Family and domestic violence (including child abuse, intimate partner abuse, and elder abuse) is a common problem in the United States and Florida. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence.
Unfortunately, each form of family violence begets interrelated forms of violence, and the "cycle of abuse" is often continued from exposed children into their adult relationships, and finally to the care of the elderly.
Intimate partner violence includes stalking, sexual and physical violence, and psychological aggression by a current or former partner. In the United States, as many as one in four women and one in nine men are victims of domestic violence. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity.
The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The numbers of individuals affected is expected to rise over the next 20 years with the increase in the elderly population.
Domestic and family violence is difficult to identify, and many cases go unreported to health professionals or legal authorities. Due to the prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and physicians will at some point evaluate and possibly treat a victim or perpetrator of domestic or family violence.
Questions Health Professionals Need to Consider
Healthcare Professional Recognition, Evaluation, and Referral
Family and domestic violence are abusive behaviors in which one individual gains power over another individual.
Center for Disease Control and Prevention
Domestic violence, spousal abuse, battering, or intimate partner violence, is typically the victimization of an individual with whom the abuser has an intimate or romantic relationship. The Centers for Disease Control and Prevention defines domestic as "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner."
Domestic and family violence has no boundaries. It occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referral.
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. It may include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner."
Domestic violence under Florida law is defined as "any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member." Family members must "reside in the same single dwelling unit, with the exception of persons who have a child in common."
Violence Abuse Types
The types of violence include stalking, economic, emotional or psychological, sexual, neglect, Munchausen by Proxy, and physical. Domestic and family violence occurs in all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or geographic limitation. It may occur in individuals with different sexual orientations.
Stalking is defined as repeated, unwanted attention that causes fear or concern for safety. This includes unwanted letters, emails, texts, or phone calls; watching, following, or spying; showing up repeatedly in the same place as the victim; damaging the victim’s property; making threats of harm.
Financial abuse occurs when an individual is forced to become dependent through improper use of money by a person in a trusting relationship. The abuser may also 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
Emotional or psychologic domestic violence includes verbal and non-verbal communication which inflicts emotional or mental harm. Emotional or psychologic violence may be subtle, but it is often very harmful to the victim; resulting in depression and suicide.
Emotional or physical abuse may involve convincing the victim that the violence is their fault, there is no way out of their situation, and the victim is worthless and needs the abuser to exist. Many abusers will isolate their victims from friends, family, school, and work.
Sexual violence is using physical coercion to force participation in unwanted sex acts. Perpetrators often incapacitate victims with alcohol or drugs. Some victims may be nursing home patients with mental disabilities or dementia.
Neglect occurs when the well-being of a child or elder is ignored by an individual who is responsible for that well-being. Neglect is defined as a failure to provide for a dependent’s emotional, physical, or social needs which includes hygiene, nutrition, clothing, shelter, and access to health care. The dependent is placed in a harmful situation. Abandonment is also a form of neglect.
Munchausen 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 he or she cares. The primary motive is to gain attention or sympathy. Unlike Munchausen syndrome, the deception involves not themselves, but someone under the person's care.
The use of physical power which results in injury, disability, or death are forms of physical violence. Other forms of physical violence include coercion, administering drugs or alcohol without permission, and denying medical care.
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 are unclear to the victims. The victims live in constant fear of the next violent attack. Violence and abuse are perpetrated in an endless cycle involving three phases: tension-building, explosive, and honeymoon.
In the tension-building phase, the abuser becomes more judgmental, temperamental, and upset; the victim may feel she is "walking on eggshells." Eventually, the tension builds to the point that the abuser explodes.
During this phase the victim may try to calm, stay away, or reason with the abuser; often to no avail. The abuser is often moody, unpredictable, screams, threatens, and intimidates. They may use children as tools to intimidate the victim and family. They often engage in alcohol and illicit drug use.
The explosive phase involves the victim attempting to protect themselves and the family, possibly by contacting authorities. This phase may result in injuries to the victim.
The abuser may start with breaking items that progress to striking, choking, and rape. The victim may be imprisoned. Emotional, verbal, physical, financial, and sexual abuse is common.
During the honeymoon phase, the victim may set up counseling, seek medical attention, and agree to stop legal proceedings. They may hold the mistaken belief and hope that the situation will not happen again. Unfortunately, this is rarely the case.
The abuser may apologize, agree to counseling, beg forgiveness, and give presents. They may declare love for the victim and family, and promise to "never do it again."
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.
Reason Abusers Need to Control
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, the gender roles can be reversed. Common risk factors include:
Domination may include emotional, physical or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.
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.
Domestic violence is a serious and challenging public health problem. Approximate one in three women and one in 10 men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1,500 deaths in the United States and as many as 200 deaths in Florida. In Florida, more than one in three women and one in four men experience physical violence, stalking, or rape.
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.
In Florida, a state task force has recommended standards to accurately measure the extent of domestic violence and develop strategies for education and increasing public awareness. The results include:
Domestic violence offenses result in approximately 200 deaths in Florida annually. Domestic violence accounts for approximately 20% of murders annually. The perpetrators are usually male and victims usually female. One-third of the perpetrators of domestic violence in Florida have a known "do not contact" order filed against them; one-fifth had a permanent injunction for protection against them filed by someone other than the victim; one-third were diagnosed with mental health disorders; one-half have a substance abuse history.
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.
Each year there are over three million referrals to child protective authorities. Despite often being the first to examine the victims, only about 10% of the referrals were from medical personnel. The fatality rate is approximately two deaths per 100,000 children. Women account for a little over half of the perpetrators.
Maltreatment of children is found in every race, culture, ethnicity, and socioeconomic status.
The genders are equally affected, but homicide rates are a little 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 result in increased 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 one to four years, and over 80% of fatalities from child abuse are in children younger than four.
Intimate Partner Violence
According to the CDC, one in four women and one in seven men will experience physical violence by their intimate partner at some point during their lifetimes. About one in three women and nearly one in six 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 six women and one in 19 men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about six in 10 female victims and four in 10 male victims.
At least five million acts of domestic violence occur annually to women aged 18 years and older, with over three 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.
African American, American Indian, Alaskan Native women and men, and Hispanic women, report higher rates of domestic violence. 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.
Women are more likely to be attacked, injured, or raped by their partners than by any other person. According to the United States Department of Justice, women are six times more likely than men to experience violence committed by a spouse or ex-spouse, boyfriend or girlfriend, or ex-boyfriend or ex-girlfriend. Of all violence against women that is 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.
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 two 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.
Due to under-reporting 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 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 older persons who are abused. While obtaining the exact frequency of elder abuse is difficult, it will be encountered commonly in clinical practice. All healthcare providers must maintain a high index of suspicion.
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.
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 considered elderly.
All racial, socioeconomic, and religious backgrounds are affected by elder abuse.
The estimated racial and ethnic distribution in older persons abused is on average:
Mortality and Morbidity
In the elderly population, victims of physical abuse and neglect have a much higher mortality rate than those never reported as abused. Early detection of elder abuse cases results in decreased morbidity and mortality. Healthcare provider involvement is important as only one in six victims will self-report mistreatment to the appropriate legal authorities.
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.
While the research is not definitive, a number of characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:
Domestic violence at home results in emotional damage which exerts continued effects as the victim matures.
According to Florida law, witnessing domestic violence is defined as "violence in the presence of a child if an offender is convicted of a primary offense of domestic violence, and that offense was committed in the presence of a child under age 16 who is a family or household member with the victim or perpetrator."
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 be assessed for signs and symptoms of domestic violence, during regular and prenatal visits. Providers should offer support and referral information.
Factors that predispose pregnant women to domestic violence include:
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%.
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 be helpful when working with gay, lesbian, bisexual, and transgender patients.
Usually domestic violence is perpetrated by men against women; however, females may exhibit violent behavior against their male partners.
Although women are the most common victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.
Elders are often mistreated by their spouses, children, or relatives.
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 elder victims of domestic violence.
The history and physical exam should be tailored to the age of the victim.
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 may 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:
Human bites can be differentiated from animal bites in that an animal bite will have torn flesh. In a human bite, the intercanine distance is usually greater than three 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:
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.
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 woman, 40% of lesbians, 60% of bisexual woman 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 the incidence may be underreported. These victims may have a history of child abuse.
Health professionals should ask geriatric patients about abuse, even if signs are absent.
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 suggestion more investigation should be considered:
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.
Domestic violence may be difficult to uncover when the victim is frightened, especially when he or she presents 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 the priority. 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.
Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.
A detailed history and careful physical exam should be performed. If head trauma is suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.
Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings similar to child abuse, as a consequence, they must be ruled out.
If bruises or contusions are present, there is no need 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:
Gastrointestinal and Chest Trauma
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 two years with suspected physical abuse. The incidence of occult fractures is as high as one in four in physically abused children younger than two years. The clinician should consider screening all siblings younger than two years.
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 which are dependent on the age, location, and nutritional status of the patient.
Three-dimensional reconstruction CT imaging is more specific in detecting skull and rib fractures but involves greater exposure to radiation.
If abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged six 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.
A CT of the abdomen and pelvis with intravenous contrast is indicated in children who are unconscious, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.
A photograph should be taken before treatment of injuries.
Intimate Partner and Elder
Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, and malnutrition. Tests to consider include:
Domestic and family violence commonly results in 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 how to package and label specimens and maintain a chain of custody. Law enforcement personnel will often assist with evidence collection, and provide specific kits.
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.
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.
The priority is stabilization of injuries. Once this is achieved, prehospital professionals should consider the following:
All EMS personnel should be trained to recognize the signs of domestic violence and be able to offer guidance.
Emergency Department and Office Care
Interventions to consider include:
Evaluation and Mangement 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:
Emotional Findings in Domestic Violence Victims
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.
The immediate concern is for the safety of the abused patient and any immediate family. If there is any concern the batterer or an individual that will report to the batterer is present, treat the patient alone, or with proper authorities present.
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 the identification, evaluation, management, and referral of victims.
Risk Determination Before Discharge
Questions to Consider Before Discharge
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 the patient returns home.
Safety Plan Elements
The Patient Should be Instructed to Have the Following Available in An Emergency
Shelters and Referral
In an emergency department setting, the primary goal after treatment of acute injuries is to bring the victim into contact with domestic violence shelters, social services, legal assistance, and support groups.
If an individual returns to a domestic violence situation she may be reinjured, sometimes with fatal outcomes.
The differential diagnosis varies with the injury type of injury and age.
Bruises and Contusions
Intimate Partner and Elder
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.
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:
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:
Screening: Reporting Family and Domestic Violence
Over 80% of victims of domestic and family violence seek care in a hospital; others may seek care in health professional offices, including dentists, therapists, and other medical offices. Routine screening should be conducted by all healthcare practitioners including nurses, physicians, physician assistants, dentists, nurse practitioners, and pharmacists. Screening is a critical component protecting victims and minimizing negative health outcomes.
Health professional interventions reduce the incidence of morbidity and mortality associated with domestic violence.
Screening: Child Abuse
Child abuse and neglect may result in acute trauma, anxiety, depression, unwanted pregnancy, substance abuse, 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 are poverty, low education, large family size, single-parent, young parents, step-parents in the home, and psychiatric disease.
Clinicians must take responsibility to identify child abuse to prevent recurrent injuries. While it has not been established that routine child abuse screening is necessary, clinicians should screen for abuse if it is suspected. Multiple missed appointments and delays in seeking medical treatment are indicators of neglect.
Many organizations offer free screening tools. However, most lack sufficient sensitivity and specificity. False-positive and false-negative results can entail serious consequences including both under- and overreporting of abuse.
Screening: Intimate Partner Violence
Some experts believe screening should only occur when signs and symptoms are present. Routine screening may, in fact, be problematic because it can stigmatize patients and result in anxiety. Further, in cases of domestic violence, victims are often unwilling to use available resources to end abuse.
Several national organizations, such as the American Medical Association and Family Violence Prevention Fund recommend screening all women for intimate partner violence. Screening tools for abuse are available for assessment, intervention, documentation, and referral.
Studies have shown that abused women who receive counseling have fewer instances of intimate partner violence during and after pregnancy.
Screening has the potential to decrease abuse and improve health outcomes. While victims may not be willing to use the information provided, serious consequences follow if abuse is ignored. A clinician can provide the resources in an effort to ensure that the patient is educated and informed.
The Center for Disease Control and Prevention (CDC) provides numerous tools to assist practitioners in the free publication, Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. These tools include:
Screening: Elder Abuse
Elderly patients are at risk of abuse in the home environment as well as in institutional settings. Risk factors for elder abuse both at home and in institutions include increased age, dementia, abnormal behaviors, cognitive decline, physical dependency, and daily living activities impairment. In an institutional setting, there may be shortages of qualified assistants, and nurse’s aids and other support staff become tired, stressed, and overwhelmed, resulting in anger and aggression that may be taken out on patients.
Screening for elder abuse should include a review of social and financial information.
The Abuse Suspicion Index is a screening tool for cognitively intact patients. In patients with dementia, often the practitioner must rely on the physical exam. Bruising can be an indicator of physical; however, elders commonly take blood thinning agents that result in easy bruising. Victims of physical abuse tend to have bruises that are larger than five centimeters, and they tend to be located on the face, lateral right arm, or posterior torso. In many instances, the victim may recall how the bruise occurred.
If abuse is suspected, radiographs of ribs, small bones, and face should be considered. A CT of the head should also be considered to rule out subdural hemorrhage. While difficult, a pelvic examination should be considered if there are any signs of sexual abuse. Weight loss may be a sign of physical or medical neglect due to malnutrition. Other common causes of weight loss should be ruled out. Pressure ulcers should raise suspicion for neglect.
All clinicians should be aware of the potential signs and symptoms of elder abuse and should be familiar with screening tools. When abuse is suspected, the history and physical exam should be carefully conducted and documented with additional laboratory, and imaging tests considered.
While screening is crucial to identify domestic and family, several barriers exist. In spite of the prevalence of domestic violence, many clinicians do take the time to screen patients. Unfortunately, no universal approach has been established to assess for domestic violence. In addition, many clinicians do not have the time, resources, or desire to get involved with abuse or neglect investigation. Many health 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 health professionals are prosecuted for failure to comply, further hindering reporting. Routine screening increases the odds domestic abuse cases will be identified.
Ongoing challenges include:
Federal Child Abuse Prevention and Treatment Act (CAPTA)
Each state has specific child abuse statues. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure recent act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation.
Elder Justice Act
The Elder Justice Act provides strategies to decrease the likelihood of elder abuse, neglect, and exploitation. The Act utilizes three significant approaches:
Patient Safety and Abuse Act
The Violence Against Woman Act makes it a federal crime to cross state lines to stalk, harass, or physically injure a partner; or enter or leave the country violating a protective order. It is a violation to possess a firearm or ammunition while subject to a protective order or if convicted of a qualifying crime of domestic violence. The victim also has a right to:
Florida Statute 415.502 requires anyone “who knows, or has reasonable cause to suspect, that a child is an abused or neglected child, shall report such knowledge or suspicion.” Thus, health professionals report when there is suspicion. Health professionals do not need confirmatory proof. Health professionals must report all cases of reasonable cause to believe that a child or adolescent has been abused or neglected or is in danger of being abused.
In Florida, the reporting requirement is not limited to the first person reporting. In other words, a health professional cannot assume that the report has been made. Health professionals must always make a report if he suspects a child is or has been abused.
Florida Statute 456.031 mandates a two-hour continuing education course on domestic violence as part of every third biennial re-licensure or recertification for health care providers.
Florida. Statute 626.9541 (1)(g)(3) applies to health, life, disability and property insurance. Florida insurance carriers cannot refuse to issue, reissue, or renew a policy, refuse to pay a claim, cancel or otherwise terminate a policy, or increase rates based upon the fact that the proposed insured has made a claim or sought or should have sought medical or psychological treatment in the past for abuse.
Florida Statute 741.316 allows for the establishment of domestic violence fatality review teams at a local, regional, or state level in order to review fatal and near-fatal incidents of domestic violence, related domestic violence matters, and suicides. Membership must include a representative from the Office of the Medical Examiner and other victim’s services.
Florida Statute 790.24 requires any physician, nurse, or employee thereof and any employee of a hospital, sanitarium, clinic, or nursing home who knowingly treats or is requested to treat any person suffering from a gunshot wound or life-threatening injury indicating an act of violence to report immediately to the sheriff’s department. Willful failure to report is punishable as a misdemeanor.
Florida Statute 877.155 requires any person who treats, or is requested to treat, second or third degree burns affecting 10% or more of the body, to report such treatment to the sheriff’s department if the burns were caused by a flammable substance and if the injury could be the result of violence or other unlawful activity.
The following agencies provide national assistance for victims of domestic and family violence:
To report abuse of children, the disabled, and the elderly:
For information and referral relating to domestic violence:
For further local assistance, the police and sheriff’s departments and local shelters should be contacted.
A Multidisciplinary Approach at Domestic Violence
In cases of acute injury or emergency, contact local law enforcement.
A 24-hour toll-free domestic violence hotline is available for counseling and information at 800-500-1119. The counselors will refer the victim to a local domestic violence center.
Florida has several domestic violence centers that will provide referral services, counseling, a 24-hour hotline, emergency shelter, educational services, assessment and referral of parents with children, and local training of law enforcement personnel.
If child abuse is suspected, contact the Children and Family Services, Department of Social Services, or National Child Abuse Hotline: 1-800-4-A-Child.
Healthcare professionals play a crucial role in the screening, identification, and reporting of child abuse. Using screening tools in clinical practice can increase the odds that child abuse will be identified.
It is important to be aware of federal and state statutes governing domestic and family abuse. Remember that reporting domestic and family violence to law enforcement does not obviate detailed documentation in the medical record.
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