Domestic Violence Assessment

Intimate Partner Violence
-Physical and/or sexual violence, use of physical force, or threat of such violence
-Psychological or emotional abuse and/or coercive tactics after prior physical violence between persons who are spouses or nonmarital partners, or former spouses or nonmarital partners
CDC
Child Abuse and Neglect
-Defined at both Federal and State level
-The Child Abuse and Prevention Treatment Act, CAPTA dictates minimum standards that must be incorporated into state statutes
Neglect- state statues
failure to provide for a child’s basic physical, educational, medical, and emotional needs
Physical abuse- state statues
physical injury due to punching, beating, kicking, biting, burning, shaking, or otherwise harming a child; even if parent or caretaker did not intend harm, such acts are considered abuse when done purposefully
Sexual abuse- state statues
includes fondling child’s genitals, incest, penetration, rape, sodomy, indecent exposure, and exploitation through prostitution or production of pornographic materials
Emotional abuse- state statues
any pattern of behavior that harms child’s emotional development or sense of self-worth; includes frequent belittling, rejection, threats, and withholding of love and support
Elder Abuse and Neglect
-Almost every state has some form of mandatory reporting of abused elderly and other vulnerable patients
-As mandatory reporters of abuse, you need only have **suspicion** that elder abuse and/or neglect may have occurred in order to call authorities
-Many nurses, physicians, and social workers are erroneously under the assumption that they must have proof of abuse before calling authorities
AMA definitions of elder abuse and neglect:
Physical abuse

violent acts that result or could result in injury, pain, impairment, and/or disease
AMA definitions of elder abuse and neglect: Physical neglect
failure of family or caregiver to provide basic goods and services such as food, shelter, health care, and medications
AMA definitions of elder abuse and neglect: Psychological abuse
behaviors that result in mental anguish
AMA definitions of elder abuse and neglect: Psychological neglect
failure to provide basic social stimulation
AMA definitions of elder abuse:
Financial abuse

intentional misuse of elderly person’s financial and material resources
AMA definitions of elder abuse: Financial neglect
failure to use elderly person’s assets to provide needed services
Health Effects of Violence
-Violent experiences have significant effects on women’s health
-Injury serious enough to require medical attention
-Abused women have significantly more chronic health problems: Neurologic, gastrointestinal, gynecologic, and chronic pain
-Forced sex that accompanies physical abuse contributes to a host of reproductive health problems including chronic pelvic pain, unintended pregnancy, sexually transmitted infections (STIs) including HIV, and urinary tract infections
Health care system can be an extremely important early point of contact
-Abused women have significantly more depression, suicidality, posttraumatic stress disorder (PTSD) symptoms, and problems with substance abuse
-Abuse during pregnancy has serious results for both the pregnant mother and the infant, including low birth weight and increased risk of child abuse
-By uncovering abuse in early stages, it is hoped the pattern of violence can be stopped and long-term health problems can be avoided or minimized
Health effects of elder abuse include:
-Complications from injuries or bleeding from trauma can cause changes in circulatory homeostasis and fluctuations in blood pressure and pulse, shock, and death
-Infections can progress to generalized sepsis, then death in immunocompromised aging patients
-Assault, or stress leading up to or following assault, can contribute to cardiac complications
Health effects of elder abuse (cont.)
-STIs and related complications for younger women are present in older sexually assaulted women
-Abuse of the elderly often is coupled with neglect
-Family or others working with aging persons may consciously, and with malice, withhold food, water, medication, and necessities, while concurrently stealing assets of the elderly, dependent person
-This type of neglect is often, by definition, criminal in nature

-Family members or others caring for elderly persons may struggle with their own severe physical and cognitive health challenges
Elderly patients may thus experience profound unintentional neglect
Unintentional neglect is reportable to adult protective service agencies
-Self-neglect raises often unanswerable questions about one’s right to live autonomously
Suspected self-neglect is also a mandatory reportable activity to adult protective services

There are many long-term physical and psychological effects of child maltreatment
-Immediate consequences include a spectrum of injuries such as bruises, fractures, and lacerations and can involve more severe injury such as shaken baby syndrome
-More severe forms of maltreatment can lead to death or long-term disability such as mental retardation, blindness, and physical disability
Child maltreatment can have long-term effects on a child’s development and adult life
-Interrupts bond between child and caregiver
-Ongoing maltreatment can lead to changes in brain structure and chemistry and may lead to long-term physical, psychological, emotional, social, and cognitive dysfunction in adulthood
-Approximately one third of abused children will abuse their own children
-Two out of three people in drug treatment programs report abuse as children
Risk factors that may contribute to child maltreatment
-Disabilities or mental retardation in children that may increase caregiver burden
-Social isolation of families
-Parents’ lack of understanding of children’s needs and child development
-Parents’ history of domestic abuse
-Poverty and other socioeconomic disadvantages, such as unemployment

-Family disorganization, dissolution, and violence,
-Substance abuse in family
-Young, single, nonbiological parents
-Parental thoughts and emotions supporting maltreatment behaviors
-Parental stress and distress, including depression or other mental health conditions
-Community violence

Assessing for Intimate Partner Violence (IPV)
-Routine, universal screening for IPV means asking every woman at every health care encounter if she has been abused by a husband, boyfriend, or other intimate partner or ex-partner
-Routine, universal screening for IPV has been called for by most nursing professional organizations
How to assess
-Many precede questions with introduction such as “Because domestic violence is so common in our society, we are asking all women the following questions.”
-Or, “Because domestic violence has such serious health care consequences, we are asking all of our female patients the questions that follow.”
-Alerts women that questions about domestic violence are coming, and makes sure they know they are not being singled out for these questions
Assessment
-If a woman answers yes to any of the Abuse Assessment Screen (AAS) questions, then ask questions to assess how recent and how serious the abuse was
-Even if the woman only says yes to the first question and calls abuse “only emotional” or “not that bad,” more abuse may be uncovered by gently continuing the assessment
-This is not “denial,” but normal minimization that often accompanies trauma from violence

-It is appropriate to show concern and distress about degree of violence
-One message that needs to be conveyed is that abuse is not the woman’s fault; this can be said several times
-Also express concern and that reassure patient that help is possible
-Furthermore, inform patient that several health problems can occur because of domestic violence and that is why it is necessary to conduct a thorough assessment

Screening Frequency Protocol:
All women Over 14 Years of Age

-Primary care: every visit for new complaint
-Emergency/urgent care: all women, all visits
-OB/GYN: each prenatal/postpartum visit; each new intimate relationship; all routine gynecological visits; all visits in STI and abortion clinics
-Mental health: every initial assessment, each new intimate relationship, and annually
-Inpatient: all admissions and discharges
Abuse Assessment Screen

Abuse Assessment Screen
Assessing for Elder and Vulnerable Person Abuse and Neglect
-Assessment of abuse or neglect in cognitively challenged persons is complicated
-Physical findings inconsistent with history provided by patient, family, or caregiver are red flags of possible abuse and neglect
Elder Abuse Screen
Has anyone:
Ever touched you inappropriately?
Made you do things you didn’t want to do?
Taken things that were yours without asking?
Physically hurt, scolded, or threatened you?
Failed to help you take care of yourself?
Have you signed documents you didn’t understand?
Are you afraid of anyone at home?
Are you alone a lot?
History
-History of traumatic injuries may have an impact on current health condition
-Assess and document prior abuse: IPV, childhood abuse, and prior rapes
-Mental status examination important in cases of IPV or elder abuse, for potential head trauma or neurological symptoms
-All survivors of violence should be given a mental status examination, with attention to mental health problems associated with violence: depression, suicidality, PTSD, substance abuse, and anxiety
Screening for Child Abuse
and Neglect

-Medical history important part of evaluation
Previous hospitalizations, injuries, or does he/she suffer from any chronic medical conditions?
Take medications that may cause easy bruising?
History of repeated visits to hospital?
Delays seeking care for other than minor injury?
-If child is verbal, history should be obtained away from caretakers through open-ended questions or spontaneous statements
Documentation: child
-When documenting history and physical findings of child abuse and neglect, use words child has used to describe how their injury occurred
-Remember the possibility that abuser may be accompanying the child
-If child is nonverbal, use reports of caregivers
-Know your institutional protocol for obtaining history in cases of suspected child maltreatment
-Some protocols may delay a full interview until it can be done by a forensically-trained interviewer

-American Academy of Pediatrics recommends screening for IPV as an active means to prevent child maltreatment
-Child abuse is reported in 33% to 77% of homes with ongoing abuse of an adult
-Positive responses should prompt nurse to involve other members of health care team

Physical Examination
-Important components of physical examination of known survivor of IPV and/or elder abuse include:
Complete head-to-toe visual examination, especially if patient is receiving health services for reported abuse
Health evaluations for known or suspected elder abuse and neglect should include baseline laboratory tests, including a complete blood count with platelet level, basic blood chemistries, serum liver function tests, a coagulation panel, and urinalysis

Physical examination of children
-Visual inspection of child from head to toe is important in any physical examination
Significant injuries can be hidden under clothing, diapers, socks, and long hair
Bruising in “atypical” places such as buttocks, hands, feet, and abdomen is exceedingly rare and should arouse concern
Any bruise in shape of an object should be considered highly specific for abuse
Bruising found in nonmobile children should raise concern for further injury, including fractures and intracranial injury

Documentation of IPV, child abuse, and elder abuse must include:
-Detailed, nonbiased progress notes
-Use of injury maps
-Photographic documentation in health record
-Other aspects of abuse history, including reports of past abusive incidents, can be paraphrased with use of partial direct quotations
Physical abuse photo
-Patterned, punchlike abrasion to the mid-forehead from an assailant wearing a ring with a stone.
-Sutured laceration to the left eyebrow.
– partial-avulsion injury to the nose.
-Punchlike contusion to the left eye involving the sclera.
-Manual strangulation-related abrasion to the neck.
Documentation of IPV and elder abuse must include detailed, nonbiased progress notes
-Use of injury maps
-Photographic documentation
-Written documentation of histories of IPV and elder abuse need to be verbatim but within reason
-Critical to document exceptionally poignant statements made by victim that identify perpetrator and severe threats of harm made by perpetrator
Detailed, nonbiased progress notes
Other aspects of abuse and reports of past abuse can be paraphrased using partial direct quotations
When quoting or paraphrasing history, do not sanitize the words reportedly heard by victim
-Verbatim documentation of reported perpetrator’s threats interlaced with curses and expletives can be extremely useful in future court proceedings
-Also, be careful to use the exact terms an abused patient may use to describe sexual organs or sexually assaultive behaviors
Assessing for
Risk of Homicide

-Women more often killed by husband, boyfriend, or ex-husband than by anyone else
-About three-fourths of these women have been abused by man who subsequently killed them
-In recent study of intimate partner homicide of women, 42% of women killed had been seen in health care system in year before she was killed
-These encounters were missed opportunities for health care professionals to identify IPV and intervene to decrease danger
Danger Assessment (DA), is a 19-item yes/no instrument used extensively by nurses in health care system
-Starts with a calendar so women can more accurately see how frequent and severe violence has become over the past year
-This is also an excellent assessment of frequency and severity of violence for health care provider
-The more yes answers, the more serious the danger of the woman’s situation
When She Says No to AAS but There are Other IPV Indicators
-Suspect IPV when she says “No” to AAS, but there are other indicators associated with IPV
-In addition, providers need to be alert for conditions associated with IPV including:
Gynecological problems, especially STIs, pelvic pain, and complaints of sexual dysfunction
Chronic irritable bowel syndrome, back pain, depression, symptoms of PTSD, problems sleeping, panic attacks, or nerves
When There are Other IPV
Indicators

-When these problems occur, and especially when they persist, a thorough and repeated assessment for domestic violence is needed.
-In this case, an instrument such as the WEB scale might be used in addition to the AAS, or gentle indirect queries
-“I am concerned about your health conditions; is there any chance that stress at home is contributing to these problems?”
Cultural competence
-Domestic violence occurs cross-culturally
It may be more difficult to determine in many cultural groups
Serious psychological distress among persons 18 years of age and over was 3.0% for the general population, 3.0% for whites, 7.1% for American Indians, and 3.0% for blacks
Heavy alcohol use by persons 12 years of age and older for the white population was 7.5%, blacks 4.4%, and American Indians 8.7% of population
Domestic violence occurs cross-culturally (cont.)
-Death rates from suicide among the general male population was 10.9 per 100,000 residents, but 16.4 per 100,000 male American Indians and 9.8 per 100,000 male blacks
-Death rates for homicide among the general male population was 9.4 per 100,000 residents, but 11.6 per 100,000 male American Indians and 36.4 per 100,000 male blacks

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