Continuing Education Activity

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." A state task force has been developed to enhance education and increase public awareness. This task force has made several changes geared toward improvements in the detection and prevention of domestic violence. Florida now has legislation requiring all physicians, osteopaths, nurses, dentists, dental hygienists, midwives, psychologists, and psychotherapists to obtain two hours of domestic violence education every third renewal period. Domestic Violence Data Resource Center (DVDRC) and Domestic Violence Fatality Review Teams have been established to examine cases of domestic violence that result in a fatality and to identify potential changes in policy that might prevent future deaths. The "Family Protection Act" requires a five-day jail term for any domestic battery crime in which the perpetrator deliberately injures the victim. The law makes a second battery crime a felony offense. A statute to the Family Protection Act includes dating relationships of six months or more, and another statute requires judges to inform victims of their rights, such as the right to appear, be notified, seek restitution, and make a victim-impact statement. The Domestic Violence Leave Act requires employers with 50 or more employees to provide guaranteed leave for domestic violence issues. This activity describes evaluation and management strategies for Florida victims of domestic abuse and stresses the role of team-based interprofessional care for these victims.

Objectives:

• Describe the cycle of abuse.
• Describe the types of domestic and family violence.
• Describe signs and symptoms of domestic violence.
• Explain interprofessional team strategies for improving care coordination and communication to identify and assist victims of domestic violence.

Introduction

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.[1][2][3]

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.

Domestic and family violence include a range of abuse including economic, physical, sexual, emotional, and psychological toward children, adults, and elders.[4][5]

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.[6][7][8]

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

1. What are the risk factors, signs, and symptoms of domestic or family violence?
2. What are the characteristics that define domestic or family violence?
3. What information is available to help health professionals assist the needs of victims of domestic or family violence?
4. What are the ethical and legal reporting requirements?

Healthcare Professional Recognition, Evaluation, and Referral

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

General Definitions

Family and domestic violence are abusive behaviors in which one individual gains power over another individual.

• Intimate partner violence typically includes sexual or physical violence, psychological aggression, and stalking. This may include former or current intimate partners.
• Child abuse involves the emotional, sexual, physical, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm.
• Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an elder.

National Definitions

Center for Disease Control and Prevention

Domestic violence, spousal abuse, battering, and intimate partner violence are terms used to describe 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.

Florida Definitions

Department of Children and Families

Domestic violence is defined by the Florida Department of Children and Families as "a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and control. 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."

Statutes

Domestic violence under Florida law is defined as "any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of 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

Violent abuse takes many forms, including stalking, economic abuse, emotional or psychological abuse, sexual abuse, neglect, Munchausen by Proxy, and physical abuse. 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

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.

Economic Abuse

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 Abuse

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, that there is no way out of their situation, and that the victim is worthless and needs the abuser to exist. Many abusers will isolate their victims from friends, family, school, and work.

Examples include:

• Child Relationship Control: Deliberately damaging relationship with a child
• Coercive: Limiting resource access, possessiveness, and constant monitoring
• Exploitation: Use of consequence to control choices, for example, “If you call the protective service, I could go to jail, and you will have no financial support.”
• Expressive: Name-calling, degradation, and threats
• Gaslighting: Presenting false information making the victim doubt his or her memory and perception; making victims question their sanity 
• Reproductive Control: Refusing birth control or forced pregnancy terminations
• Threats: Use of gestures, words, or weapons that future harm may occur

Sexual Abuse

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.

Categories include:

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

Neglect 

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.  These include hygiene, nutrition, clothing, shelter, and access to health care. 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.

Physical Abuse

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.

Examples include:

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

The Cycle of Abuse and Violence

Usually, abuse begins with verbal threats that escalate to physical violence. Violent events are often unpredictable, and the triggers 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.[9][10]

Tension-building Phase

In the tension-building phase, the abuser becomes more judgmental, temperamental, and upset; the victim may feel she is "walking on eggshells." Eventually, the tension builds to the point that the abuser explodes.

During this phase the victim may try to calm, stay away, or reason with the abuser; often to no avail. The abuser is often moody, unpredictable, screams, threatens, and intimidates. They may use children as tools to intimidate the victim and family. They often engage in alcohol and illicit drug use.

Explosive Phase

The explosive phase involves the victim attempting to protect themselves and the family, possibly by contacting authorities. This phase may result in injuries to the victim.

The abuser may start with breaking items that progress to striking, choking, and rape. The victim may be imprisoned. Emotional, verbal, physical, financial, and sexual abuse is common.

Honeymoon Phase

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."

Etiology

Domestic and family violence, which includes child abuse, intimate partner violence, and elder abuse, frequently 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.[11][12][13]

Reason Abusers Need to Control

• Anger management issues
• Jealousy
• Low self-esteem
• Feeling inferior due to less education
• Feeling inferior due to poor socioeconomic 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 for Domestic and Family Violence

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.[14]

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:

• 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 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.

Epidemiology

Domestic violence is a serious and challenging public health problem. Approximate one in three women and one in ten 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.[12][15][16]

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 Trends

• 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 that 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 Statutes

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:

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

In Florida, domestic violence offenses result in approximately 200 deaths each year. Domestic violence accounts for approximately 20% of murders annually. The perpetrators are usually male and the 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 that was filed by someone other than the victim; one-third were diagnosed with mental health disorders; one-half have a substance abuse history.[17][18][19]

Epidemiology of Child Abuse 

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.

Race

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

Gender

Males and females are equally affected, but homicide rates are slightly higher in males.

Morbidity and Mortality

Children may experience pain, humiliation, fear, loss of self esteem, and injury. Physical injury may range from minor trauma to disfigurement, 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 self esteem, 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.

Epidemiology of 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 ten million people each year.

One in six women and one in nineteen men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about six in ten female victims and four in ten male victims.

At least five million acts of domestic violence to women aged 18 years and older occur annually; over three million of these acts involve men. While most events are minor (these include 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 ten victimizations per 1,000 persons age 12 or older to approximately four per 1,000.[1][3][20]

Race

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.

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 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 report that they 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 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.  Each year, approximately 400,000 report soft tissue trauma.  50,000 report injury related intimate partner sexual assault, and 40,000 report more severe injuries such as gunshot wounds, stab wounds, fractures, internal injuries, and loss of consciousness.  Additional facts include the following:

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

Epidemiology of Elder Abuse 

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 3 to 10% of the population over 65.[21]

Elderly 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.

Gender

Women are more commonly victims of intimate partner elder 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 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 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.

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.

Characteristic of Perpetrators

While the research is not definitive, a number of 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

Findings in 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, and academic problems.  They also 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 for adverse psychosocial outcomes.
• 80% 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

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."

• In Florida, approximately seven percent of domestic homicide victims were children killed by a parent.

Healthcare professionals who treat children and adolescents should understand the signs and symptoms of domestic violence and intervene quickly to protect young children and adolescents from further abuse.

Findings in Pregnant 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.[22]

• 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, the act of impregnating a woman against her wishes by stopping her from using birth control, may occur.
• 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 status
• Young maternal age
• Lower socioeconomic status
• Unintended pregnancy
• Delayed prenatal care
• Use of alcohol, drugs, or tobacco

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

Findings in Gay, Lesbian, Bisexual, and Transgender

Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the rates are thought to be appoximately 25%, similar to  the rate in heterosexual women.[23]

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

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.

Findings in Men

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

• Approximately five percent 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 victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.

Findings in Elders

Elderly individuals are often mistreated by their spouses, children, or relatives.[21]

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

Elder 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 partner 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.

History and Physical

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

Common Findings in Child Abuse 

The most common injuries are fractures, contusions, bruises, and internal bleeding. Unexpected injuries to pre-walking infants should be investigated. The caregiver should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries should be investigated.

Children who are abused may be unkempt and/or malnourished. Some display inappropriate behavior such as aggression, while others are shy, withdrawn, and have poor communication skills. Some children may also be disruptive or hyperactive. School attendance is usually 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 intercanine distance is usually greater than three centimeters.

Common Findings in Intimate Partner Abuse 

Approximately one in three women and one in five 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

Abuse during Pregnancy

Abuse during pregnancy may cause as many as 10% of hospital admissions in this population. 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
• Overcompliance
• 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.

Same Sex Abuse

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.

Abuse in 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.

Abuse in Elders 

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 to evaluate for back injuries, contusions, bruises, and decubitus ulcers.

The following clinical findings should prompt more investigation:

• Agitation
• Bruises
• Burns
• Decubitus ulcers
• Dehydration
• Depression
• Injuries in various stages of evolution
• Lacerations
• Unexplained injuries
• Treatment delays
• Inconsistent injury to the history
• Poor hygiene
• Contradictory 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 that aware elder abuse by caregivers is a common problem that can occur in both home and institutional settings. Factors that increase the risk of elder abuse by caregivers include poor training, stress, burnout, a heavy workload, low pay, and low job satisfaction.  

Evaluation

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.[24][25][26]

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, and imaging (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.

Patient Assessment

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.[27][28]

• If there is no immediate danger, the assessment should focus on the mental and physical health and establish the 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 being victims of domestic violence 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.  As a result, they may be hesistant to leave due to their inability to support themselves or their children. 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, 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 for Suspected Abuse in 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 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.

Urine Testing

• A urine test may be used as a screen for sexually transmitted disease. Bladder or kidney trauma should be considered 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 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.

Evaluation for Bleeding disorders 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: X-Ray and Skeletal Survey

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.

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.

• 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 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.

Special Documentation

A photograph should be taken before treatment of 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.

Testing for Suspected Abuse in Adults

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 or 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 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.

Treatment / Management

The priority should be to treat any life-threatening injuries and stabilize the patient's medical condition. Once the patient is stable, emergency medical services personnel may identify problems associated with violence.[29][30][31]

Prehospital Care

The priority is 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. In such situations, Emergency Medical Service (EMS) health professionals may recognize domestic violence and suggest an appropriate intervention.

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

Emergency Department and Office Care

The following interventions should be considered:

• Provide a safe environment
• 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 these referrals

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 in plain, simple language that:

• There is no excuse for domestic violence
• Violence is not the patient's fault
• No one deserves to be abused
• It is difficult to face the situation, but resources like support, shelter, and legal advice are available
• Appropriate intervention decreases the likelihood of anxiety, depression, substance abuse, counterphobic behavior, and PTSD

When counseling and examining the patient:

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

Emotional Findings in Domestic Violence Victims

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

Documentation in Medical Record 

The medical record is often evidence used to convict 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 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.
  • Photograph Torn and damaged clothing 
  • Document injuries not shown clearly by photographs with line drawings.
  • Preserve physical evidence that may be used for prosecution.
• In cases of sexual assault, follow protocols for physical examination and evidence collection
  • Consent the patient, parent, or legal guardian.
  • Perform legally required notifications.
• Make referrals and assure a safe environment

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.

• 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

Questions to Consider Before Discharge

• Does the patient need a medical or psychiatric intervention?
• Is admission or urgent follow-up required for medical conditions?
• Does the patient express suicidal or homicidal ideation?
• Does the patient need urgent crisis counseling to deal with the stress of abuse?
• Who is waiting outside for the patient?
• Does the patient believe it is safe to go home?
• Where is the batterer now?
• Was the batterer arrested?
• Does the batterer have access to a weapon?
• Has the batterer threatened to kill the victim?
• Has the batterer been harassing or stalking the victim?
• Have abusive behaviors been escalating?
• Does the patient have friends or family with whom she or he can stay?
• Is there a danger the batterer will come home?
• Is the patient confident family or friends will not inadvertently collude with the batterer in the belief they are helping the couple?
• In what type of living situation are children and other dependents?
• Does the patient feel safe?
• Is the patient afraid of harm if going home?
• Does the patient want access to a shelter?

Disposition

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.

• 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 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

Job Safety

• Is there someone at work who can be informed of the situation and assist if needed?
• Can calls and visitors be screened?
• Make sure the patient has a plan for safely arriving and leaving work.
• Suggest they vary the time of arrival and departure to and from the children's school and work.

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.

• 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. Emphasize that this option is 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 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 or he 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.

Things to Remember

• Fouty 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.

Different Diagnosis for Child Abuse

Head Trauma

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

Bruises and Contusions

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

Burns

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

Fractures

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

Differential Diagnosis for Adult Abuse 

• 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.[5][20][32]

• 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 because 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

Pearls and Other Issues

Screening for 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 settings. 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.[2][33][34]

Health professional interventions reduce the incidence of morbidity and mortality associated with domestic violence.

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

Screening Tools

• The American Academy of Pediatricians has free guides for the history, physical, diagnostic testing, documentation, treatment, and legal issues in cases of suspected child abuse.
• The Kempe Family Stress Inventory questionnaire assesses maltreatment in young single women of low socioeconomic status.
• The Maternal History Interview uses open-ended questions and subscales to assess personality, parenting skills, life stress, and child abuse risk.
• The Center for Disease Control provides several scales assessing family relationships, including child abuse risks.
• The physical examination is still the most significant diagnostic tool to detect abuse. A child or adult with suspected abuse should be undressed, and a comprehensive physical exam should be performed. The skin should be examined for bruises, bites, burns, and injuries in different stages of healing. Examine for retinal hemorrhages, subdural hemorrhages, tympanic membrane rupture, soft tissue swelling, oral bruising, fractured teeth, and organ injury.

Screening for Child Abuse

Child abuse and neglect 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 may indicate abuse or neglect.

Many organizations offer free screening tools. However, most lack sufficient sensitivity and specificity. False positive and false negative results can entail serious consequences including both under- and overreporting of abuse.

Screening for Intimate Partner Violence

Some experts believe screening should only occur when signs and symptoms are present. Routine screening may, 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:

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

Screening for 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. Nursing 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 useful screening tool for cognitively intact patients. In patients with dementia, the practitioner must rely more heavily on the physical exam. Bruising can be an indicator of physical abuse, but elders commonly take blood thinning agents that result in easy bruising. Victims of physical abuse tend to have bruises with the following characteristics: bruises of varying age; bruises larger than five centimeters; bruises 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, but 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.

Challenges in Screening 

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 an 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:

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

Screening Recommendations

• Evaluate for organic conditions and medications that mimic abuse.
• Evaluate patients and caregivers separately
• Clinicians should regularly screen for family and domestic violence and elder abuse
• The Elder Abuse Suspicion Index can be used to assess for elder abuse
• Screen for cognitive impairment before screening for abuse in the elderly
• Pattern injury is more suspicious

National Statutes

Federal Child Abuse Prevention and Treatment Act (CAPTA)

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

Elder Justice Act

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

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

Patient Safety and Abuse Act

The Violence Against Woman Act makes it a federal crime to cross state lines to stalk, harass, or physically injure a partner.  Entering or leaving the country also violates the protective order. Finally, 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 has a right to:

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

State Statutes

Florida Statute 415.502 requires anyone “who knows, or has reasonable cause to suspect, that a child is an abused or neglected child, shall report such knowledge or suspicion.” 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.[17][35][36]

In Florida, the reporting requirement is not limited to 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.

National Resources

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

• Centers for Disease Control and Prevention: 800-CDC-INFO (800-232-4636) / TTY 888-232-6348
• Childhelp: National Child Abuse Hotline: 800-4-A-CHILD (800-422-4453)
• The coalition of Labor Union Women (cluw.org): 202-466-4615
• Corporate Alliance to End Partner Violence: 309-664-0667
• Employers Against Domestic Violence: 508-894-6322
• Futures without Violence: 415-678-5500 / TTY 800-595-4889
• Love Is Respect: National Teen Dating Abuse Helpline: 866-331-9474 / TTY: 866-331-8453
• National Center on Domestic and Sexual Violence
• National Center on Elder Abuse
• National Coalition Against Domestic Violence (www.ncadv.org)
• National Network to End Domestic Violence: 202-543-5566
• National Organization for Victim Assistance
• National Resource Center on Domestic Violence: 800-537-2238 
• National Sexual Violence Resource Center: 717-909-0710
• National Teen Dating Abuse Helpline: 866-331-9474 / TTY 866-331-8453
• Rape Abuse and Incest National Network (RAINN): 800-656-HOPE
• Sexual Assault Training and Investigations (SATI) (mysati.com): 619-561-3845
• Speaking Out About Rape (SOAR): 407-898-0693
• Stalking Resource Center, National Center for Victims of Crime: 1-800-FYI-CALL (800-394-2255) / TTY: 800-211-7996
• The Battered Women's Justice Project: 800-903-0111
• The National Center for Victims of Crime (www.victimsofcrime.org)
• The National Domestic Violence Hotline (www.thehotline.org): 800-799-7233 / TTY 1-800-787-3224
• U.S. Department of Justice, Office on Violence Against Women: 202-307-6026
• Workplaces Respond to Domestic and Sexual Violence: A National Resource Center (www.workplacesrespond.org

State Resources

To report abuse of children, the disabled, and the elderly:

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

For information and referral relating to domestic violence:

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

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

Enhancing Healthcare Team Outcomes

An Interprofessional Approach at Domestic Violence

• Healthcare professionals should document all findings and recommendations in the medical record, including statements made denying abuse
• If domestic violence is admitted, documentation should include the history, physical examination findings, laboratory and radiographic finds, any interventions, and the referrals made.
• If there are significant findings that can be recorded, pictures should be included.
• The medical record may become a court document, so it is critical to be both objective and accurate.
• Healthcare professionals should provide a follow-up appointment.
• Reassurance that additional assistance is available at any time is critical to protect the patient from harm and break the cycle of abuse.

Reporting

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.

Obstacles to Reporting

• Attitudes of clinicians
• Belief of unreasonable intrusion
• Concern over being sued for reporting
• Concern over violating privacy

Legal Considerations

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.

• Failure report child abuse is illegal in most states.
• Failure to report intimate partner and elder abuse is illegal in many states.
• Battering is a crime, and the patient should be made aware that help is available. If the patient wants legal help, the local police should be called.
• In some jurisdictions, domestic violence reporting is mandated. The legal obligation to report abuse should be explained to the patient.
• The patient should be informed how local authorities typically respond to such reports and provide follow-up procedures. Address the risk of reprisal, need for shelter, and possibly an emergency protective order (available in every state and the District of Columbia).
• If there is a possibility the patient’s safety will be jeopardized, the clinician should work with the patient and authorities to best protect the patient while meeting legal reporting obligations.
• The clinical role in managing an abused patient goes beyond obeying the laws that mandate reporting; there is a primary obligation to protect the life of the patient.
• The clinician must help mitigate the potential harm that results from reporting, to provide appropriate ongoing care and preserve the safety of the patient.
• The health professional should remain during the interview if it is desired by the patient and is acceptable to the police.
• The medical record should reflect the incident as described by the patient and any physical exam findings. Include the date and time the report was taken and the officer's name and badge number.