Family Violence Case File

Family Violence Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 36

A 20-month-old girl, new to your practice, is brought in by her mother because she's been crying and not walking for the past day. Her mother reports that the child is "very clumsy and falls a lot:' She says that the little girl may have injured her leg by falling off the sofa because, she repeats, "she really is clumsy and falls a lot:' Upon review with the mother, she states that the child has no significant medical history and takes no medications regularly. There are two older children in the family, ages 4 and 6, who are in good health but also are"clumsy and forever hurting themselves:'The husband lives in the home. Without any questioning or prompting, the mother states that her husband is "a good man but he's under a lot of stress:'You ask the mother to undress the child for an examination and she quickly replies, "Do you really have to undress her? She's very shy:' You politely, but firmly, say that you need to examine her and she removes the child's pants. You see that her right knee is visibly swollen and tender to palpation on the medial bony prominences. You also note numerous bruises of the buttocks and posterior thighs, which appear to be of different ages. There are also several small, circular scars on the legs, each about a centimeter in size. "See how clumsy she is?" the mother says, pointing to her bruises. An x-ray of the child's knee shows a corner fracture of the distal femoral metaphysis.

⯈ What is the likely mechanism of this child's injuries?

⯈ What further evaluation is necessary at this time?

⯈ What legal obligation must a physician fulfill in this circumstance?

ANSWER TO CASE 36

Family Violence

Summary: A 20-month-old girl is brought to the office for evaluation of crying and not walking. On examination, she is found to have multiple bruises and circular wounds that are suspicious for cigarette burns. Her knee x-ray shows a metaphyseal corner fracture, an injury that is inconsistent with the stated history of "falling off the sofa:'

• Most likely mechanism of injuries: Inflicted injuries, including leg injury from forceful pulling, bruising from hitting the child's legs, and cigarette burns
• Further evaluation at this time: Complete, unclothed physical examination of child (including ophthalmoscopic and neurologic examinations); radiographic skeletal survey
• Legal obligation of physician: Report of suspected child abuse to the appropriate child protective services organization

ANALYSIS

Objectives

1. Learn the symptoms and signs suggestive of child maltreatment and abuse.
2. Know the situations in which the risk of family violence increases.
3. Learn some of the medicolegal requirements involved in situations of family violence.

Considerations

Family violence can occur in families of any socioeconomic class and in households of any composition. The term family violence includes child abuse, intimate partner violence (IPV), and elder abuse. The abuse that occurs can be physical, sexual, emotional, psychologic, or economic. It can take the forms of battering, raping, threatening, intimidating, isolating from friends and family, stealing, and preventing the earning of money, among many others.

In the case presented here, there are several signs of intentionally inflicted injuries to the child. The presence of numerous bruises of varying ages, especially on relatively protected areas such as the buttocks and upper posterior thighs, should raise suspicions. Finding injuries inconsistent with the reported history also can be a clue. Certain types of fractures, such as metaphyseal corner fractures (caused by forceful jerking or twisting of the leg) are usually a result of abuse. The identification of wounds consistent with cigarette burns is highly specific for abuse.

Physicians often find these situations extremely difficult and uncomfortable to deal with. They may feel caught between two partners-both of whom are patients-but who give conflicting stories. They may have concerns about the legal implications of their findings and fear legal actions if they make reports to authorities. They may have frustrations in dealing with a person who will not leave an abusive spouse and may feel ill-trained to deal with many of these situations. By knowing situations in which family violence is more likely to occur, knowing the laws regarding disclosure and reporting, and learning to recognize the signs of family violence, physicians can be better prepared to address these situations when they occur.

Approach To:

Family Violence

DEFINITIONS

CHILD MALTREATMENT: An all-inclusive term covering physical abuse; sexual abuse; emotional abuse; parental substance abuse; physical, nutritional, and emotional neglect; supervisional neglect; and Munchausen syndrome by proxy.

ELDER MISTREATMENT: Intentional or neglectful acts by a caregiver or trusted individual that harm a vulnerable older person.

NEGLECT: Failure to provide the needs required for functioning or for the avoidance of harm.

PHYSICAL ABUSE (BATTERY): Intentional physical actions { eg, biting, kicking, punching) that can cause injury or pain to another person.

CLINICAL APPROACH

Family violence is a pattern of abusive behavior in any relationship in which one individual gains or maintains power or control over another individual. This abuse can take the form of physical violence (battery), sexual violence, intimidation, emotional and psychological abuse, economic control, neglect, threats, and isolation from others. During screening, evaluation, and intervention of cases of domestic and family violence, it is important to consider cultural influences and the unique dynamics of special populations ( eg, lesbian, gay, bisexual, transgender, older couples, and immigrant populations).

Intimate Partner Violence

Although IPV is most common to think of this as a man abusing a woman, abuse can occur both in homosexual relationships and in heterosexual relationships with a male victim. It is estimated that 1.5 million women and 834,700 men annually are raped and/ or physically assaulted by an intimate partner. Women are more likely to be injured, sexually assaulted, or murdered by an intimate partner and studies show that women have a one in four lifetime risk of such abuse.

Abuse can occur in any relationship or in any socioeconomic class. Certain situations increase the likelihood, or escalate the occurrences, of abuse. These situations include changes in family life (such as pregnancy, illnesses, and deaths), economic stresses, and substance abuse. Personal and family histories of abuse also increase the likelihood of family violence. Most women do not disclose abuse to

their physicians.

Numerous professional organizations, such as the American Medical Association, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, advocate for the routine screening of women for abuse by direct and nonjudgmental questioning. Numerous tools exist for screening, from simple questioning to more formal inventory tools. The simple question, "Do you feel safe in your home" has a sensitivity of 8.8% and a specificity of 91.2%, so more formal testing may be necessary in some cases. Since 2013, the United States Preventive Services Task Force (USPSTF) has recommended (B grade) that clinicians regularly screen women of childbearing age for intimate partner violence. It also found insufficient evidence to assess the balance of benefits and harms of screening all elderly or vulnerable adults for abuse and neglect and found insufficient evidence to recommend routine intimate partner violence screening. The USPSTF does recommend that all clinicians should be alert to physical and behavioral signs and symptoms associated with abuse and neglect and that direct questions about abuse are justifiable due to high levels of undetected abuse in women and the potential value of helping these patients. Multiple studies have shown that screening does not result in harm to participants. Recommendations regarding interactions with victims of abuse include exhibiting compassionate, nonjudgmental, supportive care in a private, secure environment.

Victims of abuse can present with varied symptoms and signs suggestive of the problem. Direct physical findings can include obvious traumatic injuries, such as contusions, fractures, "black eyes;' concussions, and internal bleeding. Genital, anal, or pharyngeal trauma, sexually transmitted diseases (STDs), and unintended pregnancy may be signs of sexual assault. Depression, anxiety, panic, somatoform and posttraumatic stress disorders, and suicide attempts can also result from abusive relationships.

Some signs and symptoms may be less obvious and may require numerous encounters until the finding of family violence is made. Victims of abuse may present to doctors frequently for health complaints or have physical symptoms that cannot otherwise be explained. Delays in treatment for physical injuries may be a sign of IPV. Chronic pain, frequently abdominal or pelvic pain, is commonly a sign of a history of abuse. The development of substance abuse or eating disorders may prompt inquiry into family violence as well. Children of women abused often directly witness the abuse of their mother. Children and adolescents of abused women can exhibit aggression, anxiety, bedwetting, and depression.

When abuse is identified, an initial priority is to assess the safety of the home situation. Direct questioning regarding increasing levels of violence, the presence of weapons in the home, as well as the need for a plan for safety for the victim and others at home (children, elders), is critical. Resources and support, such as shelters, community-based treatment, and advocacy programs, should be provided. It may be helpful to allow the patient to contact a shelter, law enforcement, family members, or friends, while still in the doctor's office. Multidisciplinary interventions, including family, medical, legal, mental health, and law enforcement, are often necessary.

The laws regarding clinician reporting of partner violence vary from state to state. It is important to know the statutes in your locality. Many states do not require contacting legal authorities if the victim of the abuse is a competent adult.

Child Abuse

Approximately 1 million cases of child abuse, with more than 1000 deaths, are reported each year in the United States; the number of unreported cases makes the overall prevalence much higher. Child abuse is the third leading cause of death in children between 1 and 4 years and almost 20% of child homicide victims have contact with health-care professionals within a month of their death. The situations that increase the risk of child abuse are similar to those that increase the likelihood of other family violence. These include parental depression and previous history of abuse, substance abuse, social isolation, and increased stress. Societal factors include dangerous neighborhoods and poor access to recreational resources. Children who are chronically ill or who have physical or developmental disorders may be at even higher risk. Protective factors include family support from community or relatives, parental ability to ask for help, and access to mental health resources. Identification of at-risk families and home visitation interventions has been shown to significantly reduce child abuse. Short- and long-term physical, psychological, and social consequences are often seen in the victims of child abuse.

Certain history and physical examination findings raise the suspicion for child abuse. Several presenting history and behavioral features may be associated with increased risk of maltreatment or abuse (Table 36-1). Injuries that are inconsistent with the stated history or a history that repeatedly changes with questioning should raise the suspicion of abuse. Children who are taken to numerous different physicians or emergency rooms, or who are brought in repeatedly with traumatic injuries, may be victims. Delay in seeking medical care for an injury may also be a clue to abuse. Any serious injury in a child less than 5 years, especially in the absence of a witnessed event, should be viewed with suspicion.

Children frequently have bruises, fractures, and other injuries that occur accidentally and it can be difficult to distinguish with certainty whether an injury is

Adapted from Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill;

2011.

accidental or intentional. However, certain types of injuries are uncommon as accidents (Table 36-2). The presence of these injuries is highly suggestive of child abuse. Neglect is also a form of child abuse. An injury or illness that occurred because of lack of appropriate supervision may be a sign of neglect. Failure to provide for basic nutritional, health-care, or safety needs may be other forms of neglect.

When an injury suspicious for child abuse is identified, attention should initially focus on treatment and protection from further injury. A complete examination should be performed and all injuries documented with drawings or photographs. An x-ray skeletal survey can be performed to look for evidence of current or previous bony injuries. Skeletal survey is typically recommended for all cases of suspected abuse in children younger than 2 years. Ophthalmologic examination should be performed to look for retinal hemorrhages. Other imaging, such as computed tomography (CT) of the head, nuclear medicine imaging, or positron emission tomography may be indicated depending on patient circumstance. Laboratory studies can be useful in both identifying disorders that might explain observed findings and finding occult or more severe injury not evident on examination. Testing for sexually transmitted illnesses may be necessary as well. The clinical findings, pertinent history, and results of evaluation should be documented carefully and legibly.

All 50 states require reporting of suspected child abuse to child protective services or other appropriate authorities (refer to local laws to determine the appropriate authority). Parents should be informed that a report is going to be made and the process that is likely to occur after the report is made in a neutral nonaccusatory manner that emphasizes your role as an advocate for the child's health and safety. Consideration must also be given to the possibility that there are other victims of abuse in the home (spouse, other children, elders). Any health-care provider who makes a good-faith report of suspected abuse or neglect is immune from any legal action, even if the investigation reveals that no abuse occurred. Providers may be held liable for failure to report child abuse.

Elder Abuse

Many types of elder abuse may occur, including physical, sexual, and psychological abuse, neglect, and financial exploitation. The estimated prevalence of elder abuse ranges from 2% to 10% and out of the 1 in 10 elders that may experience abuse, only 1 in 5 are reported. Along with the other risks for domestic violence, several factors unique to the care of elders may play a role. The majority of abusers are family

members. Caregiver frustrations and burnout are commonly heard excuses for abuse. Abusers often have histories of mental health problems or substance abuse and have little insight into the fact that they are abusing the patient. Women older than 75 years are statistically the most abused group. Persons who are older, more cognitively and physically debilitated, and have less access to resources are more likely to be abused or exploited.

A history of abuse may be difficult to obtain, as the patient may fear worsening of the abuse or may not have the cognitive ability to make an accurate report. If feasible, it is helpful to interview the patient without the presence of the caregiver. Screening the caregiver for stress, in private, with referral for community resources may prevent abuse in the elderly. The physical examination, like in child abuse, should carefully document any injuries that are found. Suspicions of dehydration or malnutrition should be confirmed with appropriate laboratory testing, and radiographs should be performed as necessary.

By law, elder abuse should be reported to the appropriate adult protective services, but the reporting requirements vary by state. A multidisciplinary approach involving medical providers, social workers, legal authorities, and families is usually necessary to address the issues involved.

COMPREHENSION QUESTIONS

36.1 A 42-year-old woman presents to your office for evaluation of chronic abdominal pain. She has seen you multiple times for this complaint, but the workup has always been negative. On examination, her abdomen is soft and there are no peritoneal signs. She has no rash, but does have a purpuric lesion lateral to her left orbit. Which of the following is the best next step in management?

A. Ask the patient about physical abuse and report suspicions to the local police.

B. Ask the patient about physical abuse and provide information about local support services.

C. Exclude a bleeding diathesis before inquiring about abuse.

D. Order an abdominal x-ray.

E. Refer to psychiatry.

36.2 A 7-month-old male infant presents to the emergency department (ED) with his father after a 1-day history of intractable vomiting. On examination, the child is lethargic. The anterior fontanel is closed. An abdominal x-ray shows a nonspecific bowel gas pattern and incidentally reveals a mid-shaft fracture of the right femur. When confronted about the fracture, the father states that the child climbed onto a chair and jumped off yesterday. Which of the following is the most appropriate next step in management?

A. Outpatient radiographic bone survey

B. Consulting a child abuse specialist

C. Social services consult

D. Disclosing to the parent the intention of contacting child protection services

E. Inpatient noncontrast CT of the head

36.3 Which of the following injuries is most likely to be caused by abuse of a toddler?

A. Three or four bruises on the shins and knees

B. Spiral fracture of the tibia

C. A displaced posterior rib fracture

D. A forehead laceration

36.4 An 80-year-old man who resides in a local nursing home is seen in your office for unexplained scratches on arms, and band-like bruises on wrists and ankles consistent with restraint use. The patient is mildly demented, and appears scared. There is no family to contact. Examination and laboratory results show no medical reason for easy bruising. Which of the following should be your next step?

A. Refer to nursing home social worker.

B. Contact nursing home ombudsmen program.

C. Have the patient observed by nursing home staff.

D. Contact nursing home vice president for nursing care.

E. Send the patient back to the nursing home.

ANSWERS

36.1 B. It is appropriate to discuss your concerns in a nonaccusatory, nonjudgmental fashion with your patient. Waiting for her to bring up the subject may result in her suffering further abuse. The reporting of the abuse of competent adults (not elders) is not mandated by law in most states. You should offer assistance, evaluate her safety, and provide her with information regarding available services in the area. There is no reason to exclude a bleeding diathesis before approaching the subject of abuse.

36.2 E. This child has injuries consistent with physical abuse. In children less than 1 year, 75% of fractures are due to abuse. Moreover, the shape of a fracturespiral, transverse, etc-is less important in suspected abuse than the age of the child and location of the fracture. The purported history of fall is inconsistent with the developmental abilities of a 7-month-old infant. The infant has intractable vomiting and is lethargic on examination. These findings are worrisome for neurologic damage. An inpatient evaluation with CT should be ordered to exclude intracranial bleed, since this disorder may lead to irreversible brain damage or even death if not identified quickly and protects the child from further abuse while workup is being completed. Outpatient management with close follow-up and referral to child protective services is appropriate if caregivers are not suspected of being the abusers. While a radiographic bone survey is indicated in all children less than 2 years with suspected abuse, it should be done after excluding more urgent conditions. If you are concerned that the child may be at further risk of abuse and that notifying the parents of your concerns would put the child at immediate danger, it is not necessary to notify the parents of your report to law enforcement or Child Protective Services. However, in most cases, the parents should have the opportunity to discuss these concerns with you. Lastly, the anterior fontanel closes between 4 and 26 months (average 13.8 months). It may bulge in conditions, such as meningitis or intracranial hemorrhage, which increase intracranial pressure.

36.3 C. A posterior rib fracture is often the result of grabbing and squeezing the chest violently. It is very suspicious for abuse. A spiral fracture of the tibia is known as a "toddler's fracture" and is a common injury that is often confused with abuse, but not often caused by abuse. Bruises on the anterior and over bony prominences such as the shins, knees, and forehead injuries are common from falls while learning to walk. Well-padded areas that are bruised such as the thigh, buttock, and cheeks increase likelihood of abuse.

36.4 B. Clinicians have a legal duty to report possible elder to abuse to adult protective Services in their community. If the patient is living in a nursing care facility, each state has nursing home ombudsmen who can investigate. The ombudsmen program is mandated by the Federal Older Americans Act. If you feel that this patient is in immediate danger, he can be admitted for evaluation of bruising while the ombudsmen and local adult protective services investigate for substandard care or abuse at the nursing care facility.

CLINICAL PEARLS

⯈ Suspected child and elder abuse must be reported. Good-faith reports of suspected abuse are a shield to lawsuits; failure to report can result in legal action against the physician.

⯈ When seeing a suspected abuse victim, always consider the possibility that there could be other abuse victims in the household.

REFERENCES

Berkowitz C. Child abuse and neglect. In: Tintinalli JE, Stapczynski J, Ma 0, et al., eds Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY : McGraw-Hill; 2011. 

Cronholm P, Fogarty C, Ambuel B, Harrison S. Intimate partner violence. Am Fam Physician. 2011 May 15;83(10):1165-1172. 

Eyler AE, Cohen M. Case studies in partner violence. Am Fam Physician. 1999:60:2569-2576. 

Gibbs LM, Mosqueda L. The importance of reporting mistreatment of the elderly. Am Fam Physician. 2007 Mar 1;75(5):628. 

Hancock M. Intimate partner violence and abuse. In: Tintinalli JE, Stapczynski J, Ma 0, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill; 2011. 

Hoover R, Polson, M. Detecting elder abuse and neglect: assessment and intervention. Am Fam Physician. 2014 Mar 15;89(6):453-460. 

Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician. 2013 Nov 15;88(10):669-675. 

Krennerich E. Trauma, burns, and common critical care emergencies. In: Engorn B, FlerlageJ, eds. The johns Hopkins Hospital: T he Harriet Lane Handbook: A Manual for Pediatric House Officers. 20th ed. Philadelphia, PA: Saunders; 2015. 

United States Preventive Services Task Force. Intimate partner violence and abuse of elderly and vulnerable adults: screening.January 2013. Available at: www.uspreventativeservicestaskforce.org. Accessed February 21, 2015.

HomeFamily Medicine Case FileFamily Violence Case File