Kentucky Domestic Violence

Etiology

Domestic and family violence, including child abuse, intimate partner violence, and elder abuse, often starts when one partner, parent, or caretaker feels the need to dominate or control. Abuse begins with emotional or verbal threats and may escalate to physical violence. Victims live in a constant state of fear. The perpetrator often becomes explosively violent. After the violent event, the perpetrator may apologize. This cycle of violence usually repeats.[7][4][8][9]

Reason Abusers Need to Control

• Anger management issues
• Jealousy
• Low self-esteem
• Feeling inferior due to less education
• Feeling inferior due to poor socio-economic background
• Cultural beliefs they have the right to control their partner
• Personality disorder or psychological disorder
• Learned behavior from growing up in a family where domestic violence was accepted
• Alcohol and drugs, as an impaired individual may be less likely to control violent impulses

Risk Factors

Risk factors for domestic and family violence include individual, relationship, community, and societal issues. There is an inverse relationship between education and domestic violence. The less education, the more likely domestic violence will occur. 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. Drug and alcohol abuse greatly increases the incidence of domestic violence.

Children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, gender roles can be reversed. Common risk factors include:

• Aggressive behavior as a youth
• Antisocial personality disorder
• Individuals with disabilities
• Corporal punishment in the household
• Pregnancy
• Economic stress/families with low annual incomes
• Females whose educational or occupational level is high relative to their spouses' educational or occupational level
• Low self-esteem
• A family history of violence
• Low education
• Poor parenting
• Psychiatric history
• Marital discord
• Marital infidelity
• Multiple children
• Poor legal sanctions or enforcement of laws
• History of abuse as children
• Unemployment
• The use and abuse of alcohol and drugs are strongly associated with a high probability of violence. Alcohol abuse is known to be a strong predictor of acute injury. Approximately half of the domestic violence victims indicate their partner was intoxicated at the time of the assault.
• New cases of HIV infection are linked to intimate partner violence.

Domination may include emotional, physical, or sexual abuse potentially caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.

No matter the underlying circumstances, nothing justifies domestic and family violence. Understanding the causes assists us in understanding the behavior of an abuser. The abuser must be separated from the potential victim and treated for destructive behavior before a major event negatively impacts the lives of all involved.

Epidemiology

Domestic violence is a serious and challenging public health problem. Approximately 1 in 3 women and one in 10 men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1500 deaths in the United States and as many as 200 deaths in Florida. In Florida, more than one in three women and one in four men experience physical violence, stalking, or rape.[10][11][12]

Domestic violence victims typically experience severe physical injuries requiring care at a hospital or clinic. The cost to individuals and society is significant. The national annual cost of medical and mental health care services related to acute domestic violence is estimated at over $8 billion. If the injury results in a long-term or chronic condition, the cost is considerably higher.

Financial hardship and unemployment are contributors to domestic violence. An economic downturn is associated with increased calls to the National Domestic Violence Hotline.

Fortunately, the national rate of nonfatal domestic violence is declining. This is thought to be due to a decline in the marriage rate, decreased domesticity, better access to domestic violence shelters, improvements in female economic status, and an increase in the average age of the population.

National

• Most perpetrators and victims do not seek help.
• Healthcare professionals are usually the first individuals with an opportunity to identify domestic violence.
• Nurses are usually the first healthcare providers victims encounter.
• Domestic violence may be perpetrated on women, men, parents, and children.
• Fifty percent of women seen in emergency departments report a history of abuse, and approximately 40% of those killed by their abuser sought help in the two years before death.
• Only one-third of police-identified victims of domestic violence are identified in the emergency department.
• Healthcare professionals who work in acute care need to maintain a high index of suspicion for domestic violence as supportive family members may, in fact, be abusers.

State

In Kentucky, a state task force (The Division of Protection and Permanency) has recommended standards to precisely measure the extent of domestic violence and develop strategies for education and increasing public awareness. The results include:

• The legislation now involves professional (rather than the former "universal") mandatory reporting law. This requires reporting by a physician, osteopath, coroner, medical examiner, medical resident, medical intern, chiropractor, nurse, dentist, optometrist, EMT, paramedic, licensed mental health professional, therapist, Cabinet employee, child care personnel, teacher, school personnel, ordained minister, victim advocate, or any agency employing these individuals.
• According to Kentucky law, primary care physicians who are granted licensure after July 1, 1996, are required to successfully complete a 3-hour domestic violence training course within 3 years of the date of initial licensure.
• The online Kentucky Child/Adult Protective Services Reporting System is available for professionals to report non-emergency situations that do not require an immediate response.
• In 2017, the state passed KRS 209A, amended by HB 309, which expands state protection to all victims (including intimate partner/dating violence).
• The statute requires reporting to law enforcement any relevant information on the death of a domestic violence victim. 
• Kentucky is one of three states (with Oklahoma and Arkansas) with a mandatory reporting law specific to domestic violence.

Domestic violence offenses result in approximately 40 deaths in Kentucky annually. The perpetrators are usually male, and victims usually female. Two-thirds of the victims lived with the perpetrators of domestic violence in one analysis of Kentucky occurrences. One in 4 had some form of domestic violence report prior to the homicide.  As stated in a Domestic Violence Fatality Review (https://ag.ky.gov/pdf_news/DVFR%20book.pdf), Kentucky "has no formal statewide surveillance system to track intimate partner violence-related homicides and no statewide formal procedure to review intimate partner-related homicide cases."

Age, family income, and ethnicity are all risk factors for both sexual abuse and physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse.

Race

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

Gender

The genders are equally affected, but homicide rates are somewhat higher in males.

Morbidity and Mortality

Children may experience pain, humiliation, fear, loss of self-esteem, and injury. Physical damage may range from minor injury to disfigurement to brain trauma and even death. Long-term health consequences and adverse experiences may increase anxiety, depression, substance abuse, self-mutilation, suicides, criminal behavior, cancer, cardiovascular disease, diabetes, premature mortality, low well-being, obesity, and chronic mental health problems.

Mortality increases with multiple episodes of trauma. Homicide is a leading cause of death in aged children 1 to 4 years, and over 80% of fatalities from child abuse are in children younger than 4.

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 experience some form of sexual violence during their lifetimes. Intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year.

One in 6 women and 1 in 19 men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about 6 in 10 female victims and 4 in 10 male victims.

At least 5 million acts of domestic violence occur annually to women aged 18 years and older, with over 3 million involving men. While most events are minor, for example, grabbing, shoving, pushing, slapping, and hitting, serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults occur. About 1 in 5 women have experienced completed or attempted rape at some point in their lives. About 1% to 2% of men have experienced completed or attempted rape.

The incidence of intimate partner violence has declined by over 60%, from about 10 victimizations per 1000 persons age 12 or older to approximately four per 1000.

Race

African American, American Indian, Alaskan Native women and men, and Hispanic women report higher domestic violence rates. Asian and Pacific Island women and men report lower rates of intimate partner violence. However, differences among groups tend to diminish when sociodemographic and relationship variables are controlled.

The spousal homicide rate among African Americans is significantly higher than for Whites. The incidence of homicide between partners is higher in interracial marriages when 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, ex-boyfriend, or ex-girlfriend. Of all violence against women committed by a single offender, an intimate partner is a perpetrator in approximately one-third of cases.

Lesbians report higher levels of sexual violence, in the range of 30% to 40%. There is some evidence that homosexual males also experience higher levels of sexual violence.

Approximately 10% of women who live with intimate female partners report being raped, physically assaulted, or stalked by their cohabitant. One-third of women living with a male partner reported victimization by their male cohabitant.

Approximately 15% of men living with a male intimate partner report being raped, physically assaulted, or stalked 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 are fleeing domestic violence.

Age

Women aged 16 to 24 years are more likely to be victims of violence at the hands of an intimate partner. Twenty to 30% of women who attend college report violence during a date.

Rates of spousal homicide peak in the 15 to 24-year-old age category. Rates decline with age in African Americans but not in whites.

As the age difference between males and females increases, so does the risk of spouse homicide.

Mortality and Morbidity

Approximately 2 million injuries and deaths occur each year as a result of domestic violence. About one-third of domestic violence patients will seek care in an emergency department. Injuries include over 40,000 gunshot wounds, stab wounds, fractures, internal injuries, and loss of consciousness; over 50,000 injured as a result of intimate partner sexual assault; and approximately 400,000 with soft tissue trauma.

• Most intimate partner murders are committed with firearms.
• The number of intimate partner homicides has decreased by about 15%.
• Almost half of the females murdered visited an emergency department within 2 years of the homicide.
• About 10% of females are abused at least once during pregnancy.
• Women are more commonly victims of intimate partner murder.
• A home in which anyone has been hurt in a family fight is approximately five times more likely to be the scene of a homicide.
• Females are the victims in 85% of intimate nonlethal violence.
• While it is commonly reported that women are more likely to be injured than men, some studies suggest male and female victims are equally affected by domestic violence.
• While males are less likely than females to be victims of gunshot wounds or be injured in an assault, they are more likely to be stabbed.

Elder

Due to underreporting and difficulty sampling, obtaining accurate incidence information on elder abuse and neglect is difficult. Elder abuse is thought to occur in three to 10% of the population of elders.

Edler patients may not report due to fear, guilt, ignorance, or shame. Clinicians underreport elder abuse due to poor recognition of the problem, lack of understanding of reporting methods and requirements, and concerns about physician-patient confidentiality.

The elderly may be unable to respond to a survey, not speak English, or have dementia, leading to inaccurate reports on the number of abused older persons. While obtaining the exact frequency of elder abuse is difficult, it will commonly be encountered in clinical practice. All healthcare providers must maintain a high index of suspicion.

Gender

Women are more commonly victims of intimate partner abuse. It is thought they report abuse at higher rates or because the severity of injuries is usually greater than in males. Some studies have found little or no differences based on gender.

Age

There is no universally accepted definition of when old age begins. As a result, statistics on elder abuse are highly variable. Typically, 60 or 65 years of age is the cutoff for being considered elderly.

Race

All racial, socioeconomic, and religious backgrounds are affected by elder abuse.

The estimated racial and ethnic distribution in older persons abused is on average:

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

Mortality and Morbidity

In the elderly population, victims of physical abuse and neglect have a much higher mortality rate than those who were never reported as abused. Early detection of elder abuse cases results in decreased morbidity and mortality. Healthcare provider involvement is important as only 1 in 6 victims will self-report mistreatment to the appropriate legal authorities.

Pathophysiology

There may be some pathologic findings in both the victims and perpetrators of domestic violence. Certain medical conditions and lifestyles make family and domestic violence more likely.[13][14][15]

Perpetrators

While the research is not definitive, several characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:

• Have a higher consumption of alcohol and illicit drugs, and assessment should include questions that explore drinking habits and violence
• Be possessive, jealous, suspicious, and paranoid
• Be controlling of everyday family activity including control of finances and social activities
• Suffer low self-esteem
• Have emotional dependence which tends to occur in both partners, but more so in the abuser

Children

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

• Approximately 45 million children will be exposed to violence during childhood.
• Approximately 10% of children are exposed to domestic violence annually, and 25% are exposed to at least one event during their childhood.
• Ninety percent are direct eyewitnesses of violence.
• Males who batter their wives batter the children 30% to 60% of the time.
• Children who witness domestic violence are at increased risk of dating violence and have a more difficult time with partnerships and parenting.
• Children who witness domestic violence are at an increased risk for post-traumatic stress disorder, aggressive behavior, anxiety, impaired development, difficulty interacting with peers, academic problems, and have a higher incidence of substance abuse.
• Children exposed to domestic violence often become victims of violence.
• Children who witness and experience domestic violence are at a greater risk of adverse psychosocial outcomes.
• Eighty to 90% of domestic violence victims abuse or neglect their children.
• Abused teens may not report abuse. Individuals 12 to 19 years of age report only about one-third of crimes against them, compared with one-half in older age groups

State

In Kentucky, KRS 600.020 states that an abused or neglected child "means a child whose health or welfare is harmed or threatened with harm when his parent, guardian, or other person exercising custodial control or supervision of the child."

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.

Pregnant and Females

The American College of Obstetricians and Gynecologists (ACOG) recommends all women undergo assessment for signs and symptoms of domestic violence during regular and prenatal visits. Providers 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 than preeclampsia and gestational diabetes.
• Reproductive abuse may occur and includes impregnating against a partner's wishes by stopping a partner from using birth control.
• Since most pregnant women receive prenatal care, this is an excellent time to assess for domestic violence.

Factors that predispose pregnant women to domestic violence include:

• Lack of social support
• Single
• 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. There is more stress, depression, and addiction to alcohol in abused pregnant women. These conditions may harm the fetus.

Gay, Lesbian, Bisexual, and Transgender

Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the rates are thought to be similar to a heterosexual woman, approximately 25%.

• There are more domestic violence cases among males living with male partners than among males who live with female partners.
• Females living with female partners experience less domestic violence than females living with males.
• Transgender individuals have a higher risk of domestic violence. Transgender victims are approximately 2 times more likely to experience physical violence.

Gay, lesbian, bisexual, and transgender victims 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 victims. Healthcare professionals should strive to help by working with gay, lesbian, bisexual, and transgender patients.

Men

Domestic violence is usually perpetrated by men against women; however, females may exhibit violent behavior against their male partners.

• Approximately 5% of males 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.
• Three out of 10 women at some point are stalked, physically assaulted, or raped by an intimate partner, compared to one out of every 10 men.
• Rape is primarily perpetrated by other men, while women engage in other forms of violence against men.

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

Elder

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

• Annually, approximately 2% experience physical abuse, 1% sexual abuse, 5% neglect, 5% financial abuse, and 5% suffer 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.
• Ten percent of nursing home staff self-report physical abuse against an elderly resident.

Elder domestic violence may be financial or physical. The elderly may be controlled financially. Elders are often hesitant to report this abuse if it is their only available caregiver. Victims 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 elder partners, it is usually part of a long-standing pattern of marital violence or as abuse developing in old age. In the latter case, abuse may be precipitated by issues related to dementia, disability, and changing family relationships.

Some states have a very high percentage of older residents and a concomitant higher percentage of elderly victims of domestic violence.

History and Physical

The history and physical exam should be tailored to the age of the victim. 

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 and/or malnourished. They may display inappropriate behavior such as aggression, or they might be shy, withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. School attendance is usually poor.

Specific injuries and associated findings 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, cords, among others
• 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. In a human bite, the inter-canine distance is usually greater than 3 centimeters.

Intimate Partner Abuse

Approximately one-third of women and one-fifth of men will be victims 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. One should be suspicious if the history is not consistent 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 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

Intimate Partner Abuse: Pregnancy and Female

Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions. There are a number of historical and physical findings that may help the provider identify individuals at risk.

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

If the examiner encounters these signs or symptoms, she should make every effort to examine the patient in private, explaining confidentiality to the patient. Be sure to ask caring, empathetic questions, and listen politely without interruption to answers.

Intimate Partner Abuse: Same-Sex

Same-sex partner abuse is common and may be difficult to identify. Over 35% of heterosexual women, 40% of lesbians, 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 make their sexual preferences public.

The provider should be aware there are fewer resources available to help individuals that are victims; further, the perpetrator and victim may have the same friends or support groups.

Intimate Partner Abuse: Men

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

Elder Abuse

Health professionals should ask geriatric patients about abuse, even if signs are absent.

Risk Factors

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

Healthcare providers should always maintain a high index of suspicion.

When evaluating a patient for elder abuse, ask simple questions in a non-threatening manner. Interview the patient and caregiver separately to detect disparities. Documentation should be accurate and objective. Be aware documentation may be used in criminal trials or guardianship hearings. Documentation should be accurate, complete, legible, and thorough. Quoting direct patient statements is helpful.

As part of the examination, disrobe the patient to evaluate for injuries. Make sure you evaluate back injuries, contusions, bruises, and decubitus ulcers.

The following clinical findings suggest more investigation is probably necessary:

• 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 caregiver and patient explanations
• Laboratory findings indicating not taking, underdosing, or overdosage of medications
• Rope marks
• Venereal disease
• Welts

During the physical examination, document the size, shape, and injury location. Take pictures or draw sketches.

The health provider should be aware elder abuse is not restricted to the home; it may occur in institutional settings. This may be due to poor training, stress, burnout, a heavy workload, low pay, and low job satisfaction; abuse is a common problem.

Evaluation

Domestic violence may be difficult to uncover when the victim is frightened, especially when they present to an emergency department or healthcare practitioner's office. The key is to establish an assessment protocol and maintain an awareness of the possibility that domestic and family violence may be the cause of the patient’s signs and symptoms. Screening should be carried out in primary care, obstetric and gynecologic, psychiatric, pediatric, urgent care, and emergency departments.

Establishing that injuries are related to domestic abuse is a challenging task. Life and limb-threatening injuries are priorities. After stabilization and physical evaluation, laboratory tests, X-rays, CT, or MRI may be indicated. It is important that healthcare professionals first attend to the underlying issue that brought the victim to the emergency department.

• The evaluation should start with a detailed history and physical examination. Clinicians should screen all females for domestic violence and refer females who screen positive. This includes females who do not have signs or symptoms of abuse. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring patients for intimate partner violence. Protocols should include referral, documentation, and follow-up.
• Health professionals and administrators should be aware of challenges such as barriers to screening for domestic violence: lack of training, time constraints, the sensitive nature of issues, and a lack of privacy to address the issues.
• Although professional and public awareness has increased, many patients and providers are still hesitant to discuss abuse.
• Patients with signs and symptoms of domestic violence should be evaluated. The obvious cues are physical: bruises, bites, cuts, broken bones, concussions, burns, knife, or 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. Abuse victims tend to have multiple injuries in various stages of healing, from acute to chronic.
• Domestic violence victims may have emotional and psychological issues, such as anxiety and depression. Complaints may include backaches, stomachaches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are more likely to experience asthma, irritable bowel syndrome, and diabetes.

Assessment

Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after the disclosure of abuse. Assessing safety is a priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.

• If there is no immediate danger, the assessment should focus on mental and physical health and establish a history of current or past abuse. These responses determine the appropriate intervention.
• During the initial assessment, a practitioner must be sensitive to the patient’s cultural beliefs. Incorporating a cultural sensitivity assessment with a history of domestic violence victims may allow more effective treatment.
• Patients that have suffered domestic violence may or may not want a referral. Many are fearful of their lives and financial well-being. Hence, they may be weighing the tradeoff in leaving the abuser leading to loss of support and perhaps the responsibility of caring for children alone. The healthcare provider needs to assure the patient that the decision is voluntary and that the provider will help regardless of the decision. The goal is to make resources accessible, safe, secure, and to enhance support.
• If the patient elects to leave their current situation, information for referral to a local domestic violence shelter to assist the victim should be given.
• If there is a risk to life or limb, or evidence of injury, the patient should be referred to local law enforcement officials.
• Counselors often include social workers, psychiatrists, and psychologists that specialize in the care of battered partners and children.

Testing

Children

A detailed history and careful physical exam should be performed. If head trauma is suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.

Laboratory

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

Urine

• A urine test may be used as a screen for sexually transmitted diseases. Also, bladder or kidney trauma may be suggested if there is blood in the urine.
• A urine toxicology screening is indicated if there is evidence of an altered level of consciousness, agitation, coma, or an apparent life-threatening event. It should also be ordered the child was discovered in a dangerous environment. Victims of child abuse have a positive urine drug screen up to 15% of the time.
• Basic urine toxicology is often unreliable, with the potential for both false positives and false negatives. Positive screens must be confirmed in cases of potential legal intervention.
• The chain of custody should be followed when sending a urine toxicology specimen to a laboratory. Confirmatory tests are usually sent to outside state-sponsored referral laboratories.

Hematology

If bruises or contusions are present, there is no need to evaluate for a bleeding disorder if the injuries are consistent with an abuse history. Some tests can be falsely elevated, so a child abuse-specialist pediatrician or hematologist should review or follow-up these tests.

Bleeding disorder tests should include:

• 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

• Consider liver and pancreas screening tests such as AST, ALT, and lipase. If the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L, consider an abdomen and pelvis CT with intravenous contrast.
• The highest-risk are those with abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15.
• A troponin level should be considered if there is any evidence of chest trauma such as abrasions, bruises, rib fractures, clavicle fractures, sternal fractures, or a fractured sternum. If elevated to greater than 0.04 ng/mL, consider obtaining a CT of the chest and an echocardiogram.

Imaging

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults such as cranial sutures and incomplete bone growth. A fracture can be misinterpreted. If there is a concern for abuse, consider consulting a radiologist.

Imaging: Skeletal Survey

A skeletal survey is indicated in children younger than 2 years with suspected physical abuse. The incidence of occult fractures is as high as 1 in 4 in physically abused children younger than 2 years. The clinician should consider screening all siblings younger than 2 years.

The skeletal survey should include two views of each extremity; anteroposterior and lateral skull; and lateral chest, spine, abdomen, pelvis, hands, and feet. A radiologist should review the films for classic metaphyseal lesions and healing fractures, most often involving the posterior ribs. A “babygram” that includes only one film of the entire body is not an adequate skeletal survey.

Skeletal fractures will remodel at different rates, depending on the patient's age, location, and nutritional status.

• Soft tissue swelling is present at zero to 10 days.
• Long bone fractures may take 10 to 21 days to form a soft callus.

Imaging: CT

Three-dimensional reconstruction CT imaging is more specific in detecting skull and rib fractures but involves greater radiation exposure.

If abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged 6 months or younger or children younger than 24 months if intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months.

An intravenous-contrast CT of the abdomen and pelvis is indicated in unconscious children; who have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds; abdominal pain, nausea, or vomiting; or have elevated AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.

Special Documentation

A photograph should be taken before treating injuries.

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

Intimate Partner and Elder

Laboratory

Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, and malnutrition. Tests to consider include:

• CBC
• Basic metabolic panel
• Urinalysis
• Sexually transmitted infection screening
• Calcium
• Magnesium
• Phosphorus
• Drug levels
• Ethanol level
• Urine drug screen

Imaging

• X-rays of bruised of tender body parts to detect fractures
• Head CT scan to evaluate for intracranial bleeding as a result of abuse or the causes of altered mental status

Other

• Pelvic examination with evidence collection if sexual assault

Evidence Collection

Domestic and family violence commonly results in the legal prosecution of the perpetrator. Preferably, a team specializing in domestic violence is called in to assist with evidence collection.

Each health facility should have a written procedure for packaging and labeling specimens and maintaining a chain of custody. Law enforcement personnel will often assist with evidence collection and provide specific kits.

It is important to avoid destroying evidence. Evidence includes tissue specimens, blood, urine, saliva, and vaginal and rectal specimens. Saliva from bites can be collected; the bite mark is swabbed with a water-moistened cotton-tipped swab.

Clothing stained with blood, saliva, semen, and vomit should be retained for forensic analysis.

Treatment / Management

The priority is the ABCs and appropriate treatment of the presenting complaints. However, once the patient is stabilized, emergency medical services personnel may identify problems associated with violence.[16][17][18]

Prehospital Care

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

• Emergency medical services personnel enter the environment where victimization occurs and may see evidence of the domestic and sexual violence that needs to be reported to the clinicians and possibly police.
• Reporting may be considered even when called into a home for a problem that is not necessarily directly related to abuse.
• Domestic violence victims may refuse ambulance transport after evaluation. Emergency Medical Service (EMS) health professionals may recognize domestic violence and suggest an appropriate intervention in such situations.

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

Emergency Department and Office Care

Interventions to consider include:

• Make sure a safe environment is provided.
• Diagnose physical injuries and other medical or surgical problems.
• Treat acute physical or life-threatening injuries.
• Identify possible sources of domestic violence.
• Establish domestic violence as the diagnosis.
• Reassure the patient that he is not at fault.
• Evaluate the emotional status and treat.
• Document the history, physical, and interventions.
• Determine the risks to the victim and assess safety options.
• Counsel the patient that violence may escalate.
• Determine if legal intervention is needed and report abuse when appropriate or mandated.
• Develop a follow-up plan.
• Offer shelter options, legal services, counseling, and facilitate such referral.

Evaluation and Management of Emotional Status

The patient needs to feel respected, cared for, listened to, and encouraged to make choices to the extent legally allowable. The victim should be informed:

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

Medical Record

The medical record is often evidence used to convict an abuser. A poorly document chart may result in an abuser going free and assaulting again.

Charting should include detailed documentation of evaluation, treatment, and referrals.

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

The immediate concern is for the safety of the abused patient and any immediate family. If there is any concern that the batterer or an individual who will report to the batterer is present, treat the patient alone, or have proper authorities present.[19][20]

The patient needs to know that health and safety are being taken seriously by healthcare professionals.

Joint Commission on Accreditation of Healthcare Organizations Requirements

Patients who are victims of alleged abuse or neglect have specialized needs during the assessment process. The Joint Commission requires hospitals to have policies for identifying, evaluating, managing, and referring victims.

• 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

• Determine if the patient will be in danger if returning home.
• Evaluate any threats by the perpetrator.
• Evaluate the patient's state of mind.
• Determine what type of help the patient is willing to accept.

Disposition

If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once they return home.

• A referral should be made to primary care or another appropriate resource.
• Advise the patient to have a safety plan and provide examples.

Safety Plan Elements

• Avoid arguments in small rooms or rooms without access to an outside door.
• Avoid alcohol and drugs that decrease the ability to protect or think logically.
• Develop escape routes through doors, windows, or fire escapes.
• Practice escape routes.
• Ask friends or neighbors to call the police if they hear suspicious noises.
• Arrange a code word for children or friends, so they know when to call for help.
• Teach children to use the telephone to contact the police or fire.

The Patient Should be Instructed to Have the Following Available in An Emergency

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

Shelters and Referral

In an emergency department setting, the primary goal after treating acute injuries is to bring the victim into contact with domestic violence shelters, social services, legal assistance, and support groups.

• The patient should be assisted in locating a safe haven; if an outpatient facility is not available, and there is no safe haven, overnight hospitalization could be considered, emphasizing that this for the patient's protection.
• The patient should be provided with the options available, including emergency shelter, contacting the police to obtain a restraining order, and services offered through support groups and hotlines.
• Some patients will choose to return to the relationship after seeking healthcare; nevertheless, the patient should be made aware of the options available to extricate the person from violence.

Consultations

• Obtain a consultation with a social worker, psychologist, or psychiatrist if the patient is suicidal or homicidal.

Deterrence

If an individual returns to a domestic violence situation she may be reinjured, sometimes with fatal outcomes.

• Appropriate suspicion, documentation, and referral can prevent further abuse.
• Prevention programs are available in many communities and typically target high-risk families.
• Long-term assessment and care vary with the needs of each patient.
• Follow-up assessment involves a visit to the home to evaluate the ongoing living environment, the family, and the condition of caregivers.
• Stress to competent patients who refuse help that abuse usually escalates.
• Inform patients that a number of programs can provide help; provide phone numbers and addresses.
• Encourage patients to develop safety and follow-up plans before they are discharged.

Remember

• Forty percent of domestic violence victims never contact the police.
• Of female victims of domestic homicide, 44% had visited a hospital emergency department within two years of their murder.
• Health professionals provide an opportunity for victims of domestic violence to obtain help.

Differential Diagnosis

The differential diagnosis varies with the injury type of injury and age.

Child

Head Trauma

• Accidental injury
• Arteriovenous malformations
• Bacterial meningitis
• Birth trauma
• Cerebral sinovenous thrombosis
• Hemophilia
• Leukemia
• Neonatal alloimmune thrombocytopenia
• Metabolic diseases
• Solid brain tumors
• Unintentional asphyxia
• Vitamin-K deficiencies

Bruises and Contusions

• Accidental bruises
• Birth trauma
• Bleeding disorder
• Coining
• Cupping
• Congenital dermal melanocytosis (Mongolian spots)
• Erythema multiforme
• Hemangioma
• Hemophilia
• Hemorrhagic disease
• Henoch-Schonlein purpura
• Idiopathic thrombocytopenic purpura
• Insect Bites
• Malignancy
• Nevi
• Phytophotodermatitis
• Subconjunctival hemorrhage from vomiting or coughing

Burns

• Accidental burns
• Atopic dermatitis
• Contact dermatitis
• Impetigo
• Inflammatory skin conditions
• Sunburn

Fractures

• Accidental
• Birth trauma
• Bone fragility with chronic disease
• Caffey disease
• Congenital syphilis
• Hypervitaminosis A
• Malignancy
• Osteogenesis imperfecta
• Osteomyelitis
• Osteopenia
• Osteopenia of prematurity
• Physiological subperiosteal new bone
• Rickets
• Scurvy
• Toddler’s fracture

Intimate Partner and Elder

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

Prognosis

Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity.

• Of those injured by domestic violence, over 75% continue to experience abuse.

• Over half of battered women who attempt suicide will try again; often, they are successful with the second attempt.

In children, the potential for poor outcomes is particularly high as abuse inflicts lifelong effects. In addition to dealing with the sequelae of physical injury, the mental consequences may be catastrophic. Studies indicate a significant association between child sexual abuse and increased risk of psychiatric disorders in later life. The potential for the cycle of violence to continued from childhood is very high.

Children raised in families of sexual abuse may develop:

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

Health Outcomes

There are multiple known and suspected negative health outcomes of family and domestic violence. There are long-term consequences to 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