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Course:  Domestic Violence

2 Contact Hours
Written By: B. Moore, HCRM RN
Prepared Especially For: infusionceus.com

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COURSE DESCRIPTION

In July 1995, the State of Florida legislature approved the addition of Domestic Violence as a licensure requirement for specific healthcare professionals. The Domestic Violence program presented here meets the mandated requirements of this legislation.  This program contains components that include information about domestic violence and the risk factors associated with Domestic Violence and AIDS.  The program will  give a statistical approach specific to professional practice and the incidence of domestic violence within that practice.  Assessment techniques, interview techniques and proper documentation of domestic violence will be reviewed in detail.  Referral information, hot lines, crisis centers, etc. will be provided.


COURSE REQUIREMENTS

     This program includes child and elder abuse.  Successful completion of the program requires that the participant pass the post test with a score of 80% or better and completes the program evaluation.  Submit the answer sheet and evaluation to earn 2 Contact Hours of continuing education.  This certificate of completion should be kept for at least four years.  The Florida Board of Nursing  requires one extra credit hour for licensure renewal in domestic violence.  In other words the one contact hour required in domestic violence is above and beyond the contact hours required for re-licensing. 


COURSE OBJECTIVES

  • Demonstrate an understanding of the broad spectrum that domestic violence encompasses.

  • Identify statistical incidence of domestic violence as it relates to each individual practitioner.

  • Discuss why domestic violence occurs.

  • List the reasons victims of domestic violence often stay in abusive relationships.

  • Discuss the reluctance of the medical community to intervene in domestic violence.

  • Identify physical indicators of abuse in women, children, and the elderly.

  • Clearly document abuse in the patient's medical record.

  • Identify the need for establishing protocols in health care settings for assisting victims and perpetrators of domestic violence.

  • Provide victims and perpetrators with sources of assistance.

WHY HEALTH CARE PROVIDERS  NEED TO KNOW ABOUT DOMESTIC VIOLENCE

  • Close to 4 million American women are physically abused each year in this country.  The rate of injury to women from battering surpasses that of car accidents and muggings combined.

  • Health care providers are uniquely situated to be effective in helping reduce the tragedy of domestic violence.  The special nature of the provider-patient relationship offers a unique opportunity to intervene in this serious problem.

  • Several studies have shown that 22% to 35% of women who visit emergency

  • departments are there for reasons related to ongoing abuse.

Emergency rooms are not the only place that people seek help from domestic violence:

  • 28% of women surveyed in three university-affiliated ambulatory care internal

  • medicine clinics had experienced domestic violence at some time during their lives.

  • One mid-western family practice clinic reported that 23% of women clients had been physically assaulted by their partners within the last year and 39% had experienced physical abuse at sometime during their lives.

  • Obstetrical health providers have an important role in identifying battered women.  Between 10 to 32% of women seeking care from prenatal health care providers have a past history of domestic abuse and 4-8% are battered while pregnant. Abused women have higher rates of miscarriages, stillbirths, premature labor, low birth weight babies, and injuries to the fetus, including fractures.

  • Mental health providers see battered women for suicide attempts, anxiety and depression.  In one study, 64% of female psychiatric inpatients experienced physical assaults and 38% experienced sexual assaults as adults.

  • Orthopedists. orthopedic nurse practitioners and physician assistants see battered women with fractures and other musculoskeletal complaints caused by domestic violence.

  • These women seek care from specialists in "head and neck" medicine for perforated eardrums, nasal fractures, dislocated mandibles, and septal hematoma.

  • Dentists see battered women with fractured teeth and broken jaws.

  • Ophthalmologists and other eye care professionals see battered women with sub-conjunctival hematoma, retinal detachments, orbital blow-out fractures, and lid lacerations.

  • Practitioners who specialize in chronic pain syndromes, such as headache, chronic pelvic pain, or functional gastrointestinal disorders, also see battered women.   HIV-positive women or women with AIDS may have contracted the virus from coerced sexual activity in the context of a battering relationship.

  • Health providers who see abused children also see battered women because child abuse and spousal abuse frequently co-exist,

     Battered women have a decreased subjective sense of their physical and mental well-being, an increase in reported symptoms across a wide variety or organ systems, and an increased utilization of medical resources.


COMPELLING REASONS FOR HEALTH CARE PROVIDERS  TO INTERVENE

     The Council on Ethical and Judicial Affairs of the American Medical Association states that the medical ethical principle of beneficence requires physicians to intervene in cases of domestic violence.  Bioethicists Edmund Pellegrino and David Thomasama say:

The aim of medicine is to address not only the bodily assault that disease or an injury inflicts but also the psychological, social, even spiritual dimensions of this assault.  To heal is to make whole or sound, to help a person reconvene the powers of the self and return, as far as possible, to his (or her) conceptions of a normal life.

     The ethical principle of non-malfeasance--do no harm--also directs physicians to diagnose domestic violence. 

     When a diagnosis of abuse is missed, treatment is likely to be inappropriate and potentially harmful.  For instance, diagnosing pain medications or mild tranquilizers these are contraindicated for abuse victims because they are at an increased risk for suicide and drug or alcohol abuse.

     Failing to diagnose abuse may further the victim's sense of entrapment.  Inability to find help often causes victims to feel that there is no escape from the violence.  Failure to diagnose domestic violence increases the patient's health risks.

     The solutions to domestic violence extend into social, legal and political realms, but the medical profession can provide a number of important interventions.  The most important contribution a physician can make to ending the cycle of abuse and protecting the health and welfare of a victim is in identifying and acknowledging the abuse.  This simple intervention can initiate the process whereby the victim may seek the necessary assistance to find safety.

     Other important responsibilities of health care professionals include: providing sensitive support, clear documentation of the abuse, providing information about options and resources, making necessary referrals (with the patient’s consent).


DEFINITION OF DOMESTIC VIOLENCE

     The Florida Statutes define domestic violence as "assault, battery, sexual assault, sexual battery, aggravated assault, aggravated battery, stalking and aggravated stalking or any criminal offense resulting in physical injury or death of one family or household member by another."  Each state may define it differently, but in essence, the meaning is the same.

     In the Florida Statutes, "Family or household member" means: spouse, former spouse, persons related by blood or marriage, persons who are presently residing together, as if a family, persons who have resided together in the past, as if a family, and persons who have a child in common regardless of whether they have been married or have resided together at any time."   Persons in other states should review their State's statutes for a definition.


PATTERNS OF DOMESTIC VIOLENCE

     Domestic violence is not an isolated individual event, but rather a pattern of perpetrator behaviors used against a victim.  It includes physical assaults, sexual assaults, and psychological assaults such as threats of violence and harm, attacks against property or pets or other acts of intimidation, emotional abuse, isolation, use of children , and use of economics.

     Domestic violence is purposeful, coercive behavior.  The abuse is directed at achieving compliance from or control over the victim.  The pattern is not random or "out of control" behavior.  Perpetrators who minimize or excuse their behavior by claiming they "lost it" or "were out of control" have actually made specific choices.  For example, they may be violent only toward their victim even though they may be in conflict with other people such as their boss or other family members. 

     Some will break only the victim's possessions and not their own.  Some will hit only in private.  Such decision-making indicates they are actually in control of their abusive behaviors.


CAUSES OF DOMESTIC VIOLENCE

    Domestic violence is learned behavior. It is learned through observation and reinforcement.  Like other forms of aggression, domestic violence is not caused by mental  illness or genetics. It is a behavior that is learned over time through multiple observations and interactions with individuals and institutions.  It is learned through direct observation (e,g., the male child witnessing the abuse of his mother by his father or from the proliferation of images of violence against women in the media).  It is also learned through the reinforcement of the perpetrators' experiences (e.g., perpetrators receiving peer support or not being held responsible, arrested, prosecuted, or sentenced appropriately for their violence). Domestic violence is repeated because it works.  Thus, the pattern of behavior is reinforced.

     Domestic violence is not caused by alcohol and other drugs.  Many people use or abuse drugs without ever battering their partners.  While research studies have found high correlations between aggression and the consumption of various substances, there is no data clearly proving a cause-and-effect relationship.

     Domestic violence is not caused by anger.  Many abuse episodes occur when the perpetrator is not angry and is, in fact, calm.  The role of anger in domestic violence is complex and cannot be simplistically reduced to one of cause-and-effect.

     Domestic violence is not caused by stress.  Life is filled with many different sources of stress and people respond to stress in a wide variety of ways.  People choose ways to reduce stress according to what they have learned about strategies that have worked for them in the past.

    It is important to hold individuals responsible for the choices they make regarding how they reduce stress, especially when those choices involve violence or other illegal behaviors.  A robbery or mugging by a stranger is not excused simply because the perpetrator claims he is stressed.  Similarly, the perpetrator of domestic violence cannot be excused simply because he is stressed.  Since domestic violence is a variety of tactics repeated over time for the purpose of controlling the victim, specific stresses are less meaningful in explaining a longitudinal pattern of abusive control.

     Domestic violence is not caused by the victim's behavior or by the relationship.  Focusing on the relationship or the victim's behavior as an explanation for domestic violence removes the perpetrator's responsibility for the violence and supports his minimization, denial, blaming, and rationalization for the violent behavior.


BARRIERS TO INTERVENTION IN DOMESTIC VIOLENCE ISSUES

Studies have indicated that physicians persist in believing several societal myths, the most harmful being:

  • domestic violence is rare,

  • domestic violence does not occur in relationships that appear "normal"

  • domestic violence is a private matter that should be resolved without outside

  • intervention,

  • battered women are responsible for their abuse.

     In one study of a group of primary care physicians in an effort to determine why doctors avoid confronting abuse, more than one-third of the doctors compared dealing with abuse to opening a ‘can of worms’ or opening ‘Pandora's box.’  The evils they feared unleashing were expressed as: too close for comfort, fear of offending, powerlessness, loss of control, tyranny of time (Sugg & Inui, 1992).

Too close for comfort :

     Almost 40 percent of the doctors in the survey identified with their patients and assumed that patients with backgrounds similar to their own (white, middle-class) could not be at risk for violence.  Spouse abuse is found at all socioeconomic and educational levels and in all ethnic and occupational groups.

Fear of offending :

     More than half the doctors in the study feared offending their patients by raising the subject of abuse, although they did raise the subject more often with women in lower socioeconomic levels.  They also felt uncomfortable about dealing with private, intimate matters such as sexual preference, sexual behavior or abuse.  Also contributing the their reluctance is the fact that women are often very ambivalent about disclosing abuse and will sometimes later deny that abuse occurred.  In addition, physicians realize they cannot report abuse of an adult to third parties without the consent of the victim.

Powerlessness and Loss of Control:

     Half the doctors did not know what to do about the abuse, as there are no straightforward solutions.  Sixty-one percent of them had no training on the subject in medical school.  Also, doctors quite naturally want to "fix" whatever is ailing a patient, and they realize that domestic violence is not so easily ‘fixed.’

Tyranny of Time:

     Seventy-one percent of the doctors said that they do not have enough time to deal with the issue of abuse so they avoid raising the issue.  They also believe that domestic violence is not prevalent enough to be worthy of their time.


PRESENTATION OF DOMESTIC VIOLENCE VICTIMS IN THE HEALTH CARE SETTING

     There are a variety of ways in which battered women may present to the health care setting and a variety of reasons for which they may seek care.  Clinical manifestations of abuse include acute injuries, medical problems, complications of pregnancy and psychiatric symptoms, as well as chronic problems related to the stress of living with ongoing abuse and danger.  Some symptoms are readily identified as being due to domestic violence.  Others are less obvious and will only be addressed if clinicians routinely ask all women patients about the presence of domestic violence in their lives.

Injuries :

     Injuries range from contusions, sprains, minor lacerations, fractures, abdominal injuries, and gun shot wounds.  Injuries may result from being punched, hit, kicked, choked, burned, or stabbed;  being thrown down stairs, against walls or out of buildings; being hit or run over by a car.

     The most common site of injuries are: the head, face, neck, and areas that are usually covered by clothing, such as the chest, breasts and abdomen.  Maxillofacial trauma is common; including eye and ear trauma, hearing loss, soft tissue injuries, fractures of the mandible, nasal bones, and orbits.  Injury to multiple sites is also a frequent indication of domestic violence.  Other indicators of abuse include injuries which do not fit the provided explanation; injuries in various states of healing; injuries with delayed presentations, such as fading bruises or partially healed lacerations, and complaints of injury without physical evidence of trauma.  Injuries to the extremities, such as fractures, sprains and lacerations are more likely to be accidental than those to the head, neck, and torso, but they too can result from battering.

Medical Presentations :

     Acute injuries may be the most obvious manifestation of domestic violence, but it is often the long-term medical and psychological consequences of battering that are the most debilitating over time.

     Pain is a common presenting symptom.  Headaches, chest pain, back pain, pelvic pain or abdominal pain may also be symptoms of domestic violence as well as functional GI complaints.  Symptoms related to stress, anxiety or depression may also be signs of domestic abuse.  They may present with exacerbation of chronic medical conditions such as diabetes, hypertension, or heart disease as they may be prevented from obtaining or taking their medications or from seeking medical care.  Abuse may also expose women to serious illness. Between 67% and 83% of HIV positive women in one clinic were or had been in abusive relationships with men who refused to use barrier protection.

     Many women are battered during pregnancy, which is associated with complications such as placental separation, ante-partum hemorrhage, fetal fracture, rupture of the uterus, and pre-term.  Women may present with psychiatric manifestations of abuse.  The prevalence of abuse among women patients is even higher in psychiatric settings than in other medical settings.  In one study, 64% of women in an inpatient psychiatric unit had experienced physical abuse and 50% of psychiatric outpatients. Rates of suicide attempts are higher in battered women.

     While a number of studies have found significant correlations between substance abuse and battering for both victims and perpetrators, it is clear that substance abuse does not cause domestic violence.  The use of alcohol and drugs by battered women does seem to increase dramatically after physical abuse begins.  Up to 50% of alcoholism in women may be precipitated by abuse.


RESPONSE BY HEALTHCARE PROVIDERS TO DOMESTIC VIOLENCE

Appropriate interventions by health care providers for domestic violence include:

  • Routinely inquiring about abuse

  • Assessing safety

  • Documenting the abuse

  • Discussing options and resources

  • Providing advocacy and referral

  • Treating medical and mental health problems

  • Providing for follow-up care

1.         Asking about abuse helps to break the isolation a battered woman may experience and lets her know resources are available if and when she can use them.  Provision of optimal care warrants that health care providers routinely ask all women patients about domestic violence.  Routine inquiry may allow for intervention before injury or illness occur, and will discover patients who are currently being battered and provide the opportunity to reduce further harm.

     A.  What to Ask
       Many women will readily talk about the violence they are experiencing if they feel safe and supported.  Because they may not define themselves as battered, the practitioner should ask direct, specific questions.  For example, asking "Has your partner ever punched or kicked you?" will be more effective than asking, "Are you being battered?"

            B. How to Ask
    
Frame questions in a way that lets the victim know that the provider takes this issue seriously, that the victim is not alone, that the healthcare worker is comfortable hearing about abuse, and that help is available.  Example: "We know domestic violence is a very common problem.  About 25% of women in this country are abused by their partners.  Has that ever happened to you?"

     In some clinical settings, it may be more appropriate to ask indirect questions before going on to direct questions.  Example: "Have you been under any stress lately?  Are you having any problems with your partner?  Do you ever argue or fight?  Do the fights ever become physical?  Are you ever afraid?  Have you ever gotten hurt?

Safety issues :

     The clinician's primary concern should be with the patient's safety and privacy.  Do not inquire about abuse in the presence of any person who accompanies the patient, (including another woman).  Appearances can be deceptive--do not assume that the person who accompanies the patient has her best interest in mind.  Some abusers threaten and intimidate health care personnel, (attempting to keep them from seeing the patient alone).

     Others are verbally or physically assaultive to their partners in the health care setting itself Clinical staff and security staff should be prepared and have a plan for separating the woman from the abuser in a way that increases her safety and makes it clear to the assailant that abusive behavior is not acceptable.

Confidentiality :

     Let the woman know that the information she gives you is confidential and, within the confines of the law, and most importantly, will not be revealed to the batterer or anyone else without her consent.  As an example of ‘within the confines of the law,’ the state of Florida requires that domestic violence be reported to law enforcement when the patient has an injury which appears to have been caused by a gun, knife, firearm, or other deadly weapon.  This can vary from state to state, so those living in states other than Florida should review the statutes within their states.

     If the patient says that abuse is not occurring, let her know your concerns and be sure to provide her with a referral sheet of where she can obtain assistance, (should she change her story).  Encourage her to return if she has problems in the future and document your concerns in the medical record.

ASSESSMENT

Immediate Safety Needs:

    Once a woman acknowledges that she is being abused, there are several issues to address before proceeding to a more detailed history and physical examination.  Let her know that the violence perpetrated against her is not her fault and that you are glad that she confided in you.

     Her immediate safety needs must be addressed.  Does she want you to call security or the police?  Does she want to keep hidden and then find a shelter?  Does she have an order of protection and does she want the abuser arrested if he shows up?  Does she need someone to pick up her children?

Chief Complaint/History of Present Illness:

     If a patient is being seen for an injury or other symptoms related to an acute battering event, ask in detail about what happened.  Record the chief complaint and detail the descriptions of the abuse, including the perpetrator, his or her relationship and the time, date, and location of the abuse.  Use the victim's own words in quotes whenever possible.  For example, "My husband hit me with a bat" is better than "Patient has been battered." Ask about previous abusive episodes.

Physical Examination and Preservation of Evidence:

     Before performing the physical examination, the woman should be asked to disrobe completely and put on a hospital gown so that all injuries can be seen.  The process of examination and evidence collection should be explained in detail.  Inform her of each step you are about to take so that the exam itself does not become another traumatic experience.  It is important to express compassion, maintain eye contact and convey respect to the patient.

     Perform a thorough physical exam including neurologic exam and mental status exam if indicated.  Be sure to palpate for areas of tenderness which may be manifestations of injuries not yet visible, such as scalp hematomas and deep bruises.

Evaluate and describe injuries:

     Include in your description the type of injuries, the number, size, and location using a body map. Indicate the degrees of resolution, possible causes, and explanations given.  Be specific, (e.g., contusions and lacerations to the throat will support allegations of attempted strangling).

     If the patient indicates there has been a recent sexual assault, assess for evidence of forced sexual activity, including injuries to the genitalia and restraint marks on the skin.  Assess for emotional trauma and lack of barrier protection (e.g., STDS, contraception/pregnancy status, exposure to HIV).

     Record non-bodily evidence of torn clothing and broken jewelry.  Preserve as evidence bloodied clothing, foreign objects or objects used as weapons.  Get permission from the patient to preserve these items after explaining that evidence may be necessary for legal documentation now or in the future.  Have her sign a release of information form and explain the conditions under which the evidence can be released (with her consent or by a court order).  Place the evidence in a sealed paper bag.  Each wet or bloodstained item should be placed in a separate bag.  The patient's name, medical record number, date and time of evidence collection, as well as a listing of the contents, should be attached to the individual bags.

     In cases where you are concerned that abuse may be occurring, but the woman denies it, be sure to note in the chart whether the injuries are compatible with her explanation.  This may help clarify the situation at a future visit as well as provide documentation in the event that she decides to pursue legal action.

     If the woman expresses suicidal ideation, obtain an emergency psychiatric evaluation. She should also be evaluated for homicidal ideation.  Check with your legal counsel for the law in your state pertaining to patient/provider confidentiality when homicide or suicide is a distinct possibility. Most women who kill their partners have been severely abused for long periods of time and see no other way out.  They kill in self defense or to prevent the murder or serious injury of themselves or their children.

     Photographs are particularly valuable as evidence.  The health care provider should ask the patient for permission and obtain written consent to take photographs.  Explain that the photos will become part of her medical record and can only be released to the police or prosecutor with her written permission or by court order.  Let her know that if a case should be filed against the assailant at some point in the future, photographs will be very useful evidence. 

     It is advisable to have the patient return for more photos in a few days after bruises and swelling become more apparent.  Polaroid photos are preferred because they can be attached to the medical record at the time of the patient's visit, thus decreasing the chance they will be misplaced.   A pre-printed or hand-drawn body map can be very useful to document injuries which may not show up well in photographs. X-rays showing old injuries can support a past history of abuse.


IF A VICTIM CHOOSES NOT TO LEAVE THE ABUSER

     It can be very frustrating to anyone who works with victims of domestic violence when the victim returns to the abusive situation.  It should be understood that most of the time, leaving the situation is a process.  One of the biggest reasons for remaining in the relationship is the hope that the abusive partner will change.  The women are in committed relationships and have often built their lives around the relationship, and they hope change will occur.  It is noteworthy that the most likely predictor of whether a battered woman will permanently separate from her abuser is whether she has the economic resources to survive without him. 

     Therefore, it is extremely important that battered women obtain support awards in protection orders and are referred to battered women's programs where they can learn about other economic supports, job training and employment opportunities.


CHILD ABUSE

     No discussion of domestic violence would be complete without addressing the problem of child abuse.  Partner abuse and child abuse frequently co-exist.  Several studies have shown that between 45 and 70 percent of men who battered a wife or girlfriend also abused a child. (Jones, 1994).  The true incidence of child abuse is unknown, but it is conservatively estimated that over 1,000,000 children nationwide are abused and/or neglected annually.


PATTERNS OF MALTREATMENT

     Analysis of official reports of abuse and neglect shows that physical abuse occurs in all age groups but the highest proportion was in age group 12 to 17 years.  The incidence of physical neglect was highest in the youngest age group, birth to 2 years.  Maltreatment occurs equally in male and female children.  Report analysis showed that Caucasians constituted about two-thirds of the total reported cases for all forms of maltreatment and blacks about one-fifth.  In cases of physical abuse and neglect, whites outnumbered blacks by about 6 to I (Star, 1987).

     Although child abuse occurs in all socioeconomic strata, an association was shown between income and maltreatment.  Seventy-nine (79) percent of physical abuse cases occurred in homes with income under $15,000 as compared with 2.7 percent in homes with income of $25,000 or more.  Ninety-one (91) percent of physical neglect cases had incomes of less than $15,000 (Star, 1987).

     The vast majority of perpetrators are natural parents (85%).  The female is more likely to maltreat the children than is the male.  Females were the perpetrators in 66 percent of physical abuse cases and 83 percent of physical neglect cases (Star, 1987).


PHYSICAL AND MEDICAL INDICATORS OF ABUSE AND NEGLECT

     Intentionally inflicted injuries can often be differentiated from accidental injuries.  A synopsis of physical and medical indicators of abuse and neglect is attached.  The health care provider should document injuries and collect evidence in a manner similar to that of adult victims of abuse.


MANDATORY REPORTING OF SUSPECTED CHILD ABUSE  /  NEGLECT

     Each state has mandatory reporting law which require health care providers to report suspected child abuse or neglect.


PHYSICAL AND MEDICAL INDICATORS OF ABUSE AND NEGLECT

Surface Skin Marks:

A. Location

     The location of the injury is a significant criterion which can aid identification of its origin.  Injuries to the thighs, calves, genitals, buttocks, cheeks, earlobes, lips, neck and back are more likely a result of abuse than injuries to the elbows, knees, shins and hands, which are frequently incurred accidentally.  Bruises over the bony parts of the child's body (e.g., chin and forehead) are common sites for falling injuries.  Bruises to any infant should be particularly suspect given the infant's limited mobility and opportunity for self harm.

B. Objects Causing Skin Marks:

     The shape of a surface skin mark or pattern of skin marks provide other clues to origin.  Bruises which have distinct configurations or which resemble instruments should be immediately suspect.  Samples of objects which cause distinct surface skin marks include:

  • belts, belt buckles, ropes and straps

  • electrical cords

  • hands (palms and fists), feet, knees, and elbows ;

  • mop or broom handles, sticks or other pieces of wood

  • wire or wood coat hangers

  • brushes and combs

  • cooking utensils (e.g., spatulas)

  • knives, scissors

  • hot liquids

  • electric appliances (e.g., irons, heating coils)

  • radiators and lighted cigarettes, matches or lighters

     Marks encircling the child's wrists, ankles or neck may be the result of being tied or restrained.  Multiple bruises extending out or downward from the corner of the child's mouth may indicate that he has been gagged.  The child who has been grabbed around the torso by another person's hands may show fingerprints in a pattern that clearly denote the pressure applied--eight fingerprints on one side of the torso and two thumb prints on the other side.

C. Bruises

     Multiple bruises on various parts of the body and in various stages of healing should receive particular attention.  One way to determine the approximate age of a given bruise is by the color.  The following lists the color of bruises and associated age.

          Age                          Color

   0-2  days        swollen, tender

   0-5  days        red, blue, purple

   5-7  days              green

  7-10 days              yellow

10-14 days               brown

  2-4  weeks             clear

     In addition to color differentiation, injuries incurred at different times will reveal older and newer scars.  Bilateral eye and facial injuries are of a suspicious origin because only one side of the face is usually injured as the result of an accident.  You should be aware that certain birthmarks, in particular ‘Mongolian Spots,’ which can be mistaken for bruises.

     Mongolian Spots are present at birth and generally last until the child is two to three years old.  These spots are grayish blue, do not change color with time and are commonly located on the buttocks and back.  The incidence of the discoloration varies for groups of different racial descent.  The following percentages of babies have Mongolian Spots:

                        95 percent of Afro-American babies

                        80 percent of Oriental and Native American babies

                        70 percent Hispanic babies

                        10 percent of Caucasian babies

D. Bite Marks

     All bite marks should be suspected as the by-product of abuse or neglect.  A bite will be evidenced by a mark in the shape of the cutting edges of the teeth.  Human bite marks differ in a number of ways from those of animals (including dogs, cats, and rodents).  In general, animal bites have a narrower arch form (shape) than human bites, leave deeper and narrower marks, and tend to have a ripping rather than crushing effect.

E. Mouth Injuries

     By-products of trauma to a child's mouth include broken teeth, lip injuries or tears to the frenum (the fold of skin under the tongue).  The latter may be the result of the forcing of an object (e.g., spoon, baby bottle) into an infant's mouth and is generally not coupled with other injuries.  Although it is possible for a toddler to accidentally incur such an injury after beginning to walk, infants less than six months old will not incur such accidental injuries. 

     Children between the ages of two and five are also not likely to accidentally tear the frenum because they move about more steadily and are less inclined to fall into objects (e.g., furniture) in a manner that would cause such a tear. 

    Lip injuries can be accidental but can also be the result of a forcible blow to this area.  Deliberate injury through use of an object should be considered.  Similarly, teeth may be broken accidentally or as the result of a blow to the mouth with an object (e.g., fist, stick).

Burns:

    The extent and characteristics of burn injuries reflect the way the injury occurred.  For example, cigarette, match tip, or incense burns produce circular lesions with blisters and ulcers.  A lesion is an injury to the body from any cause that results in damage or loss of structure or function of the body tissue involved.  Old burns are seen as pigmented scars.  The palms, soles, torso, and buttocks are the most common sites of these types of burns.

A. Dry Contact Burns

     Dry contact burns from forced contact with devices or instruments which conduct heat (e.g., irons, heating coils, radiators), usually produce second degree burns which do not form blisters, The injury resembles the contour and shape of the instrument.  It is unlikely than an accidental fall against one of these objects will cause an injury of this severity because the child wouldn't remain in contact with the device for more than an instant.

B. Scalding

     Scalding burns are a result of dipping a child into hot liquid or pouring it over the skin.  The bum appears uniform in those areas which were exposed to the hot substance with a line separating the burned area from the unburned skin. Stocking burns refer to the injury that results when a child's feet are submerged in a not liquid. Glove burns are caused when the child's hands are forcibly submerged in a hot liquid.  Another type is a dunking burn in which the scalding injury is to the feet, buttocks and perineum, corresponding to the child's posture during submersion.  Splash marks are not evident because the child's movement has been constrained.  On occasion, an area of skin within a submersion bum will show no injury.  This can happen when the submerged part of the child's body is pressed against the bottom or side of the container (e,.g., bathtub).  The degree of injury may differ because this area is not exposed to the hot liquid for the same period of time.

     Exposure to liquids of varying temperatures for different lengths of time affects the type of injury incurred.  For example, prolonged exposure to bath water (105-10 degrees) will not cause burns, while exposure to 158 degree water, even for one second, will produce third-degree burns.


HEAD INJURIES

     Violent pulling of a child's hair may cause bleeding under the skin surface, swelling of the scalp, and the simultaneous loss of hair resulting in bald spots or patches.   ***Subdural Hematoma, (bleeding between the brain and the skull) is caused when the vein bridging the two is tom.  This injury can result from a fall, a direct blow to the head or violent shaking.  The presence of swelling and bruises to the scalp, bleeding of the eye, vomiting, seizures, or a coma (or other loss of consciousness), should alert you to the possibility of this type of injury.  Fingertip encirclement bruises around the torso or bruises to the skin located over the torso; bruises to the skin located over the center of the shoulder bone and the center of the collar bones and the absence of a skull fracture with the above listed symptoms may indicate that the harm resulted from violent shaking.


INTERNAL INJURIES

     Blows (e,g., punches, kicks) to the child's chest or abdomen may cause internal injuries.  Tenderness or swelling of the skin or vomiting may signal the presence of these injuries.  The child with internal injuries may appear pale, be cold, perspire freely and / or be semicomatose.

     A variety of fractures can result from trauma to the child's bones. 

     Observable symptoms include swelling, the child's inability to move a limb, or a protrusion of the bone through the skin surface.  There are several types of fractures.  The most common are:

  • Simple - The bone is broken but there is no external wound.  Least likely.

  • Compound - The bone is broken, and there is an external wound leading down to the site, and fragments of bone protrude through the skin.

  • Complicated - The bone is broken or splintered into pieces.

  • Spiral - Twisting causes the line of the fracture to encircle the bone in the form of a spiral.

Skeletal injuries than may indicate abuse include:

  • Spiral fractures - Fractures that wrap or twist around the bone shaft.

  • Corner fracture of long bones/metaphyseal - splintering at the end of the bone.

  • Epiphyseal separation - A separation of the growth center at the end of the bone from the rest of the shaft, and periosteal elevation - a detachment of the periosternum (i.e., surface layer of the bone/membrane connective tissue) from the shaft of the bone with associated bleeding.  These injuries are caused by twisting or pulling.


SEXUAL ABUSE

     A child who has been sexually abused may have difficulty in walking or sitting; pain or itching in the genital area; and bruises, tearing, swelling or bleeding of the external genitalia, vaginal or anal areas, or the mouth.  Infections of the vagina and lower urinary tract, venereal disease in pre-pubescent children, the presence of sperm in the rectum, vagina, vulva or perineum, or on the child's clothing, and pregnancy are obvious indications of sexual abuse.


PHYSICAL NEGLECT

     Physical neglect results when a parent fails to provide for the child's basic physical needs.  This can manifest itself in a number of ways.

Failure-To-Thrive Syndrome - The child's weight, height and motor development fall significantly below the average grown rate of normal children (i.e., below the 5th percentile).  The child appears malnourished, with a noticeable absence of fatty tissue.  The child may not respond to cuddling, may not engage in eye contact and  / or may have an expressionless face.

Nutritional deprivation (malnutrition) - A child who lacks sufficient quantity or quality of  food may suffer developmental lags and incur medical problems.  In the most serious  form of this problem, the child can starve to death.

Inadequate hygiene - A child who is inadequately bathed may have repeated skin infections or other persistent skin disorders.  Severe diaper rash as well as the chronic presence of dirt or feces on the child's skin, under the nails, or on clothing may also indicate inadequate hygiene.

Medical neglect - a child who does not receive needed medical or dental care, including required medication may develop a health problem, or a pre-existing health problem may be aggravated.


ELDER ABUSE

     More is known about spouse abuse and child abuse than about elder abuse because more research has been done in those areas.  The limited data that does exist shows that the majority of victims are widowed women who live with the abuser.  Most have physical or mental disabilities that make them dependent on family members to meet their nutritional, medical, personal hygiene, or ambulatory needs.   Especially at risk are widows over 75 who are bedridden or who have two or more disabilities that impair their ability to care for themselves.  Victims are more likely to be Caucasians who live in middle-class or poverty neighborhoods.  Psychological abuse, financial abuse, and physical neglect are much more common than physical abuse in the elderly population. (Star, 1987). Much abuse and neglect of the elderly occurs outside the family setting.

     To summarize, many physical illnesses that present a patient to the healthcare worker may have an origin other than the obvious ‘slip and fall’.  Especially when children and the elderly present with physical injuries that even remotely seem suspicious, then the healthcare worker is required to follow through with that suspicion.   It is far better to have a situation investigated and found that the injury truly was an ‘accident,’ than to send one child or elder back into their abusive setting.  It is also important to note that men are not exempt from physical abuse or domestic violence.  Simply because more women and children present with this determination does not negate the fact that men are being victims of domestic abuse.   Any repeated visit to a healthcare worker for the same ‘type’ of symptom should send up a red flag; ‘what truly happened to my patient?’

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REFERENCES

Ganley, A.L., & Warshaw, C. (1995).  Improving the Health Care Response to Domestic Violence:  A Resource Manual for Health Care Providers.  San Francisco: Family Violence Prevention Fund.

Jones, A. (1994).  Next time, she'll be dead: Battering and how to stop it.  Boston: Beacon.

Star, B. (1987).  “Domestic Violence.”  Encyclopedia of Social Work.  Silver Spring: National Association of Social Workers.

Sugg, K., & Inui, T. (1992).  Primary Care Physicians' Response to Domestic Violence.  Journal of the American Medical Association, 267(23), 3157.

This information is adapted from Norman S. Ellerstein, Child Abuse and Neglect: A Medical Reference (New York: John Wiley & Sons, 1981): pp. 73-273.

Barton Schmidt, in cooperation with the American Academy of Pediatrics, University of Colorado Medical Center, The Visual Diagnosis of Non-Accidental Trauma and Failure to Thrive (videotape) (Washington, D.C. National Center on Child Abuse and Neglect, U.S. Department of Health and Human Services, 1979).

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