CHAPTER 5
Perfect Phrases for Dealing with Suspected Child Abuse, Elder Abuse, or Intimate Partner Violence
As healthcare professionals, we have myriad duties that we must perform for our patients. One important duty, with both ethical and legal aspects, is to ensure that they live in a safe environment. Three populations of patients that are especially vulnerable to abuse are the young, the old, and those patients suffering from intimate partner violence (IPV).
Bringing up the possibility of abuse or violence with our patients can be a daunting task. We may be afraid that we will offend our patients and therefore lose their trust. The subjects we may have to broach can be taboo and may offend our own sensibilities just to think of them. We may not know the best way to bring up these subjects or even if we should involve the patient’s family members. Having some key phrases and strategies ready may make these difficult conversations easier.
There are some common themes in abuse or violence among all three of these populations: dependence and fear. Until a certain age, all children are totally dependent on their parents or guardians for everything from shelter to food. The elderly can also be dependent on others, especially if age or disease has made them frail and they are not financially independent. An intimate partner may be dependent on his or her partner in many ways, including financially and emotionally.
The theme of dependence leads to the next theme, fear. Dependence may make people live through, and even accept, abuse or violence because of fear. They may fear that if they report the abuse, the perpetrators will kick them out of their homes, take away their children, stop loving them, and harm them more violently or even kill them. There is also the fear of shame in being identified as a victim of abuse.
The dependence and fear associated with abuse can be significantly negative influences that alter a patient’s behavior and even their health. We may not be able to prove or verify any of our suspicions about abuse or violence, but thankfully, that is not our job. Rather, the most important thing we can do as healthcare professionals is to consider the possibility that our patients are or have been victims of abuse or violence. We can then report the suspected abuse or offer further resources to a patient or the family.
Keep the following points in mind when dealing with suspected abuse.
It is easy to diagnose abuse in a patient with the chief complaint “My boyfriend hit me” or a small child with multiple long bone fractures.
However, abuse can be in the form of physical or sexual violence, neglect, and emotional abuse.
The emotional and physical trauma from abuse may manifest in different ways in different patients.
Patients with repeat visits to the clinic or the Emergency Department (ED) for non-specific somatic complaints may actually be suffering from abuse.
Include all forms of abuse in your differential diagnosis when evaluating patients.
Abusers Come in All Shapes and Sizes
There are certain characteristics that may be found in people who abuse others:
A history of suffering abuse themselves
Drug- or alcohol-related disorders
Personality disorders and psychiatric problems
Lower socioeconomic status
These characteristics are not present in all cases, and an abuser may or may not have them.
Abuse is found across the entire racial, ethnic, and socioeconomic spectrum.
Perform a Thorough History and Physical Exam
When the history of the injury or illness cannot explain the clinical findings, consider abuse.
A complete history and physical exam is vital if you suspect abuse of any form.
Ensure that your physical exam is standardized and well documented, as it may become legal evidence.
Transfer patients who may need a specialized exam or interview to an appropriate facility.
Pay attention to any family members or loved ones with the patient. Do they seem overly aggressive toward staff or overly protective of the patient? Does the patient seem to fear them?
Acknowledge and Respect Cultural Differences
Understand that in other cultures or countries, certain behaviors or customs may not be considered abuse.
Understand that immigrants or minorities may hesitate to contact law enforcement because they may fear deportation or unfair treatment.
Ensure the patients and family that a language interpreter, in person or by phone, is available.
Documentation Is Important
Document what a patient or family member says as direct quotes.
Activate other resources, such as a social worker or the child protective services (CPS), early, and document their input.
Remember that what you document may be used in a court of law to protect your patient or to prosecute an abuser.
We may have to form our suspicions of abuse on limited information.
As healthcare professionals, we are mandated reporters of suspected abuse.
It is not our job to take on the role of the police officer or a lawyer.
Because we rarely have all the information needed to conclusively diagnose abuse, we should approach each case with suspicion but not with an accusatory attitude.
Perfect Phrases for Suspected Child Abuse
According to the U.S. Department of Health and Human Services, in 2009, there were more than 2.5 million reported cases of suspected cases of child abuse. This statistic only reflects reported cases of suspected abuse, so it is quite possible that the actual number of instances is much higher.
Healthcare professionals are mandated reporters, meaning that we are legally obligated to report all cases of suspected child abuse to the appropriate authorities. In other words, to make a report, we don’t have to be absolutely positive that child abuse has occurred; we only need to suspect it.
A woman brings Carter, her 8-month-old son, to the ED. She tells the triage nurse that the child has not been moving his right leg for the past day. On exam, the child’s right thigh is bruised and swollen, and he cries when it is palpated. An x-ray of the extremity shows a spiral fracture of the femur.
Children suffer all types of musculoskeletal injuries due to accidents, such as falls while playing. Certain types of injuries and fractures rarely occur in children who fall while playing or in children who are below one year of age and, thus, not old enough to walk or run on their own.
Injuries Suspicious for Abuse
Patterns—injuries that outline an object, such as a hand, teeth, or an electrical cord
Bruising at areas away from bony prominences (examples of prominences are the shin or forehead)
Multiple bruises at various stages of healing
Fractures Suspicious for Abuse
Long bone fracture in a patient who hasn’t started walking
Metaphyseal fractures
Fractures of the rib, scapula, spinous process, or skull
→ Carter’s x-ray looks like he has broken his femur—that’s the bone in the thigh area. It’s unusual for a child of his age to break this bone. Do you know how this might have happened?
→ I’m not sure. When I picked him up from his crib last night, he cried a lot. This morning, when I was changing him, he was still crying. His leg looked swollen, and he wasn’t moving it.
→ Did Carter have any falls or accidents recently?
A long bone fracture, in this case, should not occur in a child who cannot walk by himself. We should try to obtain a history that can explain the injury that we have diagnosed. This case must be reported to the CPS due to the nature of the injury. Even with less severe injuries, if you cannot obtain a history that can reasonably explain the injury or that has inconsistencies, you should suspect abuse.
→ Nothing happened to him. He was fine until last night.
When questioning parents or guardians, don’t assume an accusatory tone, even when you are highly concerned about possible abuse. It is unlikely that you will know all of the facts when you evaluate the child. The parent or guardian with the child may not be the one who actually injured the child, or they may not even be aware that someone else may have abused their child. Moreover, once a parent or guardian feels that he or she is being accused of something, they can become angry and defensive.
From that point onward, they may be less likely to cooperate with any evaluation of the child.
→ This kind of injury can occur when someone is rough with a child. Do you know anyone that might have handled Carter in a rough way?
→ No. I dropped him off of the couch last week by accident, but it was onto a carpet, and the drop was less than two feet. I didn’t do anything to hurt him! How dare you accuse me of hurting him!
Even if you have maintained a non-accusatory tone, parents or guardians may take offense with your questions. Try to focus the inquiry on securing what is best for the health of the child. A social worker, if one is available, may be able to help moderate tense situations and redirect the anger of parents.
→ I’m not accusing you or anyone else of hurting Carter on purpose. But this is a pretty serious fracture, and we need to figure out how this happened. I know you want to figure this out, too.
The parent of this child is not offering any information that can reasonably explain this injury. This child needs to be admitted to the hospital to be evaluated by an orthopedic surgeon and also by CPS. Let the parent know your plan and that you will need to contact CPS.
→ We need to admit Carter to the hospital to see the bone doctors. I am also required by the state to get in touch with children’s services when a child has this kind of injury. They will help us check out every possible way that Carter could have been injured so that it doesn’t occur again.
It is not clear that you will be discharging the child to a safe environment. Regardless of the parent’s wishes, this child should not go home. In less clear-cut cases, you could hold onto the child in the ED or clinic until the CPS can evaluate him.
A young couple brings their 2-month-old son Timmy to the ED. They tell the physician that the child “has not been acting right” for the past couple of hours. On exam, the child is less than 5 percent of his expected weight on a growth chart and is lethargic but afebrile. He has faint bruises in the shape of hands, wrapping from front to back on both sides of his chest.
Children must be completely undressed, including having their diapers removed, and examined from head to toe. They should have their height and weight measured and the measurements compared with standardized growth charts. These steps are even more vital in children who cannot yet speak, as they cannot tell you what has happened to them or if they are in pain from an injury.
→ After completely undressing and thoroughly examining the child: I’m a little concerned about Timmy. He has some bruising on him, and I’m worried that his behavior isn’t normal. Did anything unusual happen at home?
→ Nothing happened. He was crying, and so I went to check up on him. I fed him and put him back to bed.
→ I haven’t seen him since this morning. When I got home from work, he wasn’t acting right, so we brought him right here.
The findings of bruising on the thorax and a depressed mental status suggest that this child may have suffered a central nervous system (CNS) injury due to abuse. A child this young will need further testing to make sure that his presentation is not due to other processes, such as an infection or a metabolic derangement. He will also need a specialized exam, imaging, and monitoring for the possibility of a brain injury. If your facility does not have the resources for these tests, this child should be transferred to a facility where these tests can be performed.
→ I think it would be best for Timmy if we watch him in the hospital. His behavior change could be due to many different things, and I’m not sure which one it is yet. We will need to do some tests on him and monitor his health.
Tell the parents what you are going to do and why, but avoid taking an accusatory tone. Referring to the CPS as “child services” is one way to keep the tone of the conversation generic until you know more facts. Always emphasize that what you are doing is in the best interest of the patient.
→ I also want to let you know ahead of time that I have to report this case to child services. You should expect some people from this agency to get in touch with you, and they may even come to your house. Sometimes, they can give you advice on “child-proofing” your house.
In cases that are less clear cut, it is still prudent to get help early in the care of the patient by calling CPS. They may arrange for the child to stay with a close family member or even come out to your facility to initiate an investigation. In these situations, the worst-case scenario is not a parent being angry with you because you have “accused” them of abuse—it is discharging a patient to be injured or die in an unsafe environment.
A woman brings her 9-year-old daughter to the pediatrician’s office because she thinks her boyfriend has been “touching” her daughter inappropriately. The mother had called the police, who told her to take her daughter to the doctor’s office.
In this case, the patient has presented with abuse already suspected. Unfortunately, it can be very challenging to interview young children about possible abuse because their understanding of right and wrong is limited. They may feel pressured to please their interviewer by offering certain answers. Some social workers, clinical psychologists, and pediatricians are specially trained and have expertise in carrying out forensic interviews with children. In cases where there is concern about sexual abuse, the child should be transferred to a facility that has expertise in examining children for sexual abuse.
When interviewing a pediatric patient about possible abuse, make sure to ask simple, open-ended, non-leading questions rather than closed or leading questions. Document everything that is said word for word and in quotes. Try to limit questions that require yes or no answers, as children may answer in the affirmative in an attempt to please the interviewer. Finally, use words that are age appropriate to the patient. A young child may not know what the word “vagina” means, so you may need to refer to their genital area as “private parts.”
Did someone hurt you?
How did they touch you?
Where on your body were you touched?
Who touched you?
Tell me more about what happened.
Closed Questions
Did your mother’s boyfriend molest you?
What did he do when he molested you?
Was he touching your private areas?
When did he molest you?
Attempt to interview the parents and the child separately. Some parents may resist allowing you to speak to the child alone. This resistance can be motivated by a fear of exposing something that has been perpetrated against the child. It can also be borne out of an overprotective parental drive for the child. A parent’s resistance to leave the child alone with you should contribute to your overall clinical suspicion of the situation, but it should not stand as proof of abuse on its own.
→ To the parent: Could you please step out of the room for just a few minutes?
→ Why do I need to leave? I want to know what you are going to ask my daughter.
→ I speak to all of my patients in private. This is standard practice at this hospital.
Unfortunately, a benign interview and a normal physical exam do not rule out physical or sexual abuse. The overall clinical suspicion must be based on speaking with the patient, his or her parents or guardians, and a physical exam. In cases where you are concerned that a child could be in danger, err on the side of caution and get help.
Perfect Phrases for Suspected Elder Abuse
The population of the United States is rapidly aging. The U.S. Census Bureau estimates that by 2020, there will be almost 55 million citizens, or 16.3 percent of the total population, over the age of 65 years. As some in this graying population develop dementia or physical infirmities, they become dependent on others to care for them. This dependence puts them at risk for abuse of all kinds: physical, sexual, emotional, neglect, and financial or material exploitation.
Identifying older patients who are victims of abuse can be challenging. Older patients may have severe dementia or medical problems that render them unable to communicate. In this case, they, like children, cannot verbalize if they are in pain or if someone has been abusing them. They may also be afraid that they will be forced out of their nursing home or their family’s house if they disclose abuse.
Nevertheless, healthcare professionals are mandated reporters of elder abuse, and we must be vigilant to include abuse in our differential diagnoses when evaluating older patients. As with all patients, a careful head-to-toe physical exam is vital to ensure that no injuries or findings are missed.
Mrs. Mathew is an 86-year-old woman who lives at home with her daughter. She has multiple medical problems, including severe dementia, and is bed bound. Her son who is visiting from out of town has brought his mother to the ED to be evaluated for the “redness” on her back. The patient’s mental status makes her incapable of answering any of your questions coherently. On exam you find a thin woman wearing a soiled diaper who has severe decubitus ulcers.
The daughter has not been adequately caring for this patient, who is most likely a victim of neglect. However, many cases of elder abuse may have much less dramatic presentations. In situations where the possibility of abuse is less clear-cut, we will have to use all our clinical skills to explore our suspicions of abuse.
Be sure to question a patient and his or her suspected abusers separately. Carry out these conversations in a non-threatening and non-judgmental manner. In the acute setting, it is unlikely that you can even be sure that the person you are interviewing is the actual abuser. The goal is not to act as proxies for law enforcement but to stop the abuse and keep our patients safe.
Closed and Aggressive Questions
Your mother looks awful. Why haven’t you been taking care of her?
How could you let her get like this?
Your mother could only get ulcers like this if she was being abused.
Was it you abusing her, or was it your sister?
Open and Explorative Questions
I’m concerned about your mother’s medical condition. Is it stressful to care for her at home?
Can you tell me about her care at home?
Have you noticed any changes in your mother’s overall condition recently?
Have your siblings been helping with your mother’s care?
Does anyone else help care for her?
Older patients can suffer from paranoia or delusions due to dementia, which limits their ability to answer questions accurately. In these cases, you will have to rely on your physical exam, prior records on this patient, and discussion with family or caregivers. The following are some physical exam findings that are suggestive of abuse in older patients.
Poor general hygiene
Lying in urine or feces
Pressure ulcers
Fractures that don’t make sense in a patient with limited ambulation
Bruising in patterns suggesting restraints or beatings with objects (extension cords)
Sedated patients who may have been intentionally overmedicated
This patient must be admitted to the hospital for wound care, and the appropriate authorities must be contacted. In some cases, patients may not have injuries that necessitate admission to a hospital. If they are not going to be discharged to a safe environment, you must admit them or arrange for them to go to a safe place, such as a different family member’s house.
Mrs. Christopher is a 77-year-old woman who has numerous medical problems and lives in a nursing home. She was brought to her family doctor’s office for evaluation of a fever. As the doctor is examining her, the patient says, “They’ve been mean to me at the nursing home.”
Elder abuse takes on many forms. It is incumbent on us, as healthcare providers, to explore if this patient is suffering from abuse when she says someone has been “mean” to her. Ask open-ended questions, using simple language. If a patient doesn’t describe a specific complaint, it is important to ask about all forms of abuse.
General Safety
Do you feel safe at your house (or nursing home)?
Are you afraid of anyone?
Are you being well cared for?
Physical Abuse
Has anyone at your house hit you?
Have you been tied down or locked in your room?
Sexual Abuse
Has anyone ever done anything sexually to you against your wishes?
Financial Abuse
Do you control your own finances/checkbook?
Have you signed financial papers that you didn’t understand, such as a will or bank forms?
Do you rely on others for your housing, or do others rely on you for money?
Neglect
Does someone help you bathe, eat, and get your medications?
Are you left alone often?
Are you hungry or thirsty at home?
Does someone help you get your walker or hearing aids?
If you need help, does someone come to help you?
Emotional Abuse
Do you feel lonely?
Do you have a lot of arguments with the people you live with?
Do people at home yell at you or call you names?
Older patients may have physical infirmities but still have sharp, clear minds. Give them a chance to answer your questions, and be sure to thoroughly explore any areas of possible abuse. You should take patients’ dementia and other medical comorbidities into account when interviewing them. Do not ignore their complaints of abuse simply because of their mental status.
Perfect Phrases for Suspected Sexual Violence and Intimate Partner Violence
Sexual violence (SV) is sexual activity that occurs without consent and includes stalking, peeping, harassment, threats, and physical contact ranging from unwanted touching to rape. According to the Centers for Disease Control and Prevention (CDC), almost 11 percent of women and just over 2 percent of men report being victims of SV at some point in their life. These numbers could actually be much higher because it is estimated that only one in three instances of SV are reported.
Intimate partner violence (IPV) is similar to SV, but it occurs between two people who have a close relationship. IPV can include physical violence, sexual violence, threats of violence, and emotional abuse. The CDC estimates that every year 4.8 million women experience IPV-related assaults and rapes and at least 1,600 women die from IPV. In addition, the Bureau of Justice reports that among all violent crimes committed against women, fully 20 percent were IPV related.
These and other statistics clearly show that SV and IPV are highly prevalent in the United States and that the vast majority of this violence is directed toward women by men. There are a number of factors that place people at risk for being victims of SV or IPV:
Female gender
Pregnancy
Age less than 35 years
Growing up in a family with domestic violence
Previous victim of SV or IPV
Drug or alcohol abuse
Low socioeconomic status
Victims of SV and IPV can present to a healthcare professional for almost any reason. They may come for medical treatment of physical injuries suffered during an assault or for treatment of sexually transmitted infections (STIs). In addition, people who are or have been victims of SV or IPV can suffer from psychological injuries that may manifest as depression, mood changes, or even vague somatic complaints. Unlike in the case of abuse of children or the elderly, healthcare professionals are not mandated to report SV and IPV. Therefore, the help that we can offer these victims is limited by how much help they are willing to accept.
Mrs. Lau is a 26-year-old woman who has had repeated visits to her family doctor for abdominal pain. She has had blood tests and a pelvic ultrasound that were all normal. During these office visits, her affect has been flat, and her mood seems depressed.
You should include IPV in your differential diagnoses when evaluating patients. Although IPV may seem like an uncomfortable topic to discuss with your patients, it should be a part of standard history taking and physical exam. Asking about IPV with standardized screening questions can make it a more routine inquiry and therefore a less uncomfortable topic.
A helpful mnemonic for IPV screening, originally developed by the Massachusetts Medical Society, is RADAR.
Routinely ask your patients about IPV. Do this in private.
→ Mrs. Lau, thanks for coming in today to follow up on your abdominal pain. I have a few other questions that I ask all my patients.
Ask directly about IPV. Maintain a non-judgmental and caring attitude. The following are examples of open-ended questions that can open a discussion about IPV.
Do you feel safe at home?
Did someone hurt you?
Did someone do something to you that you didn’t want done?
How did this person hurt you?
Where on your body were you hurt?
Is there anyone at home that is hurting you?
Do you feel safe in your current relationship?
How do you feel about your home life?
Are you afraid of your partner or anyone else?
Document what your patient has told you. Note any injuries you have observed, and write down the patient’s statements in quotes. What you document may later become a vital part of a patient’s legal record. If the patient denies IPV, make sure to document that you asked about it.
→ The patient states “Things are not great at home right now” but won’t say whether or not she feels safe and denies violence.
Assess your patient’s safety and willingness to get help. Is the patient safe at home? Are her children safe? Is the patient willing to get help at this time?
→ Mrs. Lau, some things you told me today make me a little concerned about your home situation. Are you sure that you feel safe at home? Would you like to talk about this now?
Respond, and review the options with your patient. Acknowledge what the patient has told you, and let her know what her options are for further help.
Thanks for sharing with me today; I know this must be difficult to talk about.
Would you like to talk about what is happening at home?
Would you like some help?
Would you like to know about some resources for getting help?
A patient may not disclose IPV until asked about it on multiple occasions at multiple visits. That is exactly why it is important to routinely screen your patients for IPV. Your patient may not be a victim of IPV, and he or she will never have anything to disclose. If you don’t think of it and don’t ask about it, you will never diagnose it.
Ms. Wimberly is a 19-year-old woman who has presented to an outpatient clinic with pain in her shoulder. She is evaluated by a physician and is noted to have pain in her shoulder with range of motion and bruising on her upper arm. Her boyfriend has accompanied her to the clinic.
As in pediatrics, certain physical exam findings, such as bruising, especially around the head and face, should raise suspicion of IPV. This is even more true if the injuries are not explained by the history of the present illness.
→ The nurse told me that you are having some shoulder pain. What happened to your shoulder?
→ She slipped on the sidewalk. I just need her to get an x-ray to make sure nothing is broken.
The intimate partners of some patients can be overly controlling in medical settings. This behavior doesn’t rule IPV in or out, but it should further raise your suspicion.
→ I’ll be happy to order an x-ray. Before I do that I need to examine the patient. To the patient’s boyfriend: Can you please step out while I examine the patient?
→ Why do I need to leave? Can’t you just order the x-ray?
All patients should have at least some portion of their interview or physical exam in private so that they may ask about concerns that they wish to be kept confidential from even their loved ones.
→ I speak to all of my patients in private. It’s routine and something that all the doctors in this ED do.
Ask open-ended, non-leading questions.
→ To the patient in private: I’ve noticed that some of your injuries seem like they might have come from someone being rough with you. Has anyone been rough with you?
It is very important to make sure that the patient does not feel that you will blame her for what has happened to her. She may already feel ashamed or embarrassed about what has happened to her. Make sure she knows that you can be trusted to keep what she tells you confidential.
→ Nobody deserves to be hurt by someone else. Anything you tell me will be confidential, and I won’t do anything about what you tell me unless you want me to.
The patient may not be ready or willing to tell you about IPV. Make sure the patient knows that you are always available to help if needed.
→ It is completely up to you if you want to get some help. But if you change your mind we are always here. Let me give you the phone numbers of some people who can help and also the name of our social worker here at the hospital.
Offer patients literature on IPV or the services of a social worker so that they can have somewhere to turn to if they choose to get help in the future.
Ms. Desai is a 21-year-old woman who was brought to the ED by the police. She went to the police after being sexually assaulted at a fraternity party. The police are requesting that the victim have a medical examination and that evidence be collected.
Victims of SV have undergone a terrible experience. They should be shown compassion and treated with respect. It may be your job as a healthcare professional to collect physical evidence (by using a “rape kit”) from the patient’s body that may be used against her attackers. Keep the following points in mind when examining a victim of SV.
Put the patient in a private room.
→ I can’t even imagine what you have gone through. We are going to do everything that needs to be done to help you.
Get help from a Sexual Assault Nurse Examiner (SANE) or social worker, if available.
→ I’m going to bring Nurse Catherine in with us. She is a nurse who specializes in helping people who have been assaulted.
Provide a brief overview of the interview and the examination process.
→ First, we are going to ask you some questions, and then we will perform a physical exam. After that, we will answer any questions you have and offer you any treatments or medicines you may need.
Explain that you will have to ask sensitive and perhaps painful questions.
→ We do have to ask you some very personal and painful questions about what happened. I know it will be hard to answer some of these questions, but we are asking them so that we can take care of you to the best of our abilities.
Explain that you will have to perform a detailed physical exam to collect evidence.
→ We need to perform a physical exam and collect samples from your body. Parts of the physical exam will involve your genital area. I know this will be uncomfortable for you, but it’s important to perform these tests because they can be used as evidence against whoever did this to you.
Offer prophylaxis for pregnancy, STIs, and human immunodeficiency virus (HIV) and resources for follow-up.
→ We are going to give you medications to prevent several common sexually transmitted infections. We will also put you in touch with people who can help you as you go forward.
For More Information
For detailed guidelines on diagnosing and reporting child abuse in your state refer to the website of the Child Welfare Information Gateway: www.childwelfare.gov. The American Academy of Pediatrics also has a detailed website with information on child abuse and neglect: www.aap.org/sections/scan.
The National Center on Elder Abuse, a part of the U.S. Administration on Aging, is an excellent resource for more information on elder abuse. Visit their website at: www.ncea.aoa.gov.
The CDC website has diagnostic and treatment information for healthcare professionals caring for victims of SV and IPV: www.cdc.gov/ViolencePrevention/sexualviolence. To find resources for victims of SV or IPV see the website of the Rape, Abuse & Incest National Network: www.rainn.org.