1. ABUSE Domestic Violence Child/Adult/Elder Provena United Samaritans Medical Center 2009

2. Domestic Violence Occurs when one person inflicts injury, either emotional or physical, upon another person they have or had a relationship with. It occurs between spouses and partners, parents and children, children and grandparents, brothers and sisters.

3. Domestic violence includes child, adult, and elder abuse. Victims can be of any age race or gender. Domestic violence encompasses violence against men and women and includes violence in gay and lesbian relationships.

4. Domestic violence is the single largest cause of injury to women between the ages of 15 and 44 in the U.S. Women report to police only 20% of all rapes, 25% of all physical assaults, and 50% of all stalkings perpetrated by intimate partners. Even fewer men who are victims of such crimes at the hands of an intimate partner report them to law enforcement.

5. The healthcare provider may be the first person the victim seeks help from. Unfortunately, domestic violence can go unrecognized by the healthcare provider. The most significant reason for missing the diagnosis may be failure on the part of the healthcare provider to ask the victim if they have been harmed or injured by a partner.

6. As a healthcare provider it is important to remember domestic violence fits within the framework of family violence that includes child abuse and neglect, child sexual abuse, and elder abuse. These forms of violence share many similar causes, and interventions directed at one may positively influence other forms of violence as well.

7. As a healthcare provider, especially in the ED, you are in a unique position to initiate the process that may stop the cycle of violence in all of its familial expressions.

8. The term cycle of violence is descriptive of the pattern of abuse and consists of the following 3 components. 1. Tension building – during this phase the battering victim frequently tries to be particularly compliant and kind in an attempt to avoid violence. Despite special efforts, the abuser still becomes angry with increasing frequency and intensity.

9. The abused person may be so frightened during this phase of abuse that he/she attempts to precipitate abuse, just to be done with the episode.

10. 2. Battering 3. Absence of tension – sometimes called reconciliation or honeymoon phase. The battered person is showered with expressions of love and remorse. The abuser swears it will never happen again.

11. During the first two phases the victim may be open to interventions. The victim is much less likely to seek help during the absence of tension phase. The most dangerous time for a battered women is during attempts to leave the abuser. Up to 75% of domestic assaults reported to police occur after separation of the couple, with women most likely to be murdered when reporting abuse or attempting to leave an abusive relationship.

12. Another fear of victims of domestic violence is loss of their children. Batterers often get back at the victim by abducting the children, especially during the early period of separation.

13. Assessment Obtain a History  It is important to take the history in private. The batterer often accompanies the victim to the ED and may insist on answering questions.  Inform the patient of any limits to confidentiality imposed by mandatory requirements for domestic violence and child abuse.  If a translator is necessary, should not be a member of the family.

14.  Ask simple questions. (eg. “ Has your partner ever hit you? ” ) This is critical because the patient may not interpret what occurs as domestic violence.  Questioning the family – do so with care, remember that the batterer may be among those questioned. Phrase questions in an open – ended manner such as “ Susie seems upset. Do you have any idea why? ”  Questioning the abuser – use nonjudgmental language such as, “ what happened after your partner on the floor? ” as opposed to “ what happened after you beat her? ”  Abusers often blame the victim. Be careful not to validate such claims. Assessment… continued

15. Medical Findings  Central pattern of injuries  Contusions or injuries to the head, neck, or chest – may wear clothing or jewelry to hide injuries.  Injuries suggestive of a defensive posture  Types or extent of injury that are inconsistent with the explanation.  Substantial delay between when the injury occurred and when the patient sought treatment  Injuries during pregnancy  Repeated visits to the ED  Alcohol/drug abuse  ED visits due to suicide attempts or rapes  Noncompliance with treatment regimens, missed appts. Failure to obtain/take medications – may be due to lack of money or telephones.  History of being restrained or locked in or out of shared home.

16.  Palpitations, dyspnea, atypical chest pain, abdominal or other GI complaints, dizziness, & paresthesias, while common complaints are frequently noted with domestic violence.  Current or past self- mutilation  Gynecologic complaints – frequent vaginal or urinary tract infections, difficulty urinating, and pelvic pain Healthcare providers can also obtain clues from observing a patient and his/her partner. A partner of the victim may be openly hostile, defensive or aggressive, setting up communication barriers between you and the patient.

17. Physical Injuries Suggestive of Domestic Violence  Bilateral injuries  Injuries to multiple sites  Fingernail scratches, rope burns, cigarette burns  Abrasions, minor lacerations, welts  Subconjuctival hemorrhage suggests a vigorous struggle between victim and assailant  Bite marks  Fingernail markings: impressions, scratches, claw marks  Pattern injuries: marks, designs or patterns stamped or imprinted on or immediately below the skin by weapons. Pattern injuries fall into blunt force, sharp force (incised and stabbed), and thermal categories.

18.  Blunt force trauma to the skin: abrasions, contusions, and lacerations. Circular or linear contusions suggest abuse or battering. Circular contusions 1 – 1.5cm in diameter are consistent with fingertip pressure and may be seen with grabbing. Usually present on the medial (inside) aspect of the upper arm.  Strangulation: voice changes & petechie may be observed. Neck may reveal scratches and abrasions from the victims fingernails. Both males and females with disabilities are at increased risk of abuse due to reliance on their caregiver.

19. Elder Abuse Experts estimate that one million Americans age 60 or older are abused in domestic settings each year. Many victims do not want to report the abuse due to fear, shame, or a sense of loyalty to the abuser and often deny that they are being mistreated. Often, clinicians do not even consider the possibility of abuse, and overlook its telltale signs.

20. Part of the difficulty is that certain signs of abuse may be easily attributable to the normal process of aging. Recurrent fractures, for instance, may be automatically attributed to the brittle bones of osteoporosis. Malnourishment may be attributed to the nutritional problems and poor appetite that often accompany old age.

21. One key to combating elder abuse is being open to its possibility every time you care for an older adult. In many cases, the only person outside the family who sees the victim is a healthcare provider; therefore, it is critical that healthcare providers know the signs of abuse and report cases for investigation and services.

22. The Elder Abuse and Neglect Act (Public Law 85 – 1184) enacted in 1998, provides that people – who in good faith report suspected abuse or cooperate with an investigation - shall be immune from criminal or civil liability or professional disciplinary action. It further provides the identity of the reporter shall not be disclosed except with the written permission of the reporter or court order.

23. Callers should be prepared to report the alleged victim's name and address, what happened, where and when it happened and who the suspected abuser might be. To report suspected abuse, neglect or exploitation of a elderly patient please make referrals to Case Management. Case Management will further assess the patient ’ s situation and if appropriate contact the local department on aging. Note: any healthcare provider or individual may make this call.

24. Nursing Home Patients To report suspected abuse or neglect of a patient who is a resident of a nursing home or any other type of nursing facility contact case management or contact the nursing home hotline.

25. Physical signs  Injury that has not been properly cared for  Any injury incompatible with history  Pain on touching  Cuts, lacerations, or puncture wounds  Bruises, welts, and discoloration; esp. bilaterally on upper arms, clustered on trunk  Pallor or poor skin hygiene  Sunken eyes, cheeks  Dehydration and/or malnourishment without illness  Evidence of inadequate care (gross decubiti without medical care)  Eye problems, retinal detachment

26.  Absence of hair and/or hemorrhaging below the scalp  Soiled clothing or bed  Burns – may be caused by cigarettes, caustics, acids, friction from ropes or chains, from confinement or contact with other objects.  Signs of confinement (locked in room, tied to furniture or bathroom fixtures)  Lack of bandages or stitches when indicated or evidence of unset bones  Mouth injuries, broken teeth  Inappropriate use of medications – over sedation

27. Location of an injury A significant criteria which can aid in 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 results of an accident. Bruises on the bony parts of an individual ’ s body (chin, forehead) are common sites for injuries sustained from falling. Bruises on individuals who are immoble are suspect given his/her limited mobility and opportunity to harm him/herself.

28. Behavioral Indicators These behaviors in and of themselves, do not indicate abuse or neglect; however, combined with other indicators, they may be significant: Fear, withdrawal, depression, helplessness, resignation, hesitation to talk openly, implausible stories, confusion, disorientation or contradictory statements not due to mental dysfunction, anger, denial, non-responsiveness, agitation or anxiety.

29. Sexual Abuse Defined as touching, fondling, or any other sexual activity with older person when the older person is unable to understand, unwilling to consent, threatened or physically forced to engage in sexual behavior.

30. Indicators of Sexual Abuse  Presence of semen  Pharyngeal gonorrhea  Flirtation with abuser  Inappropriate relationship with abuser  Coyness with abuser  Sexually assaulted  Forced to perform oral sex

31. Indicators of Sexual Abuse Physical indicators of sexual abuse may be diagnosed by a physician include: Pain, bruises, tearing, swelling or bleeding of the external genitalia, vaginal and or anal areas; infection of the vagina and low urinary tract; venereal disease, the presence of sperm in the rectum, vagina, vulva/perineum or on the the victim ’ s clothing.

32. Emotional Abuse Defined as verbal assaults, threats of maltreatment, harassment, or intimidation so as to compel the older person to engage in conduct from which he or she has a right abstain or refrain from conduct in which the older person has the right to engage.

33. Indicators of Emotional Abuse Abuser Actions: uses harsh tone of voice, swears at elder, talks of elder ’ s death or elder as a burden, humiliates elder, calls elder names, treats elder as a child, interrupts elder when talking, overcritical of elder May threaten elder with violence, institutionalization, guardianship, abandonment premature discharge, eviction.

34. Passive Neglect Defined as the failure by a caregiver to provide an older person with the necessities of life including, but not limited to food, clothing, shelter, or medical care, because of the caregiver ’ s failure to understand the older person ’ s needs, lack of awareness of services to help meet the needs, or lack of capacity to care for the older person.

35. Indicators of Passive Neglect might include; Improper hygiene, poor nutrition, social isolation, lack of physical care of the victim ( inadequate clothing), lack of proper medical care, condition of home in disrepair (no utilities).

36. Financial Exploitation Defined as the misuse or withholding an older person ’ s resources by another person to the disadvantage of the elderly person and/or profit or advantage of a person other than the older person. Indicators of Financial Exploitation Unusual/inappropriate bank activities of victim Inappropriate decision making by abuser Theft/vandalism by abuser Abuser controls banking decisions/cash

37. Child Abuse and Neglect The Department of Children and Family Services (DCFS) is the state agency given the responsibility by the state of Illinois to conduct investigations of child maltreatment and to arrange for needed services for children and families where credible evidence of abuse or neglect exists.

38. It is the policy of Provena United Samaritans Medical center to cooperate with Illinois DCFS in reporting all cases of suspected child abuse or neglect as mandated by the Abuse and Neglected Child Reporting Act (ANCRA) of the State of Illinois and Indiana law.

39. Mandated Reporters Illinois requires six groups of professionals to report suspected child maltreatment. Mandated reporters are:  Medical Personnel  School Personnel  Social Service/Mental Health Personnel  Law Enforcement Personnel  Coroner/Medical Examiner Personnel  Child Care Personnel  Clergy Members

40. Requirements of Mandated Reporters  Report suspected abuse of a child immediately *Privileged communication is not ground for failure to report. Willful failure to report suspected cases of child abuse or neglect is a misdemeanor (1 st violation) or a class 4 felony (2 nd or subsequent violation).  You may have to testify if the case involves legal action  State law protects the identity of all mandated reporters.  You must confirm the report in writing to the local investigation unit within 48 hrs of the hotline call – mail one copy to the State Central Register and one copy to the Case Management Dept. (see clinical care policy titled, Reporting of Suspect Abuse/Neglect Child/Adult/Elder)

41. Information to Report To The Hotline  Name, age, race, gender, etc. for adult/child subjects.  Addresses for all victims and perpetrators and current location.  Info about the other siblings or other family members  Harm to the victim(s)  Specific info about the abusive incident You should have information about when the incident occurred, the extent of the injuries, how the child said it happened, and any other pertinent information. Child is defined as any person under the age of 18 unless legally emancipated by reason of marriage or entry into a branch of the U.S. Armed Services

42. Definitions of Child Abuse and Neglect Physical Abuse occurs when a parent or a person responsible for the child ’ s welfare : Inflicts/causes/allows to inflict upon a child physical injury other than by accident, which causes death, disfigurement, impairment of physical, emotional health or loss of bodily function. Examples include: bruises, human bites, bone fx, burns Creates a substantial risk of injury likely to the physical impacts listed above. Examples include:choking, smothering, throwing the child, violently pushing or shoving a child into fixed objects. Acts of torture: defined by DCFS as deliberately and/or systematically inflecting cruel or unusual treatment which results in physical or mental suffering.

43. Definitions of Child Abuse Inflicting excessive corporal punishment – bruises inflicted on a child usually meet this definition. Commits or allows to be committed female genital mutilation Causes to be sold, transferred, distributed or given to such child under 18 a controlled substance except when prescribed by a physician Sexual Abuse Occurs when a person responsible for the child ’ s welfare commits any of the following acts: Sexually transmits disease Sexual penetration – contact between the sex organ of one person and the sex organ, mouth, anus of another

44. Definitions of Child Abuse Sexual exploitation – is the sexual use of a child for sexual arousal, gratification, advantage or profit. Examples include: child pornography & forcing a child to watch sex acts Sexual molestation – is the sexual conduct with a child when such contact, touching, or interaction is used for arousal or gratification of sexual needs or desires Examples include: fondling a child or having the child touch the perpetrator sexually Neglect Occurs when a person responsible for the child deprives or fails to provide the child with adequate food, clothing, shelter, needed medical treatment, or proper supervision. When a controlled substance is found in the blood, urine, or meconium of a newborn infant.

45. Definitions of Child Abuse … continued When struggling with determining if abuse has occurred one question to ask yourself is “ has the child been harmed or been at substantial risk of harm? ” This helps focus the issue and moves away from value judgments and attitudes about lifestyle

46. Documentation Document all readily visible evidence of physical injury to the child including: description, location, severity, number of bruises, patterns of similar injuries over time, and describe parent/child interactions Take photographs of the injury Document disclosures of sexual abuse – telling may be accidental or painfully deliberate. Do not encourage the victim to disclose information beyond what is given voluntarily. Doing so may cause further trauma to the victim. It is ok to ask clarifying questions. Neglect: the severity, frequency, duration of the conditions

47. Child Abuse Assessment Injury Assessment  Natural/normal/accidental/non-accidental Obtain the caretakers explanation for the “ accident ” prior to examining the child.  Is the situation a one-time event?  What is the age and development skills of the child? (could this accident happen the way the caretaker says it happened given the developmental skills of the child?)  Was there any delay in seeking treatment?  “ Hospital Shopping ” – has caretaker taken child to several different hospitals, so that no one hospital will have records of all injuries? When possible separate interviews should be held for the caregiver and child.

48. Injuries Accidental – usually on bone- prominent areas of the body (knees, hands, nose, skin, elbows, chin, and forehead) None-accidental – buttocks, arms, stomach/torso – fatal areas, neck, thighs, cheeks, ears 70% of non-accidental injuries occur between the neck and the knees. Bruises 1. In the shape of handprints, belt buckles, cord loops, or encirclements represent child physical abuse

49. Bruises 2. Age Dating of Bruises (when did the bruising occur?) Time Color 0-2 days Red – swollen, tender 2-5 days Blue, purple 5-7 days Green 7-10 days Yellow 10-14 days Brown 2-4 weeks Clear Note: Bruises are rare in infants who do not stand/walk

50. Bruises 3. Location – what part of the body is bruised? 4. Distribution – are the bruises distributed over a large part of the body or are they contained in one area? 5. Number of bruises – if there is one large bruise on the outside of the thigh, it might be indicative of an accidental fall; however, if there are a number of small bruises, it might be more suggestive of “ foul play ”. 6. Configuration – how many planes of the body contain the bruises?

51. Abrasions/Wounds Age Dating Time Appearance Less than 6 hours Raw,oozing blood/clear fluid More than 6 hours Dry and red Over 24 hours Scabs form

52. Physical Indicators of Child Abuse  Bruises on uncommonly injured body surface  Blunt – instrument marks or burns  Human hand/bite marks  Multiple injuries at different stages of healing  Evidence of poor care or failure to thrive  Circumferential immersion burns  Unexplained retinal hemorrhages

53. Child Sexual Abuse Indicators  Fear of being alone with an adult  Extreme repulsion/fear when being touched  Inappropriate knowledge of sexual matters  Overt sexual acting out towards adults  Simulation of sophisticated sexual activity  Bruises or hickeys: face, neck, groin, buttocks  Public masturbation  Self – mutilation  Fear of bathroom or shower  Violence towards younger children

54. Summary & Conclusion As a health care professional, if you suspect child abuse or neglect is taking place, contact the Illinois DCFS and report your observations. The DCFS will provide protection, evaluation, and medical management for children, adults and elderly whose health and welfare may be jeopardized through physical abuse, neglect or sexual assault.