Continuing Education Activity

Domestic violence in Florida is legally defined as "Any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any other criminal offenses resulting in physical injury or death of a family or household member by another family or household member." A Florida State Task Force was established to enhance education and increase public awareness regarding domestic violence. This task force implemented several changes to improve the detection and prevention of domestic violence. Florida has legislation requiring all physicians, nurses, dentists, dental hygienists, midwives, psychologists, and psychotherapists to obtain 2 hours of domestic violence education every third renewal period. The Domestic Violence Data Resource Center (DVDRC) and Domestic Violence Fatality Review teams examine cases of domestic violence that result in fatalities and identify potential policy changes that might prevent future deaths.

Domestic and family violence, including intimate partner violence, child abuse, and elder abuse, is a widespread issue in the United States, affecting an estimated 10 million people annually. These forms of violence involve children, adults, and older populations and encompass economic, physical, sexual, emotional, and psychological abuse. This activity outlines evaluation and management strategies for survivors of domestic violence in Florida and the role of healthcare providers in screening and treating individuals who have experienced abuse, with protocols established to identify signs of abuse across various medical settings. This activity also allows interdisciplinary healthcare providers to apply evidence-based guidelines in adherence to state policies and laws for survivors of domestic violence.

Objectives:

• Identify signs and symptoms of domestic violence across various patient demographics, including intimate partner violence and child and elder abuse.

• Implement Florida state protocols for documenting and reporting suspected domestic violence and child and elder abuse cases in compliance with legal requirements.

• Select appropriate referral resources, such as shelters, counseling services, and legal assistance, for survivors of domestic violence.

• Collaborate with interdisciplinary healthcare teams, including social workers, psychologists, and law enforcement, to provide comprehensive care and ongoing support for domestic violence survivors.

Introduction

Family and domestic violence, including child abuse, intimate partner abuse, and elder abuse, are prevalent problems in the United States, especially in Florida. Family and domestic violence are estimated to affect 10 million people in the United States annually. As a national public health problem, virtually all healthcare professionals will, at some point, evaluate or treat a patient who has experienced some form of domestic or family violence.[1][2][3] Unfortunately, most forms of family dysfunction lead to interconnected forms of violence, and the cycle of abuse often continues from childhood in the affected children through adult relationships and finally to the care of older individuals.[4] Domestic and family dysfunction include a range of behaviors, including economic, physical, sexual, emotional, and psychological abuse, affecting children, adults, and older individuals alike.[5][6]

Intimate partner violence can include stalking, sexual and/or physical violence, and psychological aggression by current or former partners. In the United States, as many as 1 in 4 women and 1 in 9 men are affected by domestic violence. Domestic violence is thought to be underreported, impacting the affected person and their families, coworkers, and community. The violence causes diminished psychological and physical health, decreased quality of life, and reduced productivity. The national economic cost of domestic and family violence is estimated to exceed $12 billion per year. The number of individuals affected is expected to rise over the next 20 years with an increase in the abuse of older adults.[7][8][9][10]

Domestic and family violence is difficult to identify, and many cases go unreported to healthcare professionals and legal authorities. Due to its prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physicians, physician assistants, and nurse practitioners, will, at some point, evaluate and treat an affected person or perpetrator of domestic or family violence.

Questions for Healthcare Professionals to Consider

1. What are the risk factors, signs, and symptoms of domestic or family violence?
2. What are the characteristics that define domestic or family violence?
3. What information helps healthcare professionals address the needs of those affected by domestic or family violence?
4. What are the ethical and legal reporting requirements?

Recognition, Evaluation, and Referral

• Healthcare professionals should be able to identify potential abusers.
• Healthcare professionals should be able to assess all patients for abuse and offer counseling, education, and referral.
• Survivors of domestic and family violence may suffer emotional, physical, and psychological abuse and need empathy and understanding.
• Healthcare professionals must be able to identify the signs and symptoms of a mental and physical disease, illness, and injury related to domestic and family violence and provide initial counseling.
• Injuries often require immediate evaluation and treatment after an assault. As a result, clinicians are usually the first to evaluate and identify persons affected by violence.
• All healthcare professionals need to be aware of the presence of affected persons in their clinical settings.
• Upon identifying domestic or family violence, healthcare professionals should have a plan that includes providing community resource information related to shelter, counseling, advocacy groups, child protection, and legal aid.

General Definitions

Family and domestic violence is the perpetration of abusive behaviors when an individual or individuals gain power over another individual or individuals.

• Intimate partner violence typically includes sexual or physical violence, psychological aggression, and/or stalking. This may consist of the exposure to violence of former or current intimate partners.
• Child abuse involves the emotional, sexual, or physical abuse or neglect of a child aged 18 or younger by a parent, custodian, or caregiver, resulting in potential harm, actual harm, or threat of harm.
• Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an older individual.

National Definitions

Centers for Disease Control and Prevention: Domestic violence, spousal abuse, battering, and intimate partner violence are terms used to describe the exposure to violence of individuals with whom an abuser has an intimate or romantic relationship. The Centers for Disease Control and Prevention (CDC) defines domestic violence as "physical violence, sexual violence, stalking, and psychological aggression, including coercive acts, by a current or former intimate partner." Violence occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether emotional, psychological, sexual, or physical, is common in our society, and members of the multidisciplinary team should recognize and make the appropriate referrals.

Florida Definitions

Department of Children and Families: Domestic violence is defined by the Florida Department of Children and Families as "a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and control. This may include physical, sexual, emotional, and economic abuse. In addition, it may also include threats, isolation, pet abuse, using children to manipulate the situation, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner."

Statutes

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 a family or household member by another family or household member." Family members must "reside in the same single dwelling unit, except for persons who have a child in common."

Abuse Types

Violent abuse takes many forms, including stalking and economic, emotional, sexual, physical, or psychological abuse, as well as neglect and Munchausen syndrome by proxy. Domestic and family violence occurs in all races, ages, and sexes without cultural, socioeconomic, educational, religious, or geographic limitations. This violence can affect individuals of different sexual orientations.

Stalking: Stalking is repeated, unwanted attention that causes fear or concern for safety. Behaviors include unwanted letters, emails, texts, or phone calls; watching, following, or spying; repeatedly showing up in the same place; damaging property; and making threats of harm.

Economic abuse: Economic or financial abuse occurs when an individual is forced to depend on an abuser through improper use of money by a person in a trusting relationship. The abuser may forbid employment or education to gain additional financial control. Examples include coercion to surrender, forgery, theft of possessions, and improper use of guardianship or power of attorney.

Emotional or psychological abuse: Emotional or psychological abuse includes verbal and nonverbal communication that inflicts emotional or mental harm. This type of domestic violence may be subtle but is still harmful to the survivor, often resulting in depression and suicidal thoughts. Emotional or psychological abuse may involve convincing the survivor that the violence is their fault, that no solution exists, and that they are worthless and need the abuser to exist. Many abusers will isolate their targets from friends, family, school, and work.

Examples of emotional or psychological abuse include:

• Child relationship control: Damaging a relationship with a child deliberately.
• Coercive: Limiting resource access, possessiveness, and constant monitoring.
• Exploitation: Using consequences to control choices, for example, "If you call protective services, I could go to jail, and you will have no financial support."
• Expressive: Name-calling, degradation, and threats.
• Gaslighting: Presenting false information, making the survivor doubt their memory and perception, and making the survivor question their sanity.
• Reproductive control: Refusing birth control or forced pregnancy terminations.
• Threats: Using gestures, words, or weapons to suggest that future harm may occur.

Sexual abuse: Sexual violence involves using physical coercion to force participation in unwanted sex acts. Perpetrators may incapacitate targets with alcohol or drugs. 

Categories of sexual abuse may include:

• Forced anal, oral, or vaginal penetration of a target.
• Forced penetration of someone else.
• Sexual coercion involving intimidation to pressure consent.
• Unwanted exposure to pornography, harassment, sexual violence, filming, taking, or disseminating sexual photographs or videos.
• Unwanted sexual contact.

Neglect: Neglect occurs when an individual responsible for the well-being of a child or an older individual ignores that well-being. Neglect is the failure to provide for a dependent's emotional, physical, or social needs, including hygiene, nutrition, clothing, shelter, and access to health care. Abandonment is also a form of neglect.

Munchausen syndrome by proxy: Munchausen syndrome by proxy is a factitious disorder where an individual fabricates or exaggerates mental or physical health problems in the person for whom they care. The primary motive is to gain attention or sympathy. Unlike Munchausen syndrome, the deception involves someone, not themselves, under the person's care.

Physical abuse: The use of physical power that results in injury, disability, or death is a form of physical violence. Other forms of physical violence include coercion, administering drugs or alcohol without permission, and denying medical care.

Examples of physical abuse include:

• Assault
• Biting
• Burning
• Choking
• Gagging
• Grabbing
• Kicking
• Punching
• Hair pulling 
• Restraining
• Scratching
• Shaking
• Shoving
• Slapping

The Cycle of Abuse and Violence

Usually, abuse begins with verbal threats that escalate to physical violence. Violent events are often unpredictable, and the triggers for the targets are unclear. Affected individuals live in constant fear of the next violent attack. Violence and abuse are perpetrated in an endless cycle involving 3 phases—tension-building, explosive, and honeymoon.

Tension-building phase: In this phase, the abuser becomes more judgmental, temperamental, and upset, causing the target to feel like they are "walking on eggshells." Eventually, the tension escalates until the abuser explodes. During this phase, the target may attempt to calm the situation, stay away, or reason with the abuser to no avail. The abuser exhibits moodiness and unpredictability, resorting to screaming, threats, and intimidation. They may also use children as tools for intimidation and engage in alcohol and drug use.

Explosive phase: During this phase, the target may attempt to protect themselves and their family by contacting authorities. This phase often results in injuries to the affected person. The abuser may begin by breaking items and escalate to striking, choking, and rape. The affected person could be subjected to imprisonment. Emotional, verbal, physical, financial, and sexual abuse are common.

Honeymoon phase: In this phase, the affected person may initiate counseling, seek medical attention, and agree to halt legal proceedings. They may mistakenly believe and hope that the situation will not recur. However, this hope is often unfounded. The abuser may apologize, agree to counseling, beg for forgiveness, and give presents. They may declare their love for the target and family and promise to "never do it again." [11][12][13][14]

Etiology

Domestic and family violence, including child, intimate partner, or elder abuse, frequently starts when a partner, parent, or caretaker feels the need to dominate or control. Abuse begins with emotional or verbal threats and may escalate to physical violence. Affected people live in a constant state of fear. The perpetrator may be explosively violent. After the violent event, the perpetrator may apologize. This cycle of violence usually repeats.

Reasons for Abusers' Need for Control

• Anger management issues
• Jealousy
• Low self-esteem
• Feeling inferior due to less education
• Feeling inferior due to poor socioeconomic background
• Cultural beliefs that justify controlling their partner
• Personality or psychological disorder
• Learned behavior from growing up in a family where domestic violence was accepted
• Alcohol and drugs, which can impair individuals and make them less likely to control violent impulses

Risk Factors for Domestic and Family Violence

Risk factors for domestic and family violence include individual, relationship, community, and societal issues. A recognized, inverse relationship exists between education levels and the occurrence of domestic violence—lower education levels correlate with higher likelihoods of domestic violence. Childhood abuse is commonly associated with becoming a perpetrator of domestic violence as an adult. Perpetrators of domestic violence commonly repeat acts of violence with new partners. Substance use, such as drugs and alcohol, increases the incidence of domestic violence.[15]

Children who survive or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. Men who learn that women are not equally respected are more likely to abuse women in adulthood. Women who witness domestic violence as children are more likely to experience trauma or violence from their spouses later in life. While women are usually the targets of domestic violence, gender roles can sometimes be reversed.

Common risk factors include:

• Aggressive behavior as a youth
• Antisocial personality disorder
• Individuals with disabilities
• Corporal punishment within the household
• Pregnancy
• Economic stress
• Disparities in educational or occupational levels between partners, particularly when women have higher academic or occupational attainment than their spouses
• Low self-esteem
• Family history of violence
• Limited education
• Inadequate parenting
• History of psychiatric issues
• Marital discord
• Infidelity
• Multiple children
• Poor legal sanctions or enforcement of laws
• History of childhood abuse
• Unemployment
• Substance use disorder, including the use of alcohol and drugs, which is strongly associated with a high probability of violence. Alcohol use particularly predicts acute injury, with approximately half of domestic violence incidents involving an intoxicated partner at the time of the assault.
• Intimate partner violence linked to new cases of HIV.

Domination may include emotional, physical, or sexual abuse due to several risk factors. Understanding these etiologies assists in understanding the behavior of the abuser. The abuser should be separated from the potential target and undergo treatment for their destructive behavior to prevent a major incident that could negatively impact the lives of all involved individuals.[16][17][18][19]

Epidemiology

According to the Florida Department of Children and Families website, in 2020, there were 106,515 reported crimes of domestic violence to Florida law enforcement agencies, leading to 63,217 arrests. During fiscal year 2020 to 2021, Florida's certified domestic violence centers provided 412,360 nights of emergency shelter to 10,287 survivors of domestic violence and their children. Advocates developed 150,799 individualized safety plans, offered a total of 191,451 hours of advocacy and counseling services, and responded to 72,321 domestic violence hotline calls from individuals seeking emergency assistance. Many survivors of domestic violence do not report their abusers to the police or access services due to reasons such as shame, fear, or being prevented from doing so by their abusers. Therefore, statistical figures may not accurately reflect the actual incidence of abuse.

Domestic violence is a serious and challenging public health problem—approximately 1 in 3 women and 1 in 10 men aged 18 or older experience domestic violence. Annually, domestic violence is responsible for over 1500 deaths in the United States and up to 200 deaths in Florida alone. In Florida, more than 1 in 3 women and 1 in 4 men endure physical violence, stalking, or rape. Domestic violence survivors often sustain severe physical injuries requiring medical treatment at hospitals or clinics. The cost to individuals and society is significant. The national annual expenditure on medical and mental health services related to acute domestic violence exceeds $8 billion, with even higher costs for long-term or chronic conditions.

Financial hardship and unemployment contribute significantly to domestic violence, with economic downturns correlating with increased calls to the National Domestic Violence Hotline. Fortunately, the national rate of nonfatal domestic violence is decreasing, attributed to factors such as declining marriage rates, reduced domesticity, improved access to domestic violence shelters, better economic conditions, and an aging population.[17][13][20]

National Trends

• Most perpetrators and survivors do not seek help.
• Healthcare professionals often have the first opportunity to identify domestic violence.
• Nurses are usually the first clinicians that survivors encounter.
• Domestic violence may be perpetrated on women, men, parents, and children.
• Around 50% of women visiting emergency departments report a history of abuse, and about 40% of those killed by their abuser sought help in the 2 years before their death.
• Only one-third of survivors identified by police for domestic violence are identified in the emergency department.
• Healthcare professionals in acute care settings need to maintain a high index of suspicion for domestic violence, as supportive family members may be abusers.

State Statutes in Florida

In Florida, a state task force has recommended standards for accurately measuring the extent of domestic violence and developing strategies to enhance education and increase public awareness.

The results include:

• Legislation requires all physicians, nurses, dentists, dental hygienists, midwives, psychologists, and psychotherapists to obtain 2 hours of domestic violence education every third renewal period.
• The Domestic Violence Data Resource Center (DVDRC) and National Domestic Violence Fatality Review teams have been established to examine cases of domestic violence resulting in domestic violence fatalities and identify potential policy changes to prevent future deaths.
• The "Family Protection Act" requires a 5-day jail term for any domestic battery crime where the perpetrator deliberately injures the target. The law considers a second battery offense to be a felony.
• A dating relationship of 6 months or longer is covered by the statute.
• A statute mandates that judges inform survivors of their rights, including the right to appear, receive notification, seek restitution, and make a statement.
• The Domestic Violence Leave Act requires employers with 50 or more employees to provide guaranteed leave for domestic violence issues.

In Florida, domestic violence offenses result in approximately 200 deaths each year, accounting for approximately 20% of murders annually. Perpetrators are typically men, while survivors are predominantly women. One-third of domestic violence perpetrators in Florida have a known "do not contact" order filed against them, one-fifth had a permanent injunction for protection filed by someone other than the survivor, one-third were diagnosed with mental health disorders, and one-half have a history of substance use disorders.[21][22][23]

Epidemiology of Child Abuse 

Age, family income, and ethnicity are all risk factors for both sexual and physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse. Each year, over 3,000,000 referrals to child protective authorities are made. Despite healthcare professionals often being the first to examine survivors, only about 10% of the referrals come from medical personnel. The fatality rate is approximately 2 deaths per 100,000 children, with women accounting for over half of the perpetrators.

Race: Maltreatment of children is found in every race, culture, ethnicity, and socioeconomic status.

Gender: Both men and women are affected equally by domestic violence, but homicide rates are slightly higher among men.

Morbidity and mortality: Children exposed to abuse may endure pain, humiliation, fear, and loss of self-esteem, leading to various injuries. Physical injury may range from minor trauma to severe conditions such as disfigurement, brain trauma, and even death. Long-term consequences include heightened anxiety, depression, substance use disorders, self-mutilation, suicidal tendencies, criminal behavior, and increased risks of cancer, cardiovascular disease, diabetes, premature mortality, obesity, and chronic mental health issues. Mortality rates increase with repeated episodes of trauma. Homicide is a leading cause of death in children aged 1 to 4, with over 80% of fatalities from child abuse occurring in children aged 4 or younger.

Epidemiology of Intimate Partner Violence 

According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men will experience some form of sexual violence in their lifetimes. Each year, intimate partner violence, sexual violence, and stalking affect over 10,000,000 people. Additionally, 1 in 6 women and 1 in 19 men have experienced stalking, with the majority being stalked by someone they know. An intimate partner is responsible for stalking about 6 in 10 female and 4 in 10 male targets.

At least 5,000,000 acts of domestic violence against women aged 18 and older occur annually; over 3,000,000 of these acts involve men. While most events are minor (including grabbing, shoving, pushing, slapping, and hitting), serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner rapes and physical assaults are perpetrated against women annually, and approximately 800,000 assaults occur against men. About 1 in 5 women have experienced completed or attempted rape at some point in their lives, compared to about 1% to 2% of men. The incidence of intimate partner violence has declined by over 60%, from about 10 instances of exposure to violence per 1000 persons aged 12 or older to approximately 4 per 1000.[1][3][24]

Race: African American, American Indian, Alaskan Native women and men, and Hispanic women report higher rates of domestic violence. Asian and Pacific Islander women and men report lower rates of intimate partner violence. However, group differences diminish when sociodemographic and relationship variables are controlled. The spousal homicide rate among African Americans is significantly higher than for white people. Additionally, the incidence of homicide between partners is higher in interracial marriages compared with intraracial marriages.

Gender: 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 6 times more likely than men to experience violence committed by a spouse or ex-spouse, boyfriend or girlfriend, or ex-boyfriend or ex-girlfriend. Approximately one-third of all violence against women committed by a single offender is perpetrated by an intimate partner.

Lesbians report higher levels of sexual violence, ranging from 30% to 40%. Homosexual men may also experience higher levels of sexual violence. Approximately 10% of women who live with intimate female partners report rape, physical assault, or stalking by their cohabitant. One-third of women living with a male partner report exposure to violence by their male cohabitant. Approximately 15% of men living with a male intimate partner report rape, physical assault, or stalking by their cohabitant. In comparison, less than 10% of men who have lived with a female partner experience similar problems. More than half of all homeless women and families report that they are fleeing domestic violence.

Age: Women aged 16 to 24 are more likely to be survivors of violence at the hands of an intimate partner. Approximately 20% to 30% of women who attend college report violence during a date. Rates of spousal homicide peak in women aged 15 to 24 and decline with age in African Americans but not in whites. As the age difference between men and women increases, so does the risk of spousal homicide.

Mortality and morbidity: Approximately 2,000,000 million injuries and deaths occur each year as a result of domestic violence. About one-third of patients experiencing domestic violence seek care in an emergency department. Each year, approximately 400,000 people report soft tissue trauma. Around 50,000 people report injuries related to intimate partner sexual assault, and 40,000 people report more severe injuries such as gunshot and stab wounds, fractures, internal injuries, and loss of consciousness.

Additional facts include:

• Most intimate partner murders are committed with firearms.
• The number of intimate partner homicides has decreased by about 15%.
• Almost half of the women murdered visited an emergency department within 2 years of the homicide.
• About 10% of women are abused at least once during pregnancy.
• Women are more commonly survivors of intimate partner murder.
• A home in which anyone has been hurt in a family fight is approximately 5 times more likely to be the scene of a homicide.
• Women are the survivors of 85% of intimate nonlethal violence.
• Women are more likely to sustain injuries compared to men. Some studies indicate that male and female survivors may be equally affected by domestic violence.
• Men are less likely than women to be survivors of gunshot wounds or injuries from an assault; however, they are more likely to be stabbed.

Epidemiology of Elder Abuse 

Elder abuse and neglect pose challenges to obtaining accurate incidence data due to under-reporting and sampling difficulties. Notably, it is estimated that abuse occurs in 3% to 10% of the population aged 65 and older. Many older adults may not report abuse due to fear, guilt, ignorance, or shame. Clinicians often underreport elder abuse due to several factors—poor recognition of the problem, unfamiliarity with reporting protocols, and concerns regarding patient confidentiality. Older adults may face challenges such as being unable to participate in surveys, language barriers, and having multiple preexisting health conditions. These factors contribute to inaccurate reporting on the prevalence of elder abuse. Despite the difficulties in obtaining exact frequency data, clinicians often encounter elder abuse survivors in clinical practice. 

Race: Elder abuse affects individuals across all racial, socioeconomic, and religious backgrounds. On average, the estimated racial and ethnic distribution of older persons who experience abuse is as follows:

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

Gender: Women are more commonly survivors of abuse among intimate partners and the older population. They report abuse at higher rates, likely due to the severity of injuries often being greater compared to men. However, some studies have found little or no differences based on gender in reporting rates and severity of abuse.

Age: The universally accepted definition of when old age begins is unclear, leading to variability in statistics on elder abuse. Typically, individuals aged 60 or 65 and older are considered older adults.

Mortality and morbidity: Among the older population, survivors of physical abuse and neglect have a significantly higher mortality rate compared to those who have not experienced abuse. Early detection of elder abuse cases leads to reduced morbidity and mortality. Clinician involvement is crucial, as only about 1 in 6 survivors self-report mistreatment to the appropriate authorities.[25][26]

Pathophysiology

Some pathological findings are common in both survivors and perpetrators of domestic violence. Certain medical conditions and lifestyles increase the likelihood of family and domestic violence.

Characteristics of Perpetrators

Research is unclear, but some characteristics are thought to be present in perpetrators of domestic violence.

Abusers tend to:

• Have a higher consumption of alcohol and illicit drugs; 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 from low self-esteem.
• Have emotional dependence, which tends to occur in both partners, but more so in the abusers.

Findings in Children

Domestic violence at home results in emotional damage, which exerts continued effects as the survivor matures.

• Approximately 45 million children are exposed to violence during childhood.
• Approximately 10% of children are exposed to domestic violence annually, and 25% are exposed to at least 1 event during their childhood.
• Around 90% of individuals are direct eyewitnesses of violence.
• Men who batter their wives batter the children 30% to 60% of the time.
• Children who witness domestic violence are at increased risk of dating violent individuals and have more difficulty with partnerships and parenting.
• Children who witness domestic violence are at an increased risk for posttraumatic stress disorder, aggressive behavior, anxiety, impaired development, difficulty interacting with peers, and academic problems. They also have a higher incidence of substance use disorder.
• Children exposed to domestic violence are more likely to experience further violence.
• Children who witness and experience domestic violence are at a greater risk for adverse psychosocial outcomes.
• Around 80% to 90% of domestic violence survivors abuse or neglect their children.
• Abused teens may not report abuse. Individuals aged 12 to 19 report only about one-third of crimes, compared with one-half in older age groups.

Florida State Law

According to Florida State 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 aged 16 or younger who is a family or household member with the survivor or perpetrator." In Florida, approximately 7% of domestic homicide survivors were children killed by a parent.

Healthcare professionals 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.

Findings in Pregnant Women

The American College of Obstetricians and Gynecologists (ACOG) recommends all women be assessed for signs and symptoms of domestic violence during regular and prenatal visits. Clinicians should offer support and referral information.

• 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 with preeclampsia and gestational diabetes.
• Reproductive abuse, the act of impregnating a woman against her wishes by stopping her from using birth control, may occur.
• As most pregnant women require prenatal care, this is an excellent time to assess for domestic violence.

Factors that predispose pregnant women to domestic violence include:

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

The danger of domestic violence is particularly acute as both mother and fetus are at risk. Healthcare professionals should be aware of the psychological consequences of domestic abuse during pregnancy. Increased stress, depression, and alcohol addiction are more common in abused pregnant women. These conditions may harm the growing fetus.[27]

Findings in Homosexual, Bisexual, and Transgender Individuals

Domestic violence occurs in homosexual, bisexual, and transgender couples at rates that are thought to be similar to heterosexual women, approximately 25%.

• More cases of domestic violence are common among men living with male partners than among men who live with female partners.
• Women living with female partners experience less domestic violence than women living with men.
• Transgender individuals have a higher risk of domestic violence. Transgender survivors are approximately twice as likely to experience physical violence as cisgender individuals.

Gay, lesbian, bisexual, and transgender survivors may be reticent to report domestic violence. Part of the challenge may be that support services such as shelters, support groups, and hotlines are not regularly available. This results in isolated and unsupported survivors. Healthcare professionals should strive to be helpful when working with homosexual, bisexual, and transgender patients.[28]

Findings in Men

While domestic violence is typically perpetrated by men against women, women can also exhibit violent behavior against their male partners.

• Approximately 5% of men 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.
• Around 3 out of 10 women are stalked, physically assaulted, or raped by an intimate partner, compared to 1 out of every 10 men.
• Other men primarily perpetrate rape, while women engage in other forms of violence against men.

Although women are the most common survivors of domestic violence, healthcare professionals should remember that men may also be survivors and should be evaluated if indications are present.

Findings in Older Populations

Older adults are often mistreated by their spouses, children, or relatives.

• Annually, approximately 2% of older adults experience physical abuse, 1% experience sexual abuse, 5% experience neglect, 5% suffer from financial abuse, and 5% suffer from emotional abuse.
• The annual incidence of elder abuse is estimated to be 2% to 10%, with only about 1 in 15 cases reported to the authorities.
• Approximately one-third of nursing homes disclosed at least 1 incident of physical abuse per year.
• Around 10% of nursing home staff self-report physical abuse against an older resident.

Domestic violence in older individuals may be financial or physical. Older adults are often hesitant to report this abuse if they are incurring abuse from the only available caregiver. Targets of abuse are often dependent, infirm, isolated, or mentally impaired. Healthcare professionals should be aware of the high incidence of abuse in this population. Because elder abuse is common, healthcare professionals must remain aware of the potential for abuse. When abuse occurs between older partners, the pattern of partner violence or abuse is long-standing. In the latter case, abuse may be precipitated by issues related to dementia, disability, and changing family relationships. Some states have a high percentage of older residents and a higher percentage of older survivors of domestic violence.[25]

History and Physical

Common Findings in Child Abuse 

The most common injuries are fractures, contusions, bruises, and internal bleeding. Unexpected injuries to pre-walking infants should be investigated. The caregiver should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries should be investigated. Children who are abused may be unkempt or malnourished. Some display inappropriate behavior, such as aggression, while others are shy, withdrawn, and have poor communication skills. Some children may also be disruptive or hyperactive. School attendance is usually inadequate.

Specific injuries and associated findings associated with 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

Human bites can be differentiated from animal bites in that an animal bite will have torn flesh. The inter-canine distance is usually greater than 3 cm in a human bite.

Common Findings in Intimate Partner Abuse 

Approximately 1 in 3 women and 1 in 5 men are survivors of abuse. The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. Clinicians should maintain suspicion if the history is inconsistent with the injury. Defensive injuries may be present on the forearms and hands. The patient may have psychological signs and symptoms such as anxiety, depression, and fatigue.

Medical complaints may be specific or vague, such as headaches, palpitations, chest pain, painful intercourse, or chronic pain.

Specific injuries associated with intimate partner abuse 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

Abuse During Pregnancy

Abuse during pregnancy may cause as many as 10% of hospital admissions. Many historical and physical findings may help the clinician identify individuals at risk.

Signs of potential abuse include:

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

If the examiner encounters these signs or symptoms, it is recommended that the patient be examined privately and that confidentiality be explained to the patient. Be sure to ask caring, empathetic questions and listen politely without interrupting answers.

Same-Sex Abuse

Same-sex partner abuse is common and may be challenging to identify. Over 35% of heterosexual women, 40% of homosexual women, and 60% of bisexual women experience domestic violence. For men, the incidence is slightly lower. In addition to common findings of abuse, perpetrators may try to control their partners by threatening to disclose their sexual preferences publicly. Clinicians should be aware that fewer resources are available to help survivors, and the perpetrator and survivor may share the same friends or support groups.

Abuse in Men

Men represent as much as 15% of all cases of domestic violence. Male survivors are also less likely to seek medical care, and their incidence may be underreported. These survivors may have a history of child abuse.

Elder Abuse

Healthcare professionals should inquire about abuse in geriatric patients, even in the absence of visible signs.

Risk factors:

• Dementia
• Pathological characteristics of perpetrators, including dementia, mental illness, and substance use (drug and alcohol)
• A shared living situation with the abuser
• Social isolation

Clinicians should always maintain a high index of suspicion.

When evaluating a patient for elder abuse, it is important to ask simple questions. When evaluating the patient for elder abuse, it is recommended to interview the patient and caregiver separately to detect any disparities. Documentation must be accurate and objective, considering that it may be utilized in criminal trials or guardianship hearings, and it should be thorough, complete, legible, and quote direct patient statements where possible. During the examination, it is important to disrobe the patient to assess for injuries, specifically for back injuries, contusions, bruises, and decubitus ulcers.

The following clinical findings should prompt more investigation:

• Agitation
• Bruises
• Burns
• Decubitus ulcers
• Dehydration
• Depression
• Injuries in various stages of evolution
• Lacerations
• Unexplained injuries
• Treatment delays
• Inconsistent injury to the history
• Poor hygiene
• Contradictory explanations from caregivers and patients 
• Laboratory findings indicating lack of compliance with medications
• Rope marks
• Venereal disease
• Welts

Documenting the size, shape, and location of injuries during the physical examination is important. Taking pictures or drawing sketches can aid in accurate documentation. Clinicians should be aware that elder abuse by caregivers is a common problem that can occur in both home and institutional settings. Factors that increase the risk of elder abuse by caregivers include poor training, stress, burnout, heavy workload, low pay, job satisfaction, and staffing shortages.

Evaluation

Domestic violence can be challenging for patients to divulge, particularly when fear is a factor, such as when they present at an emergency department or clinician's office. The key is to establish an assessment protocol and maintain awareness that domestic and family violence may be the cause of the patient's signs and symptoms. Screening should be routinely conducted in primary care, obstetric and gynecologic, psychiatric, pediatric, urgent care, and emergency department settings.

Establishing that injuries are related to domestic abuse poses a significant challenge. Priority is given to addressing life and limb-threatening injuries. Once stabilization and physical evaluation are completed, healthcare professionals may consider performing laboratory tests and imaging studies, such as x-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI), as indicated. The initial focus remains on addressing the immediate medical needs that led the patient to seek care in the emergency department.

• The evaluation should commence with a comprehensive history and physical examination. Clinicians should screen all individuals for domestic violence and refer those who screen positive, regardless of whether they exhibit signs or symptoms of abuse. Importantly, all healthcare facilities should have protocols in place for assessing, screening, and referring patients affected by intimate partner violence. These protocols should encompass procedures for referral, documentation, and follow-up care.

• Healthcare professionals and administrators should be aware of challenges such as barriers to screening for domestic violence, including lack of training, time constraints, the sensitive nature of the issue, and privacy concerns.

• Despite increased awareness among professionals and the public, discussing abuse remains difficult for many patients and clinicians.

• Patients displaying signs and symptoms of domestic violence should undergo evaluation. Physical indicators may include bruises, bites, cuts, broken bones, concussions, burns, or knife and gunshot wounds.

• Typical domestic injury patterns include contusions to the head, face, neck, breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more commonly involve the extremities of the body. Individuals who have experienced abuse often present with multiple injuries in various stages of healing, ranging from acute to chronic.

• Emotional and psychological issues such as anxiety and depression are common. Complaints may include backaches, stomachaches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are also more likely to experience conditions such as asthma, irritable bowel syndrome, and diabetes.[29][30][31]

Patient Assessment

Patient assessment following disclosure of abuse should prioritize safety and include a detailed evaluation once the patient is stable and not in immediate distress. Standard questions can help guide the assessment process, and if immediate danger is detected, referral to advocate support, shelters, hotlines for survivors, or legal authorities should be considered.

• If no immediate danger is evident, the assessment should shift to evaluating the patient's mental and physical health while gathering information about current or past abuse experiences. This information guides the appropriate intervention.

• During the initial assessment, clinicians must remain sensitive to the patient's cultural beliefs, as incorporating cultural sensitivity can enhance the effectiveness of treatment.

• Patients who have experienced domestic violence may be reluctant to accept referrals due to fear for their safety and financial stability, which can prevent them from leaving their abuser due to their inability to support themselves or their children. Clinicians must reassure patients that referrals are voluntary and that they act as neutral professionals. The objective is to ensure that resources are accessible to provide enhanced support.

• If the patient elects to leave their current situation, it is advisable to provide information for referral to a local domestic violence shelter to assist the survivor.

• In cases where there is a risk to life or limb or evidence of injury, the patient should be referred to local law enforcement.

• Counselors often include social workers, psychiatrists, and psychologists who specialize in the care of battered partners and children.[32][33]

Testing for Suspected Abuse in Children

Testing for suspected abuse in children involves performing a detailed history and a meticulous physical examination. In cases where head trauma is suspected, clinicians may consider involving an ophthalmologist for an indirect ophthalmoscopy. Laboratory studies are crucial in forensic evaluation and potential criminal prosecution. In addition, healthcare professionals need to be aware that certain medical conditions may mimic findings resembling child abuse.

Urine testing: Urinalysis or a urine test for suspected child abuse includes screening for sexually transmitted diseases and considering bladder or kidney trauma if blood is present.

• Urine toxicology screening is warranted in cases of altered consciousness, agitation, or coma, or if an apparent life-threatening event is suspected, or if the child is exposed to a hazardous environment. Survivors of child abuse may test positive in up to 15% of urine drug screens.

• Basic urine toxicology is often unreliable, with the potential for both false positives and false negatives. Positive screens must be confirmed in cases of legal intervention.

• The chain of custody should be followed when sending a urine toxicology specimen to a laboratory. Confirmatory tests typically require referral to external state-sponsored laboratories.

Hematology: If bruises or contusions are present, evaluation for a bleeding disorder is not indicated if the injuries are consistent with a history of abuse. However, due to potential false elevations in some tests, it is advisable for a child abuse specialist, pediatrician, or hematologist to review or follow up on these tests.

Evaluation for bleeding disorders: This may include the below-mentioned factors.

• Complete blood cell count (CBC)
• Platelet count
• Prothrombin time
• Partial thromboplastin time
• Von Willebrand factor activity and antigen
• Factors VIII and IX levels

Gastrointestinal and chest trauma:

• Liver and pancreas screening tests, such as aspartate transaminase (AST), alanine transaminase (ALT), and lipase, should be considered. If the AST or ALT level is greater than 80 IU/L or lipase is greater than 100 IU/L, an abdomen and pelvis CT with intravenous contrast should be considered.

• Patients with abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15 are at the highest risk.

• A troponin level should be considered if there is evidence of chest trauma, such as abrasions, bruises, rib fractures, clavicle fractures, sternal fractures, or a fractured sternum. A chest CT and an echocardiogram should be recommended if the troponin level exceeds 0.04 ng/mL.

Imaging: Evaluating the pediatric skeleton can be challenging for nonspecialists due to subtle differences from adults, such as cranial sutures and incomplete bone growth, which can lead to misinterpretation of fractures. If there is concern for abuse, consulting a radiologist is recommended. A skeletal survey is indicated in children aged 2 or younger with suspected physical abuse, as occult fractures occur in as many as 1 in 4 of these cases. Screening all siblings aged 2 or younger should also be considered by the clinician.

The skeletal survey should include 2 views of each extremity (anteroposterior and lateral), as well as views of the skull (lateral), chest (lateral), spine, abdomen, pelvis, hands, and feet. A radiologist review is essential to identify classic metaphyseal lesions and healing fractures, particularly those involving the posterior ribs. A "babygram," which includes only one full-body film, is insufficient as a comprehensive skeletal survey.

Skeletal fractures undergo varying rates of remodeling influenced by factors such as the patient's age, fracture location, and nutritional status.

• Soft tissue swelling is present at 0 to 10 days.
• Long bone fractures may develop a soft callus over 10 to 21 days.

Three-dimensional reconstruction CT imaging offers greater specificity in detecting skull and rib fractures but involves higher radiation exposure. When abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged 6 months or younger, or 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 for unconscious children who have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or elevated AST, an ALT greater than 80 IU/L, or lipase more than 100 IU/L.

Special documentation: Special documentation guidelines for injuries include:

• A photograph, including an identification tag photo, before the treatment of injuries.
• Photos should be captured from multiple angles and distances to document injuries comprehensively.
• The sizes of injuries should be Measured and documented accurately.
• When photographing bite marks, it should be ensured that photos focus on each dental arch to avoid distortion.
• Photos should be clear and accurately depict the injuries, as they may be used in court proceedings.

Testing for Suspected Abuse in Adults

Laboratory tests: This includes evaluating for evidence of dehydration, electrolyte abnormalities, infection, substance use, improper medication administration, and malnutrition through the following laboratory tests:

• CBC
• Basic metabolic panel
• Urinalysis
• Screening for sexually transmitted infections
• Calcium, magnesium, and phosphorus levels
• Drug levels
• Ethanol level
• Urine drug screen

Imaging: Imaging should include x-rays of bruised or tender body parts to detect fractures. A head CT scan is necessary to evaluate for intracranial bleeding due to abuse or causes of altered mental status.

Additional tests: Other considerations include performing a pelvic examination with evidence collection in cases of suspected sexual assault.

Evidence Collection

Domestic and family violence cases often lead to legal prosecution. Specialized teams in domestic violence should ideally be involved in collecting evidence. Each healthcare facility should maintain a written procedure for packaging, labeling, and preserving specimens with a secure chain of custody. Law enforcement personnel frequently aid in evidence collection by providing specialized kits. Evidence may include tissue specimens, blood, urine, saliva, as well as vaginal and rectal specimens. Saliva from bite marks can be collected using a water-moistened cotton-tipped swab. Clothing stained with blood, saliva, semen, or vomit should be retained for forensic analysis.

Treatment / Management

The priority is to address any life-threatening injuries and stabilize the patient's medical condition. Once the patient is stable, emergency medical services (EMS) personnel may identify problems associated with violence.

Prehospital Care

The priority is the stabilization of injuries. When stability is achieved, prehospital professionals should consider the following:

• EMS personnel enter the environments where exposure to violence occurs. They may see evidence of domestic and sexual violence that needs to be reported to the clinicians and possibly the police.

• Reporting the incident may be considered when called into a home for a problem that is not directly related to abuse.

• Domestic violence survivors may refuse ambulance transport after evaluation. In such situations, EMS healthcare professionals may recognize domestic violence and suggest appropriate interventions.

• All EMS personnel should be trained to recognize the signs of domestic violence and be able to offer guidance.

Emergency Department and Office Care

The following interventions should be considered:

• Providing a safe environment.
• Diagnosing physical injuries and other medical or surgical problems.
• Treating acute physical or life-threatening injuries.
• Identifying possible sources of domestic violence.
• Establishing domestic violence as the diagnosis.
• Reassuring the patient.
• Evaluating the emotional status and treating them.
• Documenting the history, physical, and interventions.
• Determining the risks to the survivor and assessing safety options.
• Counseling the patient that violence may escalate.
• Determining if legal intervention is needed and reporting abuse when appropriate or mandated.
• Developing a follow-up plan.
• Offering shelter options, legal services, and counseling, as well as facilitating referrals.

Evaluation and Management of Emotional Status

The patient needs to feel respected, cared for, listened to, and encouraged to make choices. The survivor should be informed in plain, simple language that:

• Domestic violence is unacceptable
• Violence is not the patient's fault
• No one deserves to be abused
• Resources such as support, shelter, and legal advice are available

Appropriate intervention decreases the likelihood of anxiety, depression, substance use disorder, counterphobic behavior, and posttraumatic stress disorder.

When counseling and examining the patient:

• Use simple language to explain procedures.
• Explain reactions expected during the posttraumatic period
• Respect modesty and touch the patient only with permission
• Discuss the evaluation of sexually transmitted infections and pregnancy

Emotional Findings in Survivors of Domestic Violence

Emotional findings in survivors of domestic violence are mentioned below.

• 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

Documentation in Medical Record 

The medical record is often evidence used to convict abusers. Charting should include detailed documentation of evaluation, treatment, and referrals, as mentioned below.

• The abusive event and current complaints should be described using the patient's own words.
  • The patient's behavior should be included in the record.
  • Health problems related to the abuse should be documented.
  • The alleged perpetrator's name, relationship, and address should be included.

• The physical examination of the survivor should describe their injuries, including location, color, size, amount, and degree of age.
  • Injuries should be documented with anatomical diagrams and photographs.
  • Photographs should include close-ups of all wounds and contusions of the face and torso.
  • The back of each photograph should include the patient's name, medical record number, date and time of the photograph, and witnesses.
  • Torn and damaged clothing should be photographed. 
  • Injuries not shown clearly in photographs should be documented with line drawings.
  • Physical evidence that may be used for prosecution should be preserved.

• In cases of sexual assault, protocols for physical examination and evidence collection should be followed.
  • Consent should be obtained from the patient, parent, or legal guardian.
  • Legally required notifications should be performed.

• Referrals should be made, and a safe environment should be ensured.

Joint Commission on Accreditation of Healthcare Organizations Requirements

Patients who have experienced alleged abuse or neglect have specialized needs during the assessment process. The Joint Commission requires hospitals to have policies for identifying, evaluating, addressing, and referring survivors.

• The hospital must safeguard information and potential evidence that may be used in future actions as part of the legal process.
• Hospitals must have policies and procedures that define responsibility for collecting these materials.
• Hospital policy must define activities and specify who is responsible for their implementation.

Risk Determination Before Discharge

Assessing the potential risks before discharging a patient is crucial to ensuring their safety and well-being, including:

• The hospital or healthcare providers should determine whether the patient is in danger if they return home.
• They should evaluate any threats to the patient by the perpetrator.
• They should evaluate the patient's mental status.
• They should determine what type of help the patient is willing to accept.

Questions to Consider Before Discharge

Before discharging a patient from the hospital, the following questions should be asked:

• Does the patient need a medical or psychiatric intervention?
• Is admission or urgent follow-up required for medical conditions?
• Does the patient express suicidal or homicidal ideation?
• Does the patient need urgent crisis counseling to deal with the stress of abuse?
• Who is waiting outside for the patient?
• Does the patient believe going home is safe?
• Where is the abuser now?
• Was the abuser arrested?
• Does the abuser have access to a weapon?
• Has the abuser threatened to kill the patient?
• Has the abuser been harassing or stalking the patient?
• Have abusive behaviors been escalating?
• Does the patient have friends or family to stay with?
• If the abuser returns home, is danger a possibility?
• Is the patient confident that 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 patient feel safe?
• Is the patient afraid of harm if going home?
• Does the patient want access to a shelter?

Disposition

The key points include:

• If the patient chooses not to go to a shelter, they should be provided with telephone numbers for domestic violence or crisis hotlines and support services for later use.
• Patients should be given verbal instructions, as written materials may pose a risk when they return home.
• Referral should be made to primary care or another appropriate resource for the patient.
• Patients should have a safety plan in place, and examples of such plans should be provided.

Safety Plan Elements

The safety plan elements include:

• Avoiding arguments in small rooms or rooms without access to an outside door.
• Avoiding alcohol and drugs that decrease the ability to protect or think logically.
• Developing escape routes through doors, windows, or fire escapes.
• Practicing escape routes regularly.
• Asking friends or neighbors to call the police if they hear suspicious noises.
• Arranging a code word for children or friends so they know when to call for help.
• Teaching children to use the telephone to contact police or fire services.

Emergency Situations

In case of an emergency:

• In the event of an emergency, it is advisable to gather essential documents such as driver's licenses, 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 licenses, address books, protective or restraining orders, divorce or custody papers, court documents, money, checkbook, bankbook, and credit cards.

• Prescription medicines should be readily accessible.

• Clothing, toys, and other items should be prepared for children.

• Keys to the car, house, office, and safe deposit box should be secured.

• Safety devices, such as extra locks, window bars, and electronic security systems, should be installed.

• To enhance safety, smoke detectors, fire extinguishers, and rope ladders should be purchased and installed on upper-floor windows. 

Job Safety

Ensuring job safety is crucial for individuals navigating domestic violence violence situations, involving considerations such as:

• Informing someone at the workplace of the situation and assisting if necessary.
• Screening of calls and visitors should be effectively managed at work.
• Ensuring the survivor has a plan for safely arriving and leaving work.
• Suggesting varying the arrival and departure times to and from the children's school and work can enhance safety measures.

Shelters and Referral

In an emergency department, the primary goal after treatment of acute injuries is to connect the survivor with domestic violence shelters, social services, legal assistance, and support groups.

• The patient should be assisted in locating a shelter. If outpatient facilities are unavailable, overnight hospitalization may be considered, emphasizing it as a protective measure.

• Options available to the patient should include emergency shelters, contacting the police for a restraining order, and services provided by support groups and hotlines.

• While some patients may choose to return to the relationship after seeking healthcare, presenting options to remove the person from violence is essential.

Consultations

A consultation with a social worker, psychologist, or psychiatrist should be obtained if the patient is suicidal or homicidal.

Deterrence

If an individual decides to return to a domestic violence situation, they may be reinjured, sometimes with fatal outcomes.

• Appropriate suspicion, documentation, and referral can prevent further abuse.
• Prevention programs are available in many communities and generally focus on high-risk families.
• Long-term assessment and care should be tailored to the individual patient's needs.
• Follow-up assessment includes a home visit to assess the living environment, family dynamics, and caregiver conditions.
• Patients should be informed about available support programs, along with their contact information.
• Patients should be encouraged to develop safety and follow-up plans before discharge.

Important Pearls

Key points to keep in mind regarding domestic violence include:

• Approximately 40% of individuals experiencing domestic violence never report it to the police.
• Among female survivors of domestic homicide, 44% had visited a hospital emergency department within 2 years before their murder.
• Healthcare professionals play a crucial role in providing survivors of domestic violence with an opportunity to seek assistance.[34][35][36]

Differential Diagnosis

Different Diagnoses for Child Abuse

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 fracture

Differential Diagnoses for Adult Abuse 

• Accidental burns
• Alcohol use disorder
• Accidental fall
• Acute subdural hematoma
• Consensual intercourse
• Depression
• Suicidal attempt
• Substance use disorder

Prognosis

Without social services, mental health intervention, and treatment, all forms of abuse (domestic and family violence) can often recur and escalate in both frequency and severity, leading to a poor prognosis for recovery. Statistics show that:

• Approximately 75% of survivors continue to experience abuse.
• More than half of abused women who attempt suicide will make subsequent attempts, often resulting in success.

In children, the potential for poor outcomes is particularly high due to the lifelong effects of abuse. In addition to managing physical injuries, the mental consequences can be catastrophic. Research indicates a significant association between child sexual abuse and increased risk of psychiatric disorders in adulthood. Moreover, there is a considerable risk that the cycle of violence will perpetuate following childhood exposure.

Children raised in families where sexual abuse occurs may develop a range of psychological conditions, including:

• Attention-deficit hyperactivity disorder (ADHD)
• Conduct disorder
• Depression
• Bipolar disorder
• Panic disorder
• Sleep disorders
• Suicide attempts
• Posttraumatic stress disorder (PTSD)

Multiple known and suspected negative health outcomes of family and domestic violence are apparent. Long-term consequences include broken bones, traumatic brain injuries, and internal injuries.

Patients may also develop multiple comorbidities such as:

• Asthma
• Insomnia
• Fibromyalgia
• Headaches
• High blood pressure
• Chronic pain
• Gastrointestinal disorders
• Gynecologic disorders
• Depression
• Panic attacks
• PTSD [6][24][37]

Pearls and Other Issues

Screening for Family and Domestic Violence

Over 80% of survivors of domestic and family violence seek care in a hospital. Others may seek care in professional offices under the guidance of dentists, therapists, and other clinicians. Routine screening should be conducted by all healthcare professionals, including nurses, physicians, physician assistants, nurse practitioners, and pharmacists. Screening is a critical component of protecting survivors and minimizing negative health outcomes.

Interventions reduce the incidence of morbidity and mortality associated with domestic violence.

• As family and domestic violence is a significant public health and social problem, all healthcare professionals should be aware of and use screening tools.
• The United States Preventive Service Task Force (USPSTF) recommends routine screening of women for intimate partner violence in all primary care settings.
• Insurance plans are required to cover the costs of intimate partner violence screening for adolescent and adult women.
• Screening for family and domestic violence raises concerns regarding compromising patient privacy and the ethical, legal, and professional responsibilities of clinicians.

Screening Tools

• The American Academy of Pediatrics (AAP) provides free guides covering the history, physical examination, 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 lower socioeconomic status.
• The Maternal History Interview uses open-ended questions and subscales to assess personality, parenting skills, life stress, and risk of child abuse.
• The CDC provides several scales assessing family relationships, including child abuse risks.
• A physical examination remains the most significant diagnostic tool for detecting abuse. A comprehensive physical exam should be performed on a child or adult with suspected abuse. The patient should be undressed, and the skin examined for bruises, bites, burns, and injuries in different stages of healing. Additionally, healthcare professionals should examine for retinal hemorrhages, subdural hemorrhages, tympanic membrane rupture, soft tissue swelling, oral bruising, fractured teeth, and organ injury.

Screening for Child Abuse

Child abuse and neglect can result in acute trauma, anxiety, depression, unwanted pregnancy, substance use disorder, suicide, and risky behaviors. Children are more likely to be involved in family and intimate partner abuse. The most common risk factors for child abuse and neglect include poverty, low education, large family size, single-parent households, young parents, step-parents in the home, and psychiatric disease. Clinicians must take responsibility for identifying child abuse to prevent recurrent injuries.

While routine child abuse screening is not yet established, it is necessary. Multiple missed appointments and delays in seeking medical treatment may indicate abuse or neglect. Many organizations offer free screening tools; however, most lack sufficient sensitivity and specificity. False positive and false negative results can have serious consequences, including both under- and overreporting of abuse.

Screening for Intimate Partner Violence

Some experts believe screening should only occur when signs and symptoms are present. Routine screening may be problematic due to the stigma, which can result in patient anxiety. Additionally, patients who have experienced abuse may be unwilling to use available resources to end the abuse. Nonetheless, 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 to assist with assessment, intervention, documentation, and referral.

Studies have shown that abused women who receive counseling experience fewer instances of intimate partner violence during and after pregnancy. Screening has the potential to decrease abuse and improve health outcomes. Although targets of abuse may not always be willing to use the information provided, ignoring abuse can lead to severe consequences. Clinicians can play a crucial role by providing the necessary resources to educate and inform patients.

The CDC provides numerous tools to assist clinicians 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 clinicians recognize and treat intimate partner violence.
• WAST (Woman, Abuse, Screening, Tool): A screening tool used by family and emergency clinicians.

Screening for Elder Abuse

Older patients are at risk of abuse in both home environments and institutional settings. Risk factors for elder abuse include increased age, dementia, abnormal behaviors, cognitive decline, physical dependency, and impairment in daily living activities. In institutional settings, a shortage of qualified staff is a significant constraint. Screening for elder abuse should include a review of social and financial information. The Abuse Suspicion Index is a useful screening tool for cognitively intact patients. For patients with dementia, clinicians must rely on the physical exam. Bruising can indicate physical abuse, but older individuals commonly take blood-thinning agents that result in easy bruising. Survivors of physical abuse tend to have bruises with specific characteristics, such as bruises of varying age, larger than 5 cm, located on the face, lateral right arm, or posterior torso. In many instances, the survivor may recall how the bruise occurred.

If abuse is suspected, radiographs of ribs, small bones, and the face should be considered. A CT head scan should also be considered to rule out subdural hemorrhage. A pelvic examination should be conducted if any signs of sexual abuse are apparent. Weight loss may indicate physical or medical neglect due to malnutrition, but other common causes of weight loss should be ruled out. Pressure ulcers should raise suspicion of neglect. All clinicians should be aware of the potential signs and symptoms of elder abuse and be familiar with screening tools. When abuse is suspected, the history and physical examination should be carefully conducted and documented with additional laboratory and imaging tests as needed.

Challenges in Screening 

While screening is crucial to identify domestic and family, several barriers exist, and many clinicians do not take the time to screen patients. Unfortunately, no universal approach has been established to assess domestic violence. In addition, many clinicians do not have the time, resources, or desire to get involved. Many healthcare professionals 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 professionals are prosecuted for failure to comply, hindering reporting. Routine screening increases the odds of cases being identified.

Challenges in screening include:

• Lack of recognition
• Lack of standard screening tools
• Limited time
• Limited resources
• Lack of motivation to screen

Screening Recommendations

• Healthcare professionals should evaluate for organic conditions and medications that mimic abuse.
• Healthcare professionals should evaluate patients and caregivers separately.
• Clinicians should regularly screen for family and domestic violence and elder abuse.
• The Elder Abuse Suspicion Index can be used to assess for elder abuse.
• Cognitive impairment screening should be conducted before screening for elder abuse.
• Pattern injuries are more suspicious.

National Statutes

Federal Child Abuse Prevention and Treatment Act (CAPTA): Each state has specific child abuse statutes. 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.

The Elder Justice Act: The Elder Justice Act provides strategies to decrease the likelihood of elder abuse, neglect, and exploitation. The Act utilizes 3 significant approaches:

• Creation of a coordinating council and an advisory board: These entities are charged with recommending multidisciplinary tactics for reducing elder abuse at the local, state, and federal levels.
• Allotment of grant money and monetary incentives: These funds aim to improve staffing, quality of care, and technology in long-term care facilities and to increase support for state adult protective services departments.
• Adherence to strict reporting requirements: Facilities receiving federal funding are required to comply with stringent reporting protocols as outlined by the Elder Justice Act (EJA).

Patient Safety and Abuse Act: The Violence Against Women Act indicates that crossing state lines to stalk, harass, or physically injure a partner is against the law. Entering or leaving the country in violation of a protective order is also prohibited. Additionally, possessing a firearm or ammunition while subject to a protective order or after being convicted of a qualifying crime of domestic violence is a violation.

The survivor has a right to:

• Restitution
• Information about the offender
• Notification and presence at court proceedings
• Dignity and privacy
• Protection from the accused offender
• Conference with an attorney [2][38][39][40][41]

State Statutes

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." Healthcare professionals must report when suspicion arises and do not need affirmative proof. They are required to report all cases where there is reasonable cause to believe that a child or adolescent has been abused or neglected or is in danger of being abused.

In Florida, the reporting requirement is not limited to first-person reporting. Healthcare professionals cannot assume that someone else has made a report. They must always make a report if they suspect a child is or has been abused.

• Florida Statute 456.031 mandates a 2-hour continuing education course on domestic violence as part of every third biennial re-licensure or recertification for healthcare professionals.
• 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 on 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 matters, and suicides. Membership must include a representative from the medical examiner's office 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 a flammable substance caused the burns and if the injury could be the result of violence or other unlawful activity.[21][42][43] 

National Resources

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

• CDC: 800-CDC-INFO (800-232-4636) / TTY (888-232-6348)
• Childhelp: National Child Abuse Hotline, 800-4-A-CHILD (800-422-4453)
• Coalition of Labor Union Women (cluw.org): 202-466-4615
• Corporate Alliance to End Partner Violence: 309-664-0667
• Employers Against Domestic Violence: 508-894-6322
• Futures without Violence: 415-678-5500 / TTY (800-595-4889)
• Love Is Respect: National Teen Dating Abuse Helpline 866-331-9474 / TTY (866-331-8453)
• National Center on Domestic and Sexual Violence
• National Center on Elder Abuse
• National Coalition Against Domestic Violence (www.ncadv.org)
• National Network to End Domestic Violence: 202-543-5566
• National Organization for Victim Assistance
• 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 / TTY (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 (800-394-2255) / TTY (800-211-7996)
• The Battered Women's Justice Project: 800-903-0111
• The National Center for Victims of Crime (www.victimsofcrime.org)
• The National Domestic Violence Hotline (www.thehotline.org): 800-799-7233 / TTY (1-800-787-3224)
• US 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)

State Resources

To report abuse of children, people with disabilities, and the older populations:

• Department of Children and Families Florida Abuse Registry: 1-800-96-ABUSE (1-800-962-2873)

For information and referral relating to domestic violence:

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

Enhancing Healthcare Team Outcomes

Interprofessional Approach to Addressing Domestic Violence

An interprofessional approach to addressing domestic violence involves collaboration among multidisciplinary healthcare professionals, including social workers, law enforcement, psychiatrists, psychologists, and community support services to ensure comprehensive care and support for survivors.

• Healthcare professionals play a crucial role in addressing domestic violence, documenting all findings and recommendations in the medical record.
• If domestic violence is admitted, thorough documentation should encompass the history, physical examination findings, laboratory and radiographic results, interventions, and referrals.
• Photographs should accompany significant findings when possible
• Maintaining objectivity and accuracy is crucial, given the potential for the medical record to become a court document.
• Healthcare professionals should schedule a follow-up appointment to ensure ongoing support and care.
• Patients should be reassured that additional assistance is available at any time, which is crucial for breaking the cycle of abuse.

Reporting Abuse

Reporting incidents of domestic violence and child abuse is a critical responsibility for healthcare professionals, ensuring immediate support and intervention for survivors in need. Here are the resources and steps involved in effective reporting:

• In cases of acute injury or emergency, healthcare professionals should contact local law enforcement promptly.
• A 24-hour toll-free domestic violence hotline number, 800-500-1119, offers counseling and information. The counselors refer the survivor to local domestic violence centers.
• Florida hosts several domestic violence centers offering a range of services, including referral services, counseling, a 24-hour hotline, emergency shelter, educational programs, assessment and referral for parents with children, and local law enforcement personnel training.
• If child abuse is suspected, healthcare professionals should contact Children and Family Services, the Department of Social Services, or the National Child Abuse Hotline at 1-800-4-A-Child.
• Healthcare professionals play a crucial role in screening, identifying, and reporting child abuse, utilizing screening tools to enhance detection in clinical practice.

Obstacles to Reporting

Healthcare professionals may encounter several obstacles when considering reporting domestic violence, including:

• Attitudes of clinicians
• Belief in unreasonable intrusion
• Concern over legal consequences for reporting
• Concern over violating privacy

Legal Considerations

Awareness of federal and state statutes governing domestic and family abuse is crucial. Notably, reporting domestic and family violence to law enforcement does not negate the necessity for detailed documentation in the medical record.

• Failure to report child abuse is illegal in most states.
• Failure to report intimate partner and elder abuse is illegal in many states.
• Battering is a crime; patients should know that assistance is available. 
• In some jurisdictions, reporting domestic violence is mandated. The patient should be informed of the legal obligation to report abuse.
• The patient should receive information on how local authorities typically respond to such reports and be given guidance on follow-up procedures, including addressing the risk of reprisal, the need for shelter, and potentially obtaining an emergency protective order (available in every state and the District of Columbia).
• If the patient's safety is at risk, the clinician should collaborate with the patient and authorities to ensure the patient's safety while fulfilling legal reporting obligations.
• The clinical role in addressing abused patients extends beyond compliance with mandatory reporting laws; it primarily involves safeguarding the patient's life and well-being.
• The clinician must help mitigate potential harm from reporting, provide appropriate ongoing care, and ensure patient safety.
• The healthcare professional should remain present during the interview if requested by the patient.
• The medical record should accurately reflect the incident reported by the patient and any physical examination findings, including the date and time of the report and the officer's name and badge number.