Abuse and neglect are commonly encountered in both children and the elderly. It occurs when a caregiver, whether through willful action or lack of appropriate action, causes harm or distress to the person under their care. The victims can be encountered in different healthcare settings and may be at risk of various health consequences. The optimal outcome for these individuals may depend upon early recognition of the signs and symptoms of abuse and/or neglect and prompt evaluation. The following activity will provide an overview of the clinical features, evaluation, and approach to a patient with suspected abuse or neglect.
Abuse and neglect of the child and the elderly are often perpetrated by the parent or caregiver responsible for their care. This can include physical abuse, sexual abuse or exploitation, psychological abuse, neglect or abandonment, and confinement.
Predisposing factors for child abuse and neglect are multifactorial, ranging from socioeconomic stressors to harmful cultural practices all contributing to the various degree of vulnerability among the world child population. Some of the identified risks are as follows:
The following factors predispose the elderly to abuse and neglect:
The prevalence of child abuse and neglect varies widely. Available estimates suggest that as much as a quarter of the world adult population may have experienced some form of abuse or neglect during childhood with a slightly higher incidence in female subjects.
These values may not truly represent the actual incidence due to under-reporting.
Children are also victims of war and violent crimes. The World Health Organization (WHO) in 2014 estimated about 41,000 cases of child homicide occur yearly.
Abuse of the elderly is equally common. In the United States of America, 1 in 10 people older than the age of 60 may have experienced some form of abuse, amounting to about 5 million cases per year.
Child Abuse and Neglect
Depending on the age of the child, historical information is often primarily obtained from the caregiver and the comments provided by the patient (especially in older children and adolescents). Children who suffer from abuse or neglect may present with typical presenting complaints (i.e. vomiting). Therefore, for the clinician who sees pediatric patients regularly, it is important to keep child abuse or neglect in the differential diagnosis during every visit to enhance the likelihood of recognition.
The approach to history taking should be structured, systematic, with the flexibility to allow different lines of questions, and thus similar to how a clinician obtains a routine history. This will not only ensure rapport with the patient and the caregiver, but it enhances the ability of the clinician to quickly investigate any historical and physical features that are concerning for child abuse or neglect.
There are various historical features that should raise the suspicion for abuse.
1. Lack of history of trauma in a pediatric patient with severe injuries
2. History describing the mechanism of injury inconsistent with the child's developmental level
3. Unexplained delay in seeking care before presenting to a medical provider
4. History describing injuries attributed to household pets or other young children
5. The initial history is vague or changes amongst different caregiver accounts
The physical examination should be routine, systematic, and focus on findings that may indicate an underlying etiology of the child's initial complaint, including the possibility of child abuse or neglect. This begins with the general appearance of the patient and how they interact with their caregiver. This may include but is not limited to lack of interaction between the patient and the caregiver (i.e. patient not seeking comfort or caregiver not offering comfort), not appreciating the severity of the patient's condition, assigning blame to the child for their injuries or illness, treating the patient differently than the other children in the room, and if the patient displays fear towards the caregiver present.
There are various presenting features that should raise the suspicion for abuse. These include:
1. Bruises in infants less than 6 months (infants not yet freely mobile), bruises situated away from bony prominences, and bruises with a unique shape (like the shape of an object) are highly suggestive of abuse
2. Human bite marks
3. Oral injuries (including frenulum tears, lip lacerations, tongue lacerations, fractures; especially in infants)
9. Intentional burns (scalds from hot tap water, burns that resemble the shape of burning objects, cigarette burns)
1. Nonspecific symptoms (abdominal pain, fecal incontinence, constipation)
2. Genital bruising and/or bleeding
4. Behavioral or personality changes
5. Inappropriate behavior especially of the sexual nature (for example, an unusual interest in genitals of other children or even adults)
Emotional abuse and neglect
1. Poor hygiene
2. Signs of malnutrition (child may refuse meals)
3. Child may appear withdrawn with inadequate social interaction
4. Developmental milestone delays (such as speech and motor delays)
Adult Abuse and Neglect
Depending on the patient's underlying health condition, historical information may be obtained from the caregiver and the comments provided by the patient. If possible, it is best to solicit the history from the patient and the caregiver separately.
The approach to history taking should be structured, systematic, with the flexibility to allow different lines of questions, and thus similar to how a clinician routinely obtains a history. This will not only ensure rapport with the patient and the caregiver, but it enhances the ability of the clinician to quickly investigate any historical and physical features that are concerning for elder abuse or neglect.
There are various historical features that should raise the suspicion for abuse. These include:
1. Mechanism of injury that is implausible based on the patient's condition
2. History is inconsistent, vague or different between the patient and caregiver
3. Delay in seeking medical attention
4. Past history of frequent injuries or unexplained visits to the emergency department
6. Caregiver answers questions for the patient
7. The patient is reluctant to answer questions
The physical examination should be routine, systematic, and focus on findings that may indicate an underlying etiology of the patient's reason for the visit. This begins with the general appearance of the patient and how they interact with their caregiver. The clinician should observe the patient for any signs of fear, anxiety, infantile behavior, poor self-esteem, and/or mistrust in the presence of the caregiver. Caregivers may be emotionally abusive.
There are various physical features that should raise the suspicion for abuse. These include:
1. Unexplained signs of injury: Bruises, burns, scald, fracture, signs of restraints on the hands and feet
2. Bedsores (pressure ulcers)
3. Poor hygiene
4. Signs and symptoms of dehydration, malnutrition, or unexplainable weight loss
5. Emotionally withdrawn and showing signs of depression
6. Refusal to take routine medications or drug overdose
7. Hair loss
8. Broken teeth
10. Evidence of trauma on a genitourinary exam or vaginal bleeding
When abuse or neglect is suspected in a patient of any age, the clinician should order testing as indicated by the history and physical examination. These may include:
3. Global skeletal surveys in children that images subtle metaphyseal, rib, and other injuries specific for abuse
4. 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 injuries
5. Ophthalmologic evaluation to rule out the presence of retinal hemorrhages
2. Toxicology Testing to rule out the presence of malicious administration of substances
4. Serum Lipase to rule out pancreatic injury
5. Hepatic Function Panel to rule out the presence of intraabdominal injury
9. Urine organic acids to rule out the presence of metabolic conditions such as glutaric acid type I
A high index of suspicion is required to make a diagnosis of non-accidental injury or abuse and neglect. While promptly attending to physical injuries, it is important to note that abuse and neglect have more lingering emotional or psychological sequelae that require management. The care of abused and neglected individuals and therefore requires a multidisciplinary approach. In managing child abuse and neglect, the following specialists must work together: general practitioners, emergency room doctors, pediatricians, psychiatrists, child psychologists, social workers, law enforcement officers, and members of the child protective services. Elder abuse and neglect require the services of general practitioners, emergency room doctors, geriatric specialists, psychiatrists, social workers, law enforcement officers, and members of adult protective services.
Management of abuse and neglect involves:
There are various conditions where the clinical manifestations may be mistaken for child abuse. The clinician must be familiar with these diseases as some may require prompt initiation of appropriate therapy for the actual underlying condition and to avoid unnecessary evaluation for child abuse.
This is summarized below by the clinical findings:
4. Intracranial Hemorrhage
For elder abuse and neglect the following conditions should be considered:
Elder abuse and neglect are associated with increased morbidity (particularly the development of depression, dementia, cognitive impairment, loss of functional capacity) and increased mortality. Child abuse and neglect are associated with lifelong medical, psychological, and social consequences as well as increased risk of future abuse.
Parents and caregivers of children and the elderly should be counseled on the common signs and symptoms indicative of child and elder abuse and neglect.
For the child, parents and caregivers should be counseled to observe for unexplained bruises or markings, oral injuries, change in behavior (i.e. withdrawn in a young child, excessive crying in an infant), genitourinary abnormalities, behavioral change, inappropriate behavior (especially of a sexual nature).
For the elderly, the caregiver or family member should observe for unexplained injuries (including bruises, burns, fractures), pressure sores, change in behavior, weight loss, lack of food, dehydration, urinary or fecal incontinence, genitourinary injury, and poor hygiene.
If a caregiver is having difficulty providing care, they should be advised to notify a physician or nurse. The physician or nurse can counsel the caregiver, especially if they are the primary caregiver of the child or elderly person, in how they can obtain support or help so that they are not overwhelmed.
Different countries have legislation and policies for abuse and neglect against children or the elderly. The healthcare provider is mandated by law to report non-accidental injuries and suspected cases of abuse and neglect. The failure to report abuse may qualify legally as a misdemeanor.
Child abuse and neglect is a major public health problem. Even though there is more awareness of this social problem among healthcare workers, the problem still exists. Every day, at least 700 children are removed from their homes because of abuse and neglect. For many, the scars of physical, sexual, and mental abuse linger throughout life. Countering child abuse and neglect is not only the responsibility of the physician but all healthcare workers. There are laws in every state which encourage all healthcare workers to report child abuse, without fear of any repercussions.
The diagnosis of child abuse is not simple and requires a high degree of suspicion on the part of healthcare workers who encounter the child and the family. Abused children not only present to the physician but may have encounters with nurses, pharmacists, therapists, lab technologists, and many other allied professionals and all these professionals have a legal and moral duty to report any suspicion of child abuse. Those who do not report child abuse can even incur legal penalties. When child abuse goes undetected, it carries enormous morbidity and mortality for the child. Abused children often have unhealthy development with emotional scars that remain for life.
Child advocacy centers recommend an interprofessional team approach for child abuse detection. In many circumstances, a child may remain silent in the presence of a clinician but may reveal the dark secrets of abuse to other professionals. Thus, nurses, pharmacists, and other allied healthcare professionals must be vigilant about child abuse. Many screening tools have been developed, which can help healthcare workers make the diagnosis of child neglect or abuse. When a nurse or other health professional determines abuse is a concern, they should report to the clinical team leader their findings. Only through teamwork will better outcomes be achieved.
Despite better awareness of the problem of child abuse, healthcare workers still miss many cases of abuse and neglect. The key reason is that some healthcare workers falsely believe that it is physicians who are solely responsible for intervention, which is erroneous thinking. All healthcare workers should report any suspicious case of child abuse and can verify with other members of the healthcare team to corroborate their findings. If done in good faith, the law will always protect them. This discernment and interaction/communication is a key component of a properly functioning interprofessional team and can be lifesaving as much as any other therapeutic activity.[Level V]
Elder abuse and neglect is also a major public health concern. Clinicians must have a high index of suspicion and distinguish the clinical features of aging from elder abuse and neglect. In patients with risk factors, this may require the creation and use of screening questions (by all professionals), prompting further evaluation, and referral to the appropriate adult protective agency.[Level V]
Multidisciplinary medical response teams dedicated to elder abuse and neglect may be utilized to help evaluate suspected patients of abuse or neglect and confirming the presence of abuse. [Level 5]
|||Merrick MT,Guinn AS, Child Abuse and Neglect: Breaking the Intergenerational Link. American journal of public health. 2018 Sep [PubMed PMID: 30088995]|
|||Mullen S,Quinn-Scoggins HD,Nuttall D,Kemp AM, Qualitative analysis of clinician experience in utilising the BuRN Tool (Burns Risk assessment for Neglect or abuse Tool) in clinical practice. Burns : journal of the International Society for Burn Injuries. 2018 Jul 31 [PubMed PMID: 30075971]|
|||Norman RE,Byambaa M,De R,Butchart A,Scott J,Vos T, The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS medicine. 2012 [PubMed PMID: 23209385]|
|||Lachs MS,Pillemer K, Elder abuse. Lancet (London, England). 2004 Oct 2-8 [PubMed PMID: 15464188]|
|||Carey C,Hodges J,Webb JK, Changes in state legislation and the impacts on elder financial fraud and exploitation. Journal of elder abuse [PubMed PMID: 30024309]|
|||Christoffersen MN,Armour C,Lasgaard M,Andersen TE,Elklit A, The prevalence of four types of childhood maltreatment in denmark. Clinical practice and epidemiology in mental health : CP & EMH. 2013 [PubMed PMID: 24155769]|
|||Sattler KMP,Font SA,Gershoff ET, Age-specific risk factors associated with placement instability among foster children. Child abuse [PubMed PMID: 30099229]|
|||Chandraratne NK,Fernando AD,Gunawardena N, Cultural adaptation, translation and validation of the ISPCAN Child Abuse Screening Tool - Retrospective Version (ICAST-R) for young adults in Sri Lanka. Child abuse [PubMed PMID: 30036689]|
|||Devries K,Knight L,Petzold M,Merrill KG,Maxwell L,Williams A,Cappa C,Chan KL,Garcia-Moreno C,Hollis N,Kress H,Peterman A,Walsh SD,Kishor S,Guedes A,Bott S,Butron Riveros BC,Watts C,Abrahams N, Who perpetrates violence against children? A systematic analysis of age-specific and sex-specific data. BMJ paediatrics open. 2018 [PubMed PMID: 29637183]|
|||Tarantola D, Child Maltreatment: Daunting and Universally Prevalent. American journal of public health. 2018 Sep; [PubMed PMID: 30088997]|
|||Devakumar D,Osrin D, Child Homicide: A Global Public Health Concern. PLoS medicine. 2016 Apr; [PubMed PMID: 27115911]|
|||Rosen T,Stern ME,Mulcare MR,Elman A,McCarthy TJ,LoFaso VM,Bloemen EM,Clark S,Sharma R,Breckman R,Lachs MS, Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team. Emergency medicine journal : EMJ. 2018 Aug 9 [PubMed PMID: 30093378]|
|||Kellogg ND, Evaluation of suspected child physical abuse. Pediatrics. 2007 Jun [PubMed PMID: 17545397]|
|||Christian CW, The evaluation of suspected child physical abuse. Pediatrics. 2015 May; [PubMed PMID: 25917988]|
|||Feldman KW,Bethel R,Shugerman RP,Grossman DC,Grady MS,Ellenbogen RG, The cause of infant and toddler subdural hemorrhage: a prospective study. Pediatrics. 2001 Sep; [PubMed PMID: 11533330]|
|||Sittig JS,Post ED,Russel IM,van Dijk IA,Nieuwenhuis EE,van de Putte EM, Evaluation of suspected child abuse at the ED; implementation of American Academy of Pediatrics guidelines in the Netherlands. The American journal of emergency medicine. 2014 Jan [PubMed PMID: 24099714]|
|||Leetch AN,Woolridge D, Emergency department evaluation of child abuse. Emergency medicine clinics of North America. 2013 Aug [PubMed PMID: 23915607]|
|||Sink EL,Hyman JE,Matheny T,Georgopoulos G,Kleinman P, Child abuse: the role of the orthopaedic surgeon in nonaccidental trauma. Clinical orthopaedics and related research. 2011 Mar [PubMed PMID: 20941649]|
|||Vrolijk-Bosschaart TF,Brilleslijper-Kater SN,Widdershoven GA,Teeuw ARH,Verlinden E,Voskes Y,van Duin EM,Verhoeff AP,Benninga MA,Lindauer RJL, Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study. European journal of pediatrics. 2017 Oct [PubMed PMID: 28844100]|
|||Essabar L,Khalqallah A,Dakhama BS, Child sexual abuse: report of 311 cases with review of literature. The Pan African medical journal. 2015 [PubMed PMID: 26090005]|
|||Wolfe DA, Child-abusive parents: an empirical review and analysis. Psychological bulletin. 1985 May [PubMed PMID: 3889964]|
|||Kairys SW,Johnson CF, The psychological maltreatment of children--technical report. Pediatrics. 2002 Apr [PubMed PMID: 11927741]|
|||Karatekin C,Almy B,Mason SM,Borowsky I,Barnes A, Mental and Physical Health Profiles of Maltreated Youth. Child abuse [PubMed PMID: 30036690]|
|||Christian CW,Levin AV, The Eye Examination in the Evaluation of Child Abuse. Pediatrics. 2018 Aug [PubMed PMID: 30037976]|
|||Nagarajan SK, Craniofacial and oral manifestation of child abuse: A dental surgeon's guide. Journal of forensic dental sciences. 2018 Jan-Apr [PubMed PMID: 30122862]|
|||Vrolijk-Bosschaart TF,Brilleslijper-Kater SN,Benninga MA,Lindauer RJL,Teeuw AH, Clinical practice: recognizing child sexual abuse-what makes it so difficult? European journal of pediatrics. 2018 Sep [PubMed PMID: 29938356]|
|||Al Odhayani A,Watson WJ,Watson L, Behavioural consequences of child abuse. Canadian family physician Medecin de famille canadien. 2013 Aug [PubMed PMID: 23946022]|
|||Menke A,Lehrieder D,Fietz J,Leistner C,Wurst C,Stonawski S,Reitz J,Lechner K,Busch Y,Weber H,Deckert J,Domschke K, Childhood trauma dependent anxious depression sensitizes HPA axis function. Psychoneuroendocrinology. 2018 Jul 26 [PubMed PMID: 30086534]|
|||Lachs MS,Pillemer K, Abuse and neglect of elderly persons. The New England journal of medicine. 1995 Feb 16 [PubMed PMID: 7632211]|
|||Hullick C,Carpenter CR,Critchlow R,Burkett E,Arendts G,Nagaraj G,Rosen T, Abuse of the older person: Is this the case you missed last shift? Emergency medicine Australasia : EMA. 2017 Apr [PubMed PMID: 28273679]|
|||Yaffe MJ,Tazkarji B, Understanding elder abuse in family practice. Canadian family physician Medecin de famille canadien. 2012 Dec [PubMed PMID: 23242889]|
|||DeLiema M,Homeier DC,Anglin D,Li D,Wilber KH, The Forensic Lens: Bringing Elder Neglect Into Focus in the Emergency Department. Annals of emergency medicine. 2016 Sep [PubMed PMID: 27005449]|
|||Sanford AM,Gammack JK, Elder abuse: golden years' lost luster. Missouri medicine. 2013 Nov-Dec [PubMed PMID: 24564004]|
|||Wang XM,Brisbin S,Loo T,Straus S, Elder abuse: an approach to identification, assessment and intervention. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2015 May 19 [PubMed PMID: 25852037]|
|||Papaioannou ES,Räihä I,Kivelä SL, Self-neglect of the elderly. An overview. The European journal of general practice. 2012 Sep [PubMed PMID: 22640528]|
|||Rosen T,Bloemen EM,LoFaso VM,Clark S,Flomenbaum NE,Lachs MS, Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse. The Journal of emergency medicine. 2016 Mar [PubMed PMID: 26810019]|
|||Diagnostic imaging of child abuse. Pediatrics. 2009 May; [PubMed PMID: 19403511]|
|||Campbell KA,Olson LM,Keenan HT, Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015 Jul [PubMed PMID: 26101359]|
|||Rosen T,Mehta-Naik N,Elman A,Mulcare MR,Stern ME,Clark S,Sharma R,LoFaso VM,Breckman R,Lachs M,Needell N, Improving Quality of Care in Hospitals for Victims of Elder Mistreatment: Development of the Vulnerable Elder Protection Team. Joint Commission journal on quality and patient safety. 2018 Mar [PubMed PMID: 29499813]|
|||Howell S,Bailey L,Coffman J, Evaluation of drug-endangered children: The yield of toxicology and skeletal survey screening. Child abuse & neglect. 2019 Oct [PubMed PMID: 31344584]|
|||Rosen T,Stern ME,Elman A,Mulcare MR, Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department. Clinics in geriatric medicine. 2018 Aug [PubMed PMID: 30031426]|
|||Schwengel D,Ludwig S, Rhabdomyolysis and myoglobinuria as manifestations of child abuse. Pediatric emergency care. 1985 Dec [PubMed PMID: 3842165]|
|||Ringel JS,Schultz D,Mendelsohn J,Holliday SB,Sieck K,Edochie I,Davis L, Improving Child Welfare Outcomes: Balancing Investments in Prevention and Treatment. Rand health quarterly. 2018 Mar [PubMed PMID: 30083416]|
|||Anderst JD,Carpenter SL,Abshire TC, Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013 Apr [PubMed PMID: 23530182]|
|||O'Hare AE,Eden OB, Bleeding disorders and non-accidental injury. Archives of disease in childhood. 1984 Sep [PubMed PMID: 6486863]|
|||Lawee D, Atypical clinical course of Henoch-Schonlein purpura. Canadian family physician Medecin de famille canadien. 2008 Aug [PubMed PMID: 18697972]|
|||Oranje A,Bilo RA, Skin signs in child abuse and differential diagnosis. Minerva pediatrica. 2011 Aug [PubMed PMID: 21909067]|
|||Greig AV,Harris DL, A study of perceptions of facial hemangiomas in professionals involved in child abuse surveillance. Pediatric dermatology. 2003 Jan-Feb [PubMed PMID: 12558837]|
|||Vaibhav A,Smith R,Millman G,Cooper J,Dwyer J, Subaponeurotic or subgaleal fluid collections in infancy: an unusual but distinct cause of scalp swelling in infancy. BMJ case reports. 2010 Nov 2 [PubMed PMID: 22791778]|
|||Adler R,Kane-Nussen B, Erythema multiforme: confusion with child battering syndrome. Pediatrics. 1983 Nov [PubMed PMID: 6634277]|
|||Davis RE, Cultural health care or child abuse? The Southeast Asian practice of cao gio. Journal of the American Academy of Nurse Practitioners. 2000 Mar [PubMed PMID: 11033688]|
|||Pandya NK,Baldwin K,Kamath AF,Wenger DR,Hosalkar HS, Unexplained fractures: child abuse or bone disease? A systematic review. Clinical orthopaedics and related research. 2011 Mar [PubMed PMID: 20878560]|
|||Holick MF,Hossein-Nezhad A,Tabatabaei F, Multiple fractures in infants who have Ehlers-Danlos/hypermobility syndrome and or vitamin D deficiency: A case series of 72 infants whose parents were accused of child abuse and neglect. Dermato-endocrinology. 2017 [PubMed PMID: 29511428]|
|||Feldman KW,Brewer DK, Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics. 1984 Mar [PubMed PMID: 6701057]|
|||Lang C,Cox M, Pediatric cutaneous bleach burns. Child abuse & neglect. 2013 Jul [PubMed PMID: 23545350]|
|||Oates RK, Overturning the diagnosis of child abuse. Archives of disease in childhood. 1984 Jul [PubMed PMID: 6465937]|
|||Schwartz KA,Metz J,Feldman K,Sidbury R,Lindberg DM, Cutaneous Findings Mistaken for Physical Abuse: Present but Not Pervasive. Pediatric dermatology. 2014 Feb 26 [PubMed PMID: 24612322]|
|||Asati DP,Singh S,Sharma VK,Tiwari S, Dermatoses misdiagnosed as deliberate injuries. Medicine, science, and the law. 2012 Oct [PubMed PMID: 22623714]|
|||Isaac CV,Cornelison JB,Castellani RJ,deJong JL, A Unique Type of Birth Trauma Mistaken for Abuse. Journal of forensic sciences. 2018 Mar [PubMed PMID: 28605024]|
|||Vester ME,Bilo RA,Karst WA,Daams JG,Duijst WL,van Rijn RR, Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review. Forensic science, medicine, and pathology. 2015 Sep [PubMed PMID: 26219480]|
|||Addy DP,Hudson FP, Diencephalic syndrome of infantile emaciation. Analysis of literature and report of further 3 cases. Archives of disease in childhood. 1972 Jun [PubMed PMID: 5034666]|
|||Reddy AR,Clarke M,Long VW, Unilateral retinal hemorrhages with subarachnoid hemorrhage in a 5-week-old infant: is this nonaccidental injury? European journal of ophthalmology. 2010 Jul-Aug [PubMed PMID: 20099243]|
|||Wysokiński A,Sobów T,Kłoszewska I,Kostka T, Mechanisms of the anorexia of aging-a review. Age (Dordrecht, Netherlands). 2015 Aug [PubMed PMID: 26232135]|
|||Chen AL,Koval KJ, Elder abuse: the role of the orthopaedic surgeon in diagnosis and management. The Journal of the American Academy of Orthopaedic Surgeons. 2002 Jan-Feb [PubMed PMID: 11809048]|
|||Dyer CB,Pavlik VN,Murphy KP,Hyman DJ, The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society. 2000 Feb [PubMed PMID: 10682951]|
|||Ellaway BA,Payne EH,Rolfe K,Dunstan FD,Kemp AM,Butler I,Sibert JR, Are abused babies protected from further abuse? Archives of disease in childhood. 2004 Sep [PubMed PMID: 15321863]|
|||Adelman RD,Tmanova LL,Delgado D,Dion S,Lachs MS, Caregiver burden: a clinical review. JAMA. 2014 Mar 12 [PubMed PMID: 24618967]|
|||Ventura F,Caputo F,Molinelli A, Medico-legal aspects of deaths related to neglect and abandonment in the elderly. Aging clinical and experimental research. 2018 Feb 14 [PubMed PMID: 29442235]|
|||Krugman RD,Bross DC, Medicolegal aspects of child abuse and neglect. Neurosurgery clinics of North America. 2002 Apr [PubMed PMID: 12391708]|
|||Ridout KK,Khan M,Ridout SJ, Adverse Childhood Experiences Run Deep: Toxic Early Life Stress, Telomeres, and Mitochondrial DNA Copy Number, the Biological Markers of Cumulative Stress. BioEssays : news and reviews in molecular, cellular and developmental biology. 2018 Aug 1 [PubMed PMID: 30067291]|
|||Carr A,Duff H,Craddock F, A Systematic Review of Reviews of the Outcome of Severe Neglect in Underresourced Childcare Institutions. Trauma, violence [PubMed PMID: 29779452]|
|||Teeuw AH,Kraan RBJ,van Rijn RR,Bossuyt PMM,Heymans HSA, Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases. Acta paediatrica (Oslo, Norway : 1992). 2018 Jul 10 [PubMed PMID: 29992712]|
|||Sampson M,Read J, Are mental health staff getting better at asking about abuse and neglect? International journal of mental health nursing. 2017 Feb [PubMed PMID: 27600259]|
|||Darlington Y,Feeney JA,Rixon K, Interagency collaboration between child protection and mental health services: practices, attitudes and barriers. Child abuse [PubMed PMID: 16315352]|
|||Gallione C,Dal Molin A,Cristina FVB,Ferns H,Mattioli M,Suardi B, Screening tools for identification of elder abuse: a systematic review. Journal of clinical nursing. 2017 Aug [PubMed PMID: 28042891]|
|||Brijnath B,Gahan L,Gaffy E,Dow B, "Build Rapport, Otherwise No Screening Tools in the World Are Going to Help": Frontline Service Providers' Views on Current Screening Tools for Elder Abuse. The Gerontologist. 2020 Apr 2 [PubMed PMID: 30576536]|
|||Mosqueda L,Burnight K,Liao S,Kemp B, Advancing the field of elder mistreatment: a new model for integration of social and medical services. The Gerontologist. 2004 Oct [PubMed PMID: 15498847]|
|||Dyer CB,Halphen JM,Lee J,Flores RJ,Booker JG,Reilley B,Burnett J, Stemming the Tide of Elder Mistreatment: A Medical School-State Agency Collaborative. Academic medicine : journal of the Association of American Medical Colleges. 2020 Apr [PubMed PMID: 31599756]|