may be a concern for sexual abuse. It is important to understand that a normal physical examination does not rule out sexual abuse. Indeed, most sexual abuse victims have a normal anogenital examination. In most cases, the strongest evidence that sexual abuse has occurred is the child’s statement.

Children who are abused may be unkept and/or malnourished, and may also display inappropriate behavior such as aggression, being withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. They also may have poor school attendance.

Specific injuries and associated findings of child abuse include:

Bites	Chipped teeth
Cigarette or cigar burns	Craniofacial and neck injuries
Friction burns	Injuries at different stages of healing
Injuries to multiple organs	Intracranial hemorrhage
Long-bone fractures	Marks shaped like belt buckles and cords
Oral burns, contusions, or cuts	Patterned injuries
Poor dental health	Sexually transmitted diseases
Skull fractures	Strangulation injuries
Unusual injuries

When considering child abuse, one must also identify differential diagnoses’ that may coincide with injuries. The diagnosis and injury type can vary with the child’s age.

Head Trauma	Accidental injury Arteriovenous malformations Bacterial meningitis Birth trauma Cerebral sinovenous thrombosis Hemophilia Leukemia Neonatal alloimmune thrombocytopenia Metabolic diseases Solid brain tumors Unintentional asphyxia Vitamin K deficiencies
Bruises and Contusions	Accidental bruises Birth trauma Bleeding disorder Coining Cupping Congenital dermal melanocytosis (Mongolian spots) Erythema multiforme Hemangioma Hemophilia Hemorrhagic disease Henoch-Schonlein purpura Idiopathic thrombocytopenic purpura Insect Bites Malignancy Nevi Phytophotodermatitis Subconjunctival hemorrhage from vomiting or coughing
Burns	Accidental burns Atopic dermatitis Contact dermatitis Impetigo Inflammatory skin conditions Sunburn
Fractures	Accidental Birth trauma Bone fragility with chronic disease Caffey disease Congenital syphilis Hypervitaminosis A Malignancy Osteogenesis imperfecta Osteomyelitis Osteopenia Osteopenia of prematurity Physiological subperiosteal new bone Rickets Scurvy Toddler’s fracture

Question 14

Laboratory Testing for Suspected Abuse

Answer

Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings that are like child abuse, and consequently, they must be ruled out.

Urine	A urine test may be used as a screen for sexually transmitted disease. Also, there is blood in the urine, bladder, or kidney trauma may be suspected. A urine toxicology test is indicated if there is evidence of altered level of consciousness, agitation, coma, or an apparent life-threatening event. It should also be ordered if a child was discovered in a dangerous environment, because up to 15% of victims of child abuse will have positive urine drug screens. Positive screens must be confirmed through blood analysis in cases of potential legal intervention. The chain of custody should be followed when sending a urine toxicology specimen to a laboratory. Confirmatory tests are usually sent to outside state-sponsored referral laboratories.
Hematology	If the injuries on a child are consistent with a history of abuse, then it is unlikely that the injuries are the result of a bleeding disorder. Some tests can be falsely elevated, so a pediatrician who specializes in child abuse or hematologist should review the results of the tests. Tests to assist in diagnosing a bleeding disorder include: · Complete blood cell count (CBC) · Platelet count · Prothrombin time · International Normalized Ratio · Partial thromboplastin time · Von Willebrand factor activity and antigen · Factors VIII and IX levels Laboratory evaluations that may be performed to rule out other diseases as causes of the injuries can include: · Bone injury: Calcium, magnesium, phosphate, alkaline phosphatase · Liver injury: Aspartate aminotransferase (AST), alanine aminotransferase (ALT) · Metabolic injury: Glucose, blood urea nitrogen (BUN), creatinine, albumin, protein · Pancreas injury: Amylase and lipase
Gastrointestinal and Chest Trauma:	Children who experience abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15 are the highest risk of domestic violence related health complications. In suspected gastrointestinal trauma, if the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L, an abdomen and pelvis CT with intravenous contrast should be performed. If there is any evidence of chest traumas such as abrasions, bruises, rib fractures, clavicle fractures, sternal fractures, or a fractured sternum, a troponin level should be performed. If the results of the troponin test are elevated to greater than 0.04 ng/mL, a CT of the chest and an echocardiogram. Should be obtained.

Question 15

Diagnostic Imaging for Suspected Abuse

Answer

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults and children, such as cranial sutures and incomplete bone growth. As a result, a fracture can be misinterpreted. When child abuse is suspected, a radiologist should be consulted to review the imaging results.

Skeletal Survey:

A skeletal survey is indicated in children younger than two years with suspected physical abuse. The incidence of occult fractures is as high as one in four in physically abused children younger than two years. The clinician should consider screening all siblings younger than two years. A skeletal survey consists of 21 dedicated views, as recommended by the American College of Radiology. The views include anteroposterior (AP) and lateral aspects of the skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest/rib technique; AP pelvis; AP of each femur; AP of each leg; AP of each humerus; AP of each forearm; posterior and anterior views of each hand; AP (dorsoventral) of each foot. If the findings are abnormal or equivocal, a follow-up survey is indicated in 2 weeks to visualize healing patterns.

A “babygram” that includes only one film of the entire body is not an adequate skeletal survey.
Skeletal fractures will remodel at different rates which are dependent on the age, location, and nutritional status of the patient.
· Soft tissue swelling is present at zero to 10 days.
· Long bone fractures may take 10 to 21 days to form a soft callus.

Computed tomography scan (CT) scan:

Three-dimensional reconstruction CT imaging is more specific in detecting skull and rib fractures, but also involves greater exposure to radiation. If abuse or head trauma is suspected, a CT scan of the head should be performed on all children younger than 24 months if intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months. A CT of the abdomen and pelvis with intravenous contrast is indicated in children who are unconscious, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.

Question 16

Treatment

Answer

Initial management of an abused child involves stabilization, including assessing the patient’s airway, breathing, and circulation. Once ensured that the patient is stable, a complete history and physical examination is required. Child protective services must be informed of any suspicion of child abuse. Having a child abuse specialist involved during the exam is optimal. If the child is seen in an outpatient setting, there may be a need to transfer the child to a hospital for laboratory and diagnostic testing as well as the appropriate continuation of care. Even if a child is transferred to another healthcare provider or facility, the initial healthcare provider first involved with the child’s care has the responsibility of being a mandated reporter. It is not the responsibility of the healthcare provider to identify the perpetrator, but it is to their responsibility to recognize potential abuse. The healthcare provider must continue to advocate for the child and ensure that they receive the appropriate follow-up care and services.

Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed as well as empiric treatment for human immunodeficiency virus (HIV), gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection. This management is possible if the child presents to a healthcare provider within 72 hours of the abuse to receive appropriate care as well as emergency contraception if desired. Prepubertal children are not provided with the prophylactic treatment due to the low incidence of sexually transmitted infections in this age group. Urgent evaluation is beneficial in children for forensic evidence, who have anogenital injury, who need prophylactic treatment, need child protection, and in those having suicidal ideation or any other form of symptom and/or injury requiring urgent medical care. ¹¹˒¹²˒¹³

Question 17

Child Abuse Resources

Answer

American Professional Society on the Abuse of Children	This is a nonprofit national organization that focuses on helping professionals get what they need to help abused children and their families. They offer the latest in practices in all disciplines that are related to child abuse.
ChildHelp USA	Treatment programs such as ChildHelp Group Homes and ChildHelp Advocacy centers have been designed to help children who are suffering from child abuse. There are also prevention programs, including ChildHelp Speak Up Be Safe for Educators.
Children’s Safety Network	This program offers resources and assistance to maternal and child health agencies that are looking to reduce violence towards children and reducing injuries that happen unintentionally. There are four Children’s Safety Network Resource Centers that are funded by the Maternal and Child Health Bureau of the US Department of Health and Human Services.
Darkness to Light	The mission of this program is to empower people to prevent child sexual abuse. It raises awareness of how common child sexual abuse is, and the consequences. Adults are educated so they know how to prevent this type of abuse, as well as recognize it and react appropriately.
Healthy Families America	This is the signature program from Prevent Child Abuse America. The national office, which is located in Chicago, IL, offer support, training, technical assistance, affiliation, and accreditation to more than 580 affiliates sites in 38 states, as well as the District of Columbia, American Samoa, Guam, Puerto Rico, Canada, and the Commonwealth of the Northern Mariana Islands.
International Society for Prevention of Child Abuse and Neglect	This organization has a mission to prevent cruelty to children in all parts of the world. Cruelty can include sexual abuse, physical abuse, neglect, child prostitution, street children, children of war, emotional abuse, child fatalities, and child labor through the increase of public awareness.
Kelso Lawyers	If you need to find more resources about child abuse, Kelso Lawyers can help. They offer resources for victims, such as symptoms of child sexual abuse, reporting abuse, abuse prevention, and causes of child sexual abuse. There are also resources for families, including child abuse statistics and child abuse counselling.
National Center for Missing and Exploited Children	This organization offers help to parents, children, schools, law enforcement, and the community to find missing children. It also works to raise public awareness about how to prevent child abduction, child molestation, and sexual exploitation.
National Center on Shaken Baby Syndrome	The mission of this organization is to help educate parents about the dangers of shaking babies, and to train parents and professionals on the subject. It also conducts research that will help to prevent the shaking of babies. The website is designed to help you find information, answers to questions about this issue, and ideas on how to prevent shaken baby syndrome.
Stop it Now	This program was founded by Fran Henry, who survived childhood sexual abuse herself. Her vision was to have sexual abuse of children seen as a preventable public health issue, to help parents focus on the prevention of abuse, and to create programs that are based on these same principles.

Question 18

Special Considerations

Answer

When feasible, and without delaying care to the child, photographs of injuries should be taken prior to initiating treatment of suspected injuries of child abuse.

Take an identification tag photo.
Take photos from multiple injury angles and distances.
Measure and document injury sizes.
When photographing bite marks include photos focusing on each dental arch to avoid distortion.
Check photos as they may be used in court.

Question 19

Outcomes

Answer

Child abuse is a public health problem that leads to lifelong health consequences, both physically and psychologically. Physically, children who are victims of abusive head trauma may have neurologic deficits, developmental delays, cerebral palsy, and other forms of disability. Psychologically, victims of child abuse tend to have higher rates of depression, conduct disorder, and substance abuse. Academically, these children may have poor performance at school with decreased cognitive function. It is important for healthcare providers to have a high index of suspicion for child abuse because early identification may be lifesaving. All healthcare providers should report child abuse without hesitation.

When it comes to child abuse, all healthcare providers have a legal, medical, and moral obligation to identify the suspected abuse and report it to child protective services. Many child abuse problems present to the Emergency Department; hence nurses and physicians are often the first ones to notice the problem. The key is to be aware of the problem; allowing abused children to return to their perpetrators usually leads to more violence, and sometimes even death. Even if child abuse is only suspected, the social worker must be informed so that the child can be followed on an outpatient basis. The law favors the healthcare provider for reporting child abuse, even if it is only a suspicion. On the other hand, failing to report child abuse can have repercussions on the healthcare provider. Unfortunately, despite the best practices, many children continue to suffer from child abuse. ¹⁴˒¹⁵˒¹⁶

Evidence-based outcomes

Child abuse is a serious problem in many countries. While there is an acute awareness of the problem, many children fail to be referred to child protective services and consequently continue to suffer abuse, sometimes even death. In a busy emergency room, signs of child abuse are missed, and thus healthcare workers must be vigilant of abuse in any child who presents with injuries that are out of place. ²˒¹⁷

Question 20

Intimate Partner Violence Statistical Data

Answer

physical violence by their intimate partner, and about 33% of  women and nearly 16% of men will experience some form of sexual violence at some point during their lifetimes. The occurrences of intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year.

Approximately 16% of women and 5% of men have experienced stalking. The majority are stalked by someone they know; an intimate partner stalks about 60% of female victims and 40% of male victims.
At least five million acts of domestic violence occur annually to women aged 18 years and older, with over three million of the acts involving men. While most events are minor in comparison, for example grabbing, shoving, pushing, slapping, and hitting, serious injuries requiring hospitalization and even fatal injuries have occurred. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults also occur. About 20% of women have experienced attempted or completed rape. Likewise, at some point in their lives, about 1% to 2% of men have also experienced attempted or completed rape. ¹˒³˒²⁰
African American, American Indian, Alaskan Native women and men, and Hispanic women report higher rates of domestic violence. The incidence of homicide between partners is higher in interracial marriages when compared with same race marriages. Asian and Pacific Island women and men report lower rates of intimate partner violence. However, differences among groups tend to diminish when sociodemographic and relationship variables are controlled.
Women are more likely to be attacked, injured, or raped by their partners than by any other person. According to the United States Department of Justice, women are six times more likely than men to experience violence committed by a spouse or ex-spouse, boyfriend or girlfriend, or ex-boyfriend or ex-girlfriend. An intimate partner is the perpetrator in approximately one-third of all cases of violence against women that is committed by a single offender. Women aged 16 to 24 years are more likely to be victims of violence at the hands of an intimate partner. Twenty to 30% of women who attend college report violence during a date.
Rates of spousal homicide peak in the 15 to 24-year-old age category. Rates decline with age in African Americans but not in whites. As the age difference between males and females increases so does the risk of spouse homicide.
Lesbians report higher levels of sexual violence, in the range of 30% to 40%. There is some evidence that homosexual males also experience higher levels of sexual violence. Approximately 10% of women who live with intimate female partners report being raped, physically assaulted, or stalked by their partner. Also, 33% of women living with a male partner reported victimization.
Approximately 15% of men living with a male intimate partner report being raped, physically assaulted, or stalked by their partner. In comparison, less than 10% of men who have lived with a female partner experience similar problem.
More than half of all homeless women and families are fleeing domestic violence.
Approximately two million injuries and deaths occur each year because of domestic violence. About one-third of domestic violence patients will seek care in an emergency department. Injuries include over 40,000 gunshot wounds, stab wounds, fractures, internal injuries, and loss of consciousness. Over 50,000 victims are injured because of intimate partner sexual assault, and approximately 400,000 have soft tissue trauma.
Most intimate partner murders are committed with firearms.
The number of intimate partner homicides has decreased by about 15%.
Almost half of the females murdered visited an emergency department within two years of the homicide.
About 10% of females are abused at least once during pregnancy.
Women are more commonly victims of intimate partner murder.
A home in which anyone has been hurt in a family fight is approximately five times more likely to be the scene of a homicide.
Females are the victims in 85% of intimate nonlethal violence.
While it is commonly reported that women are more likely to be injured than men, some studies suggest male and female victims are equally affected by domestic violence.
While males are less likely than females to be victims of gunshot wounds or be injured in an assault, they are more likely to be stabbed.
Domestic violence affects approximately 325,000 pregnant women each year.
The average reported prevalence during pregnancy is approximately 30% emotional abuse, 15% physical abuse, and 8% sexual abuse.
Domestic violence is more common among pregnant women than preeclampsia and gestational diabetes.
Reproductive abuse may occur and includes impregnating against a partner’s wishes by stopping a partner from using birth control.
Since most pregnant women receive prenatal care, this is an excellent time to assess for domestic violence.

Question 21

Pregnant Women

Answer

The American College of Obstetricians and Gynecologists (ACOG) recommends that all women be assessed for signs and symptoms of domestic violence during regular and prenatal visits. Healthcare providers should offer support and referral information if domestic violence is suspected or verbalized. ²²

Factors that predispose pregnant women to domestic violence include:

Delayed prenatal care
Lack of social support
Lower socioeconomic status
Single
Unintended pregnancy
Use of alcohol, drugs, or tobacco
Young maternal age

The danger of domestic violence is particularly serious as both mother and fetus are at risk. Healthcare providers should be aware of the psychological consequences of domestic abuse during pregnancy, which includes stress, depression, substance addiction, and preterm labor. All these conditions can cause harm to the fetus.

Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions. There are several historical and physical findings that may help the healthcare provider identify women at risk, such as:

Anxiety or depression
Chronic unexplained pain
Distrust
Flat affect
Fright
High parity
Late prenatal care
Multiple emergency department or office visits
Overcompliance
Post-traumatic stress symptoms
Prior history of abuse
Single
Substance abuse
Suicide attempts
The abuser, if present, may be overly solicitous, answering questions, being hostile, refusing to leave the bedside, and correcting responses to questions.
Unplanned pregnancy
Young age

If the healthcare provider encounters any of these signs or symptoms, they should explain confidentiality to the pregnant woman, and assess her in a private room. The healthcare provider should communicate by asking caring, empathetic questions and listening politely without interruption to answers throughout the interaction with a victim of domestic violence.

Question 22

Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning

Answer

Domestic violence occurs in lesbian, gay, bisexual, transgender, queer and/or questioning (LGBTQ) couples, and the rates are thought to be like a heterosexual woman at approximately 25%. Although the rates of domestic violence are thought to be similar, the following instances show variations in the occurrences between partners, depending on the sex of the partners involved: ²³

Over 35% of heterosexual women, 40% of lesbians, 60% of bisexual women experience domestic violence.
For heterosexual men, the incidence is slightly lower.
There are more cases of domestic violence among males living with male partners than among males who live with female partners.
Females living with female partners experience less domestic violence than females living with males.
Transgender individuals have a higher risk of domestic violence. Transgender victims are approximately two times more likely to experience physical violence.
Abusive partners in LGBTQ relationships use all the same tactics to gain power and control as abusive partners in heterosexual relationships, such as emotional, physical, or sexual abuse, financial control, isolation and more. Abusive partners in LGBTQ relationships also use power and control over their victim with societal factors that compound the complexity a survivor faces in leaving or getting safe in an LGBTQ relationship, such as threatening to make their sexual preferences public.

Same-sex partner abuse is common and may be difficult to identify, and LGBTQ victims may be reluctant to report domestic violence. Part of the reason maybe that support services such as shelters, support groups, and hotlines are not readily or routinely available. This results in unsupported victims. Often, the perpetrator and victim may have the same friends or support groups. This situation puts the victim at increased risk for continued violence as they may be reluctant to leave their support system. Healthcare professionals should be aware that there are fewer resources available to help the LGBTQ victim, and they should provide all available resources to help the victim of domestic violence. Resources available include, but are not limited to:

The LGBT Foundation: https://www.lgbt.foundation
The National Domestic Violence Hotline: 1-800-799-7293/1-800-787-3224 (TTY)
The Network / La Red Hotline:1-617- 742-4911, http://www.thenetworklared.org/
National Domestic Violence Hotline:1-800-799-7233, www.ndvh.org
Gay Men’s Domestic Violence Project: http://www.glbtqdvp.org/
GALAEI – Queer Latin@ Social Justice: www.galaei.org
The Network / La Red: http://www.thenetworklared.org/

Question 23

Intimate Partner Abuse

Answer

Approximately 33% of women and 20% of men will be victims of abuse. Usually domestic violence is perpetrated by men against women; however, females may exhibit violent behavior against their male partners.

Approximately five percent of male victims of domestic violence are killed by their intimate partners.
Each year, approximately 500,000 women are physically assaulted or raped by an intimate partner compared to 100,000 men.
Approximately 33% of women at some point are stalked, physically assaulted, or raped by an intimate partner, compared to about 10% of men.
Rape is primarily perpetrated by other men, while women engage in other forms of violence against men.

The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. A healthcare provider should be suspicious if the history and complaint is not consistent with the injury. Defensive injuries may be present on the forearms and hands. The victim may also have psychological signs and symptoms such as anxiety, depression, and fatigue. Medical complaints may also be vague or specific. Vague medical complaints may include headaches, palpitations, chest pain, painful intercourse, or chronic pain.

Specific injuries may include:

Abdominal bruises or cuts	Bilateral injuries	Bites
Black eyes	Bruises	Burns
Cigarette burns	Fractured bones	Fractured teeth
Rope burns	Wounds in several stages of healing

Differential Diagnosis’ in Intimate Partner Domestic Violence Include:

Accidental burn	Alcohol abuse	Accidental fall
Acute subdural hematoma	Consensual intercourse	Depression
Suicide attempt	Substance abuse

Men represent as much as 15% of all cases of domestic partner violence. Male victims are less likely to seek medical care so the incidence may be underreported. Although women are the most common victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.

Laboratory and diagnostic testing for intimate partner-related domestic violence is like elder abuse and will be discussed in the elder abuse section to follow.

Question 24

Elder Abuse

Answer

There is no universally accepted definition of when old age begins. As a result, statistics on elder abuse are highly variable. All racial, socioeconomic, and religious backgrounds are affected by elder abuse.

The estimated racial and ethnic distribution in elders who are abused is:

White: 60%
Black: 20%
Hispanic: 10%
Other: 5%

Typically, 60 or 65 years of age is considered elderly. Obtaining accurate information on elder abuse and neglect is difficult. This may be due to under reporting of the incidences. Elder abuse is thought to occur in approximately 30% of the elder population. ²¹ Elders may not report elder abuse out of fear, guilt, ignorance, or shame. Healthcare providers also underreport elder abuse because of lack of recognition of the problem, lack of understanding reporting methods and requirements, and concerns about confidentiality. Other circumstances that may lead to underreporting may include the elder’s inability to respond to a survey, speak English, or having degenerative conditions such as dementia. These all may lead to inaccurate reporting on the number of elders who are abused. Although obtaining the exact frequency of elder abuse is difficult, it is commonly encountered in the clinical setting. All healthcare providers must maintain a high index of suspicion for abuse.

In the elderly population, victims of physical abuse and neglect have a much higher mortality rate than those who have no history of abuse being reported. Early detection of elder abuse cases results in decreased morbidity and mortality. Healthcare provider involvement is important as only 16% of victims will self-report mistreatment to the appropriate legal authorities.

Elders are often mistreated by their spouses, children, or relatives. ²¹

Annually, approximately two percent experience physical abuse, one percent sexual abuse, five percent neglect, five percent financial abuse, and five percent suffer emotional abuse.
The annual incidence of elder abuse is estimated to be two to ten percent with only about 6% of cases reported to the authorities.
Approximately one-third of nursing homes disclosed at least one incident of physical abuse per year.
Ten percent of nursing home staff self-report physical abuse against an elderly resident.

Elder abuse may be financial or physical. The elderly may be controlled financially and are often hesitant to report this form of abuse, especially if the perpetrator is their caregiver. Victims are often dependent, infirm, isolated, or mentally impaired. Healthcare providers should be aware of the high incidence of abuse in this population. elder abuse is not restricted to the home; it may occur in institutional settings. This may be due to poor training, stress, burnout, a heavy workload, low pay, and low job satisfaction; abuse is a common problem.

Factors that increase the risk for elder abuse include:

A shared living situation with the abuser
Dementia
Pathologic characteristics of perpetrators including dementia, mental illness, and drug and alcohol abuse
Social isolation

Because elder abuse is common, healthcare providers must remain aware of the potential for abuse. When abuse occurs between elder partners, it is usually part of a long-standing pattern of marital violence, or as abuse developing in old age. In the latter case, abuse may be precipitated by issues related to dementia, disability, and changing family relationships. When elder abuse is suspected, the healthcare provider should complete a full assessment and evaluate all injuries. The following may suggest elder abuse, and more investigation should be considered:

Agitation
Bruises
Burns
Contradictory caregiver and patient explanations
Decubitus ulcers
Dehydration
Depression
Inconsistent injury to the history
Injuries in various stages of evolution
Laboratory findings indicating not taking, underdosing, or overdosage of medications
Lacerations
Poor hygiene
Rope marks
Treatment delays
Unexplained injuries
Venereal disease
Welts

Differential Diagnosis of Elder Abuse to take into consideration include:

Anorexia	· Acute and Chronic Infection (i.e. urinary tract infection, sepsis, tuberculosis, endocarditis) · Adverse effects of prescribed, over the counter, herbal medications · Cerebral vascular accidents (multiple resulting in increasing difficulty or dependency in completing activities of daily living) · Delirium · Dementia · Dental problems · Depression or other psychiatric conditions · Dysphagia · Endocrinologic diseases (i.e. hyperthyroidism) · Use of alcohol or illicit drugs
Bruising	· Benign Tumors · Bleeding disorders · Congenital birthmarks · Cultural practices to improve circulation and relieve common symptoms (such as coining or cupping) · Delayed subaponeurotic fluid mass · Hypersensitivity syndromes · Ingestion of anticoagulant medications · Vasculitis
Burns	· Chemical and irritants (i.e. bleach, complementary and alternative therapies) · Dermatological conditions (i.e. diaper dermatitis) · Infection (i.e. impetigo, blistering distal dactylitis, ringworm) · Stephen-Johnson Syndrome · Toxic epidermal necrolysis
Fractures	· Malignancy (resulting in pathologic fractures) · Osteopenia (resulting in pathologic fracture
Intracranial Hemorrhage	· Bleeding disorders⁴⁴ · Collagen vascular disease ⁵³ · Congenital vascular conditions⁶² · Inborn errors of metabolism⁶⁰ · Neoplastic diseases⁶¹ · Trauma not secondary to abuse⁵⁹

The healthcare provider should ask elder patients about abuse, even if signs are absent. When evaluating a patient for elder abuse, the healthcare provider should ask simple questions in a non-threatening manner. They should also interview the patient and caregiver separately to detect disparities. The documentation should be accurate, objective, complete, legible, and thorough with quotations of patient statements, because documentation may be used in criminal trials or guardianship hearings.

Question 25

Intimate Partner Domestic Violence and Elder Abuse Assessments

Answer

A detailed assessment of the victim should occur after they disclose that abuse has occurred. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient’s evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.²⁷˒²⁸If there is no immediate danger, the assessment should focus on the victim’s mental and physical health and establish the history of current or past abuse. These responses determine the appropriate intervention. An example of questions to assess domestic violence and abuse include:

Assessing the danger risk:

Are you in danger right now?
Where is your domestic partner/caregiver?
Where will your domestic partner/caregiver be when you finish receiving medical care?
Do you want the police to be notified?

Determining abuse patterns and history:

How long has the domestic violence/abuse been happening?
Have you been harmed sexually?
Have any of your family members, friends, or pets been harmed?
How much control does your partner/caregiver have over your finances, activities, or home life?

Determining if there is a connection between health and the domestic violence:

Is the violence or abuse behavior having an affection your mental or physical health?

Determining whether the domestic violence could escalate:

Is the violence escalating in frequency or harshness of abuse?
Have you experienced death threats?

Determining whether support groups or other resources have been used:

What options have your used in the past for help?
Have you stayed connected with any support groups or legal counsel?
Would you like some resources on support and legal counsel?

During the assessment, the victim of domestic violence needs to feel respected, cared for, listened to, and encouraged to make choices to the extent legally allowable. The victim should be informed:

There is no excuse for domestic violence.
Violence is not the patient’s fault.
No one deserves to be abused.
It is difficult to face the situation, but resources like support, shelter, and legal advice are available.
Appropriate intervention decreases the likelihood of anxiety, depression, substance abuse, counterphobic behavior, and PTSD.
Use plain language to explain procedures.
Explain reactions expected during the post-trauma period
When examining the patient, respect modesty; touch the patient only with permission.
Discuss evaluation of sexually transmitted infections and pregnancy.

During the initial assessment, a healthcare provider must be sensitive to the victim’s cultural beliefs. Incorporating a cultural sensitivity assessment with a history of victims of domestic violence may allow more effective treatment. Victims of domestic violence may exhibit the following behaviors:

Dissociation: Feeling separated from the body, reality, or both
Eidetic memory: Flashbacks experiencing the memory
Recall: Repetition of the trauma
Hyperarousal of the autonomic nervous system
Vigilance: Intense paranoid awareness of every word and act of the staff

Occasionally, victims who have suffered domestic violence may or may not want a referral for support resources. Many victims are fearful of their lives and financial well-being and may heavily weigh the benefits in leaving the abuser which could lead to loss of financial support or fear of being alone. The healthcare provider must assure the victim that the decision is voluntary, and that the provider will help regardless of the decision. The goal is to make safe resources accessible and to enhance support.

If the victim elects to leave their abuser, information for referrals on domestic violence should be given to the victim. Counselors that often include social workers, psychiatrists, and psychologists should also be contacted for assistance. If there is a risk to life or limb or evidence of injury, the victim be referred to local law enforcement officials.

Question 26

Testing

Answer

The healthcare provider should evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, malnutrition, physical abuse, and sexual abuse. Tests to consider include:

Laboratory Testing 

25-hydroxy vitamin D level, intact parathyroid hormone level, calcium level¹³
Basic Metabolic Panel to evaluate for any electrolyte or nutritional abnormalities

Coagulation Profile to rule out the presence of bleeding disorders¹³ 
Creatinine kinase level to rule out the presence of rhabdomyolysis
Hepatic Function Panel to rule out the presence of intraabdominal injury¹³
Serum Lipase to rule out pancreatic injury
Toxicology Testing to rule out the presence of malicious administration of substances
Urinalysis to rule out the presence of myoglobinuria
Urine organic acids to rule out the presence of metabolic conditions such as glutaric acid type I¹³

Imaging Studies 

Chest radiographs to rule out thoracic injuries and/or the presence of any acute fractures or fractures in various stages of healing
Computed tomography of the abdomen to rule out the presence of any intraabdominal injuries particularly duodenal or pancreatic injuries, but also liver, spleen, kidney, adrenal gland, mesentery, and/or intestinal injuries¹³
Computed tomography of the brain to rule out any intracranial hemorrhages
Global skeletal surveys in children that images subtle metaphyseal, rib, and other injuries specific for abuse
Ophthalmologic evaluation to rule out the presence of retinal hemorrhages¹³

Other

Pelvic examination with evidence collection if sexual assault is suspected

Question 27

Evidence Collection

Answer

Domestic and family violence commonly results in legal prosecution of the perpetrator. It is important to avoid destroying evidence. Preferably, a team specializing in domestic violence should aid with evidence collection. Evidence includes tissue specimens, blood, urine, saliva, and vaginal and rectal specimens. For example, saliva from bites can be collected; the bite mark is swabbed with a water-moistened cotton-tipped swab. Clothing stained with blood, saliva, semen, and vomit should be retained for forensic analysis.

Each healthcare facility should have a written procedure for how to package and label specimens and maintain a chain of custody. Law enforcement personnel will often assist with evidence collection and provide specific kits.

Question 28

Documentation

Answer

The medical record is often evidence used to convict an abuser. A poorly documented chart may result in an abuser not being prosecuted.

Charting should include detailed documentation of the assessment, treatment, and referrals provided, Descriptors in the documentation include:

Describe the abusive event and current complaints using the patient’s own words.
Include behavior of the patient in the record.
Include health problems related to the abuse.
Include the alleged perpetrator’s name, relationship, and address.
The assessment should include a description of the victim’s injuries including location, color, size, amount, and degree of age bruises and contusions.
Document injuries with anatomical diagrams and photographs.
Photographs should include close-ups of all wounds and contusions of the face and torso.
Include the name of the victim, medical record number, date, and time of the photograph, and witnesses on the back of each photograph.
Torn and damaged clothing should also be photographed.
Document injuries not shown clearly by photographs with line drawings.
Preserve physical evidence that may be used for prosecution.
With sexual assault, follow protocols for physical examination and evidence collection.
Consent the patient, parent, or legal guardian.
Perform legally required notifications.
Make referrals.
Assure a safe environment.

The immediate concern is for the safety of the abused victim and any immediate family members. If there is any concern that the perpetrator or an individual that will report to the perpetrator is present, the healthcare provider should provide treatment to the victim in private or with the proper authorities present.

The victim needs to know that their health and safety are being taken seriously by healthcare provider. The primary goal after treatment of acute injuries is to bring the victim into contact with domestic violence shelters, social services, legal assistance, and support groups. The victim should be assisted in locating someplace that is a safe. If an outpatient facility is not available and if there is no safe place to go, overnight hospitalization could be considered, emphasizing that this for the victim’s protection. The victim should be provided with all the options available, including contacting the police to obtain a restraining order, and services offered through support groups and hotlines.

Some victims will choose to return to the relationship after seeking healthcare. Nevertheless, the victim should be made aware of programs available to leave a violent situation. The healthcare provider should provide email addresses and phone numbers of the programs available, and they should inform the victim that if they return to a domestic violence situation, they may be reinjured, and with escalating violence, the injuries may be fatal. Appropriate suspicion, documentation, and referral can prevent further abuse. The healthcare provider should encourage the victim to develop safety and follow-up plans before they are discharged. In some situations, a follow-up assessment in the home to evaluate the ongoing living environment, the family, and the condition of caregivers may be necessary.

Question 29

Domestic Violence and Abuse Resources

Answer

In cases of acute injury or emergency, contact local law enforcement.

A 24-hour toll-free domestic violence hotline is available for counseling and information at 800-500-1119. The counselors will refer the victim to a local domestic violence center.

Florida has several domestic violence centers that will provide referral services, counseling, a 24-hour hotline, emergency shelter, educational services, assessment, and referral of parents with children, and local training of law enforcement personnel.

If child abuse is suspected, contact the Florida Children and Family abuse registry at 1-800-96-ABUSE (962-2873), or National Child Abuse Hotline at 1-800-4-A-Child.

For information and referral relating to domestic violence in Florida:

Florida Coalition Against Domestic Violence: 1-800-500-1119
Florida Council Against Sexual Violence: 1-888-956-RAPE

For further local assistance, the police and sheriff’s departments and local shelters should be contacted.

The following agencies provide national assistance for victims of domestic and family violence:

Asian and Pacific Islander Institute on Domestic Violence: 1-415-954-9988, www.apiidv.org
Casa de Esperanza: Linea de crisis 24-horas/24-hour crisis line 651-772-1611, www.casadeesperanza.org
Centers for Disease Control and Prevention: (800-CDC-INFO (232-4636)/TTY: 888-232-6348
ChildHelp USA/National Child Abuse Hotline: 1-800-422-4453 www.childhelpusa.org

Corporate Alliance to End Partner Violence: 309-664-0667
Domestic Violence Initiative: 303-839-5510/ 877-839-5510 www.dviforwomen.org
Employers Against Domestic Violence: 508-894-6322
Futures without Violence: 415-678-5500/TTY 800-595-4889

www.futureswithoutviolence.org

INCITE! Women of Color Against Violence: incite.natl@gmail.com, www.incite-national.org
Institute on Domestic Violence in the African American Community:  877-643-8222
www.dvinstitute.org
Love Is Respect: National Teen Dating Abuse Helpline: 866-331-9474 /TTY: 866-331-8453
National Center on Domestic Violence, Trauma & Mental Health: 312-726-7020 ext. 2011 www.nationalcenterdvtraumamh.org
National Coalition Against Domestic Violence: www.ncadv.org
National Network to End Domestic Violence: 202-543-5566
National Resource Center on Domestic Violence: 800-537-2238
www.nrcdv.org and www.vawnet.org
National Resource Center on Domestic Violence: 800-537-2238 
National Sexual Violence Resource Center: 717-909-0710
National Teen Dating Abuse Helpline: 866-331-9474 or TTY 1-866-331-8453
Rape Abuse and Incest National Network (RAINN): 800-656-HOPE
Sexual Assault Training and Investigations (SATI): mysati.com 619-561-3845
Speaking Out About Rape (SOAR): 407-898-0693
Stalking Resource Center, National Center for Victims of Crime: (1-800-FYI-CALL (394-2255)/TTY: 800-211-7996
The Battered Women’s Justice Project: 800-903-0111
The coalition of Labor Union Women (cluw.org): 202-466-4615
The National Center for Victims of Crime: www.victimsofcrime.org
The National Domestic Violence Hotline: 1-800-799-7233 (SAFE) www.ndvh.org
National Sexual Assault Hotline: 1-800-656-4673 (HOPE) www.rainn.org
The National Domestic Violence Hotline (www.thehotline.org): 800-799-7233 or TTY 800-787-3224
U.S. Department of Justice, Office on Violence Against Women: 202-307-6026
Workplaces Respond to Domestic and Sexual Violence: A National Resource Center www.workplacesrespond.org

Question 30

Discharge Considerations

Answer

Prior to discharge, the healthcare provider should evaluate the victim of domestic violence to determine if the patient will be in danger if returning home. Questions to consider before discharging a victim include:

Does the victim need a medical or psychiatric intervention?
Is admission or urgent follow-up required for medical conditions?
Does the victim express suicidal or homicidal ideation?
Does the victim need urgent crisis counseling to deal with the stress of abuse?
Who is waiting outside for the victim?
Does the victim believe it is safe to go home?
Where is the abuser now?
Was the abuser arrested?
Does the abuser have access to a weapon?
Has the abuser threatened to kill the victim?
Has the abuser been harassing or stalking the victim?
Have abusive behaviors been escalating?
Does the victim have friends or family with whom they can stay?
Is there a danger the abuser will come home?
Is the victim confident family or friends will not inadvertently collude with the abuser in the belief they are helping the couple?
In what type of living situation are children and other dependents?
Does the victim feel safe?
Is the victim afraid of harm if going home?
Does the victim want access to a shelter? If the victim does not want to go to a shelter, the healthcare provider should provide telephone numbers for domestic violence, crisis hotlines, and support services for potential later use. A referral should also be made to primary care physician or other appropriate resource. The healthcare provider should also advise the victim to have a safety plan in place and provide examples one. The following are examples safety plan elements:
Avoid arguments in small rooms or rooms without access to an outside door.
Avoid alcohol and drugs that decrease the ability to protect or think logically.

Develop escape routes through doors, windows, or fire escapes.
Practice escape routes.
Ask friends or neighbors to call the police if they hear suspicious noises.
Arrange a code word for children or friends, so they know when to call for help.
Teach children to use the telephone to contact the police or fire department.

The victim should also be instructed to have the following items readily available in case of an emergency:

Driver’s license, birth certificates, social security cards, green cards, passports, school and health records, welfare identification, insurance records, automobile titles, lease or rental agreements, mortgage papers, marriage license, address book, protective or restraining orders, divorce or custody papers, court documents, money, checkbook, bankbook, and credit card
Prescription medicines
Clothing, toys, and other items for children
Keys to the car, house, office, and safe-deposit box
Change the locks on doors and windows
Install safety devices, such as extra locks, window bars, and electronic security systems
Install smoke detectors, purchase fire extinguishers, and rope ladders for upper floor window

Question 31

Special Considerations in Screening for Family and Domestic Violence

Answer

Healthcare providers play a crucial role in screening, identification, and reporting domestic violence. Using screening tools in clinical practice can increase the chances that domestic violence will be identified.

Over 80% of victims of domestic and family violence seek care in a hospital; others may seek care in healthcare provider offices. Routine screening should be conducted by all healthcare providers. Screening is a critical component in protecting victims and minimizing negative health outcomes, ² as the healthcare provider’s interventions reduces the incidence of morbidity and mortality associated with domestic violence. Because family and domestic violence is a significant public and social problem, all healthcare professionals should be aware of screening tools and use them to assess for family and domestic violence. This includes routine screening of children, women, and the elderly in all primary care settings.

Tools

The physical examination is still the most significant diagnostic tool to detect abuse. A child or adult with suspected abuse should be undressed, and a comprehensive physical exam should be performed. The skin should be examined for bruises, bites, burns, and injuries in different stages of healing. The healthcare provider should also examine for retinal hemorrhages, subdural hemorrhages, tympanic membrane rupture, soft tissue swelling, oral bruising, fractured teeth, and organ injury. There are several other tools available that are age/population specific, such as:

The American Academy of Pediatricians has free guides for the history, physical, diagnostic testing, documentation, treatment, and legal issues in cases of suspected child abuse.
The Kempe Family Stress Inventory questionnaire assesses maltreatment in young single women of low socioeconomic status.
The Maternal History Interview uses open-ended questions and subscales to assess personality, parenting skills, life stress, and child abuse risk.
The Center for Disease Control provides several scales assessing family relationships, including child abuse risks.

Child Abuse

Healthcare providers must take responsibility to identify child abuse to prevent recurrent injuries. While it has not been established that routine child abuse screening is necessary, clinicians should screen for abuse if it is suspected. Multiple missed appointments and delays in seeking medical treatment are indicators of neglect. The most common risk factors for child abuse and neglect are poverty, low education, large family size, single-parent, young parents, stepparents in the home, and psychiatric disease. Many organizations offer free screening tools. However, most lack sufficient sensitivity and specificity. False-positive and false-negative results can entail serious consequences including both under- and overreporting of abuse.

Intimate Partner Violence

Some experts believe screening should only occur when signs and symptoms are present. Routine screening may, in fact, be problematic because it can stigmatize victims and result in anxiety. Further, in cases of domestic violence, victims are often unwilling to use available resources to end abuse.

Several national organizations, such as the American Medical Association and Family Violence Prevention Fund recommend screening all women for intimate partner violence. Screening tools for abuse are available for assessment, intervention, documentation, and referral. Screening has the potential to decrease abuse and improve health outcomes. While victims may not be willing to use the information provided, serious consequences follow if abuse is ignored. A healthcare provider can provide the resources to ensure that the patient is educated and informed.

The Center for Disease Control and Prevention (CDC) provides numerous tools to assist practitioners in the free publication, Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. These tools include:

AAS (Abuse, Assessment, Screen): A tool used to detect abuse limited to women
HITS (Hurt, Insult, Threaten, Scream): a screening tool used in outpatient medical offices
PVS (Partner, Violence, Screen): an abbreviated emergency department screening tool
RADAR (Routinely, Ask, Document, Assess, Review): helps providers recognize and treat intimate partner violence
WAST (Woman, Abuse, Screening, Tool): a screening tool used by family and emergency practitioners

Elder Abuse

The elderly is at risk of abuse in the home environment as well as in institutional settings. Risk factors for elder abuse both at home and in institutions include increased age, dementia, abnormal behaviors, cognitive decline, physical dependency, and daily living activities impairment. Screening for elder abuse should include a review of social and financial information.

The Abuse Suspicion Index is a screening tool for cognitively intact suspected victims. In elders with dementia, often the healthcare provider must rely on the physical exam. Bruising can be an indicator of physical abuse; however, elders commonly take blood thinning agents that result in easy bruising. Victims of physical abuse tend to have bruises that are larger than five centimeters, and they tend to be located on the face, lateral right arm, or posterior torso. In many instances, the victim may recall how the bruise occurred.

If abuse is suspected, radiographs of ribs, small bones, and face should be considered. A commutated tomography (CT) of the head should also be considered to rule out subdural hemorrhage. While difficult, a pelvic examination should be considered if there are any signs of sexual abuse. Weight loss may be a sign of physical or medical neglect due to malnutrition. Other common causes of weight loss should be ruled out. Pressure ulcers should also raise suspicion for neglect.

All healthcare providers should be aware of the potential signs and symptoms of elder abuse and should be familiar with screening tools. When abuse is suspected, the history and physical exam should be carefully conducted and documented with additional laboratory, and imaging tests considered.

Screening Challenges

While screening is crucial to identify domestic and family, several barriers exist. Despite the prevalence of domestic violence, many healthcare providers do take the time to screen patients who could be victims. Unfortunately, no universal approach has been established to assess for domestic violence. In addition, many healthcare providers do not have the time, resources, or desire to get involved with an abuse or neglect investigation. Many healthcare providers remain ignorant of the warning signs and risk factors. In most states, reporting of suspected elder abuse or neglect is required by statute, however, few healthcare providers are prosecuted for failure to comply with the statute. Routine screening increases the odds domestic abuse cases will be identified.

Screening Recommendations

The following provides recommendations for screening abuse:

The healthcare provider should evaluate for organic conditions and medications that mimic abuse
The healthcare provider should evaluate the suspected victim and caregiver separately
The healthcare provider should screen for family and domestic violence and elder abuse
The Elder Abuse Suspicion Index can be used to assess for elder abuse
The healthcare provider should screen for cognitive impairment before screening for abuse in the elderly
Pattern injury is more suspicious

Question 32

Conclusion

Answer

Domestic violence may be difficult to uncover when the victim is frightened, especially when they present to a hospital or healthcare practitioner’s office. The key is to establish an assessment protocol and maintain an awareness of the possibility that domestic and family violence may be the cause of the presentation of signs and symptoms. Screening should be carried out in all healthcare settings.

Establishing that injuries are related to domestic abuse is a challenging task. Life and limb-threatening injuries are the priority. After physical evaluation and stabilization, laboratory tests, radiologic films, computerized tomography, or magnetic resonance imaging may be indicated. It is important that healthcare providers first attend to the underlying issue that requires the most immediate treatment. The evaluation should start with a detailed history and physical examination. All children, females and elders should be screened for domestic violence, even if they do not have signs or symptoms of abuse. A referral should be made for any child, female or elder who screens positive. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring victims of child abuse, intimate partner violence and elder abuse. Protocols should include referral, documentation, and follow-up.

Without referrals for social service and mental health intervention, all forms of abuse can recur and escalate in both frequency and severity. ⁵ When this happens, the prognosis for domestic violence recovery is poor. Healthcare providers should be able to identify domestic and family violence victims and potential abusers, be able to assess all patients for abuse and offer immediate treatment to injuries, counseling, education, and referrals, and assist the victim in creating a plan that includes community resource information related to shelter, counseling, advocacy groups, child protection, and legal aid.

Question 33

References

Answer

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Question 34

Domestic Violence Posttest

Answer

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Question 35

Domestic Violence Evaluation

Answer

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Domestic Violence-Florida

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