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Domestic Violence
Martin R. Huecker; Kevin C. King; Gary A. Jordan; William Smock.

Author Information

Last Update: August 26, 2021.

Go to:

Continuing Education Activity

Family and domestic violence is a common problem in the United States, affecting an
estimated 10 million people every year; as many as one in four women and one in
nine men are victims of domestic violence. Virtually all healthcare professionals will
at some point evaluate or treat a patient who is a victim of domestic or family
violence. Domestic and family violence includes economic, physical, sexual,
emotional, and psychological abuse of children, adults, or elders. Domestic violence
causes worsened psychological and physical health, decreased quality of life,
decreased productivity, and in some cases, mortality. Domestic and family violence
can be difficult to identify. Many cases are not reported to health professionals or legal
authorities. This activity describes the evaluation, reporting, and management
strategies for victims of domestic abuse and stresses the role of team-based
interprofessional care for these victims.

Objectives:
 ● Identify the epidemiology of domestic violence.
● Describe the types of domestic violence.
● Explain challenges associated with reporting domestic violence.
● Review some interprofessional team strategies for improving care coordination
and communication to identify domestic violence and improve outcomes for its
victims.

Access free multiple choice questions on this topic.

Go to:

Introduction

Family and domestic violence including child abuse, intimate partner abuse, and elder
abuse is a common problem in the United States. Family and domestic health violence
are estimated to affect 10 million people in the United States every year. It is a
national public health problem, and virtually all healthcare professionals will at some
point evaluate or treat a patient who is a victim of some form of domestic or family
violence.[1][2][3][4][5]

Unfortunately, each form of family violence begets interrelated forms of violence. The
"cycle of abuse" is often continued from exposed children into their adult relationships
and finally to the care of the elderly.

Domestic and family violence includes a range of abuse, including economic,

physical, sexual, emotional, and psychological, toward children, adults, and elders.

Intimate partner violence includes stalking, sexual and physical violence, and
psychological aggression by a current or former partner. In the United States, as many
as one in four women and one in nine men are victims of domestic violence. Domestic
violence is thought to be underreported. Domestic violence affects the victim,
families, co-workers, and community. It causes diminished psychological and physical
health, decreases the quality of life, and results in decreased productivity.

The national economic cost of domestic and family violence is estimated to be over 12
billion dollars per year. The number of individuals affected is expected to rise over the
next 20 years, increasing the elderly population.

Domestic and family violence is difficult to identify, and many cases go unreported to
health professionals or legal authorities. Due to the prevalence in our society, all
healthcare professionals, including psychologists, nurses, pharmacists, dentists,
physician assistants, nurse practitioners, and physicians, will evaluate and possibly
treat a victim or perpetrator of domestic or family violence.[6][7]

Definitions

Family and domestic violence are abusive behaviors in which one individual gains
power over another individual.

● Intimate partner violence typically includes sexual or physical violence,

psychological aggression, and stalking. This may include former or current
intimate partners.
● Child abuse involves the emotional, sexual, physical, or neglect of a child
under 18 by a parent, custodian, or caregiver that results in potential harm,
harm, or a threat of harm.
● Elder abuse is a failure to act or an intentional act by a caregiver that causes or
creates a risk of harm to an elder.

Center for Disease Control and Prevention (CDC)

Domestic violence, spousal abuse, battering, or intimate partner violence, is typically
the victimization of an individual with whom the abuser has an intimate or romantic
relationship. The CDC defines domestic violence as "physical violence, sexual
violence, stalking, and psychological aggression (including coercive acts) by a current
or former intimate partner."

Domestic and family violence has no boundaries. This violence occurs in intimate
relationships regardless of culture, race, religion, or socioeconomic status. All
healthcare professionals must understand that domestic violence, whether in the form
of emotional, psychological, sexual, or physical violence, is common in our society
and should develop the ability to recognize it and make the appropriate referral.

Violence Abuse Types

The types of violence include stalking, economic, emotional or psychological, sexual,

neglect, Munchausen by proxy, and physical. Domestic and family violence occurs in
all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or
geographic limitation. It may occur in individuals with different sexual orientations.

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Etiology

Reason Abusers Need to Control[8][9][10]

● Anger management issues

● Jealousy
● Low self-esteem
● Feeling inferior
 ● Cultural beliefs they have the right to control their partner
● Personality disorder or psychological disorder
● Learned behavior from growing up in a family where domestic violence was
accepted
● Alcohol and drugs, as an impaired individual may be less likely to control
violent impulses

Risk Factors

Risk factors for domestic and family violence include individual, relationship,
community, and societal issues. There is an inverse relationship between education
and domestic violence. Lower education levels correlate with more likely domestic
violence. Childhood abuse is commonly associated with becoming a perpetrator of
domestic violence as an adult. Perpetrators of domestic violence commonly repeat
acts of violence with new partners. Drug and alcohol abuse greatly increases the
incidence of domestic violence.

Children who are victims or witness domestic and family violence may believe that
violence is a reasonable way to resolve a conflict. Males who learn that females are
not equally respected are more likely to abuse females in adulthood. Females who
witness domestic violence as children are more likely to be victimized by their
spouses. While females are often the victim of domestic violence, gender roles can be
reversed.

Domination may include emotional, physical, or sexual abuse that may be caused by
an interaction of situational and individual factors. This means the abuser learns
violent behavior from their family, community, or culture. They see violence and are
victims of violence.

Go to:
Epidemiology

Domestic violence is a serious and challenging public health problem. Approximately

1 in 3 women and 1 in 10 men 18 years of age or older experience domestic violence.
Annually, domestic violence is responsible for over 1500 deaths in the United
States.[11][12][13]

Domestic violence victims typically experience severe physical injuries requiring care
at a hospital or clinic. The cost to individuals and society is significant. The national
annual cost of medical and mental health care services related to acute domestic
violence is estimated at over $8 billion. If the injury results in a long-term or chronic
condition, the cost is considerably higher.

Financial hardship and unemployment are contributors to domestic violence. An

economic downturn is associated with increased calls to the National Domestic
Violence Hotline.

Fortunately, the national rate of nonfatal domestic violence is declining. This is

thought to be due to a decline in the marriage rate, decreased domesticity, better
access to domestic violence shelters, improvements in female economic status, and an
increase in the average age of the population.

National

● Most perpetrators and victims do not seek help.

● Healthcare professionals are usually the first individuals with an opportunity to
identify domestic violence.
● Nurses are usually the first healthcare providers victims encounter.
● Domestic violence may be perpetrated on women, men, parents, and children.
 ● Fifty percent of women seen in emergency departments report a history of
abuse, and approximately 40% of those killed by their abuser sought help in
the 2 years before death.
● Only one-third of police-identified victims of domestic violence are identified
in the emergency department.
● Healthcare professionals who work in acute care need to maintain a high index
of suspicion for domestic violence as supportive family members may, in fact,
be abusers.

Child Abuse

Age, family income, and ethnicity are all risk factors for both sexual abuse and
physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse.

Each year there are over 3 million referrals to child protective authorities. Despite
often being the first to examine the victims, only about 10% of the referrals were from
medical personnel. The fatality rate is approximately two deaths per 100,000 children.
Women account for a little over half of the perpetrators.

Intimate Partner Violence

According to the CDC, 1 in 4 women and 1 in 7 men will experience physical

violence by their intimate partner at some point during their lifetimes. About 1 in 3
women and nearly 1 in 6 men experience some form of sexual violence during their
lifetimes. Intimate partner violence, sexual violence, and stalking are high, with
intimate partner violence occurring in over 10 million people each year.

One in 6 women and 1 in 19 men have experienced stalking during their lifetimes.
The majority are stalked by someone they know. An intimate partner stalks about 6 in
10 female victims and 4 in 10 male victims.
At least 5 million acts of domestic violence occur annually to women aged 18 years
and older, with over 3 million involving men. While most events are minor, for
example grabbing, shoving, pushing, slapping, and hitting, serious and sometimes
fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and
physical assaults are perpetrated annually, and approximately 800,000 male assaults
occur. About 1 in 5 women have experienced completed or attempted rape at some
point in their lives. About 1% to 2% of men have experienced completed or attempted
rape.

The incidence of intimate partner violence has declined by over 60%, from about ten
victimizations per 1000 persons age 12 or older to approximately 4 per 1000.

Elderly

Due to underreporting and difficulty sampling, obtaining accurate incidence

information on elder abuse and neglect is difficult. Elderly abuse is thought to occur in
3% to 10% of the population of elders.

Elderly patients may not report due to fear, guilt, ignorance, or shame. Clinicians
underreport elder abuse due to poor recognition of the problem, lack of understanding
of reporting methods and requirements, and concerns about physician-patient
confidentiality.

Go to:

Pathophysiology
There may be some pathologic findings in both the victims and perpetrators of
domestic violence. Certain medical conditions and lifestyles make family and
domestic violence more likely.[13][14][15]

Perpetrators

While the research is not definitive, a number of characteristics are thought to be

present in perpetrators of domestic violence. Abusers tend to:

● Have a higher consumption of alcohol and illicit drugs and assessment should
include questions that explore drinking habits and violence
● Be possessive, jealous, suspicious, and paranoid.
● Be controlling of everyday family activity, including control of finances and
social activities.
● Suffer low self-esteem
● Have emotional dependence, which tends to occur in both partners, but more
so in the abuser

Children

Domestic violence at home results in emotional damage, which exerts continued

effects as the victim matures.

● Approximately 45 million children will be exposed to violence during

childhood.
● Approximately 10% of children are exposed to domestic violence annually,
and 25% are exposed to at least 1 event during their childhood.
● Ninety percent are direct eyewitnesses of violence.
● Males who batter their wives batter the children 30% to 60% of the time.
● Children who witness domestic violence are at increased risk of dating
violence and have a more difficult time with partnerships and parenting.
 ● Children who witness domestic violence are at an increased risk for
post-traumatic stress disorder, aggressive behavior, anxiety, impaired
development, difficulty interacting with peers, academic problems, and they
have a higher incidence of substance abuse.
● Children exposed to domestic violence often become victims of violence.
● Children who witness and experience domestic violence are at a greater risk
for adverse psychosocial outcomes.
● Eighty to 90% of domestic violence victims abuse or neglect their children.
● Abused teens may not report abuse. Individuals 12 to 19 years of age report
only about one-third of crimes against them, compared with one-half in older
age groups

Pregnant and Females

The American College of Obstetricians and Gynecologists (ACOG) recommends all

women be assessed for signs and symptoms of domestic violence during regular and
prenatal visits. Providers should offer support and referral information.

● Domestic violence affects approximately 325,000 pregnant women each year.

● The average reported prevalence during pregnancy is approximately 30%
emotional abuse, 15% physical abuse, and 8% sexual abuse.
● Domestic violence is more common among pregnant women than
preeclampsia and gestational diabetes.
● Reproductive abuse may occur and includes impregnating against a partner's
wishes by stopping a partner from using birth control.
● Since most pregnant women receive prenatal care, this is an excellent time to
assess for domestic violence.

The danger of domestic violence is particularly acute as both mother and fetus are at
risk. Healthcare professionals should be aware of the psychological consequences of
domestic abuse during pregnancy. There is more stress, depression, and addiction to
alcohol in abused pregnant women. These conditions may harm the fetus.
Gay, Lesbian, Bisexual, and Transgender

Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the
rates are thought to be similar to a heterosexual woman, approximately 25%.

● There are more cases of domestic violence among males living with male
partners than among males who live with female partners.
● Females living with female partners experience less domestic violence than
females living with males.
● Transgender individuals have a higher risk of domestic violence. Transgender
victims are approximately two times more likely to experience physical
violence.

Gay, lesbian, bisexual, and transgender victims may be reticent to report domestic
violence. Part of the challenge may be that support services such as shelters, support
groups, and hotlines are not regularly available. This results in isolated and
unsupported victims. Healthcare professionals should strive to be helpful when
working with gay, lesbian, bisexual, and transgender patients.

Men

Usually, domestic violence is perpetrated by men against women; however, females

may exhibit violent behavior against their male partners.

● Approximately 5% of males are killed by their intimate partners.

● Each year, approximately 500,000 women are physically assaulted or raped by
an intimate partner compared to 100,000 men.
● Three out of 10 women at some point are stalked, physically assaulted, or
raped by an intimate partner, compared to 1 out of every 10 men.
● Rape is primarily perpetrated by other men, while women engage in other
forms of violence against men.
Although women are the most common victims of domestic violence, healthcare
professionals should remember that men may also be victims and should be evaluated
if there are indications present.

Elderly

The elderly are often mistreated by their spouses, children, or relatives.

● Annually, approximately 2% of the elderly experience physical abuse, 1%

sexual abuse, 5% neglect, 5% financial abuse, and 5% suffer emotional abuse.
● The annual incidence of elder abuse is estimated to be 2% to 10%, with only
about 1 in 15 cases reported to the authorities.
● Approximately one-third of nursing homes disclosed at least 1 incident of
physical abuse per year.
● Ten percent of nursing home staff self-report physical abuse against an elderly
resident.

Elder domestic violence may be financial or physical. The elderly may be controlled
financially. Elders are often hesitant to report this abuse if it is their only available
caregiver. Victims are often dependent, infirm, isolated, or mentally impaired.
Healthcare professionals should be aware of the high incidence of abuse in this
population.

Go to:

History and Physical

The history and physical exam should be tailored to the age of the victim.
Child Abuse

The most common injuries are fractures, contusions, bruises, and internal bleeding.
Unexpected injuries to pre-walking infants should be investigated. The caregiver
should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries
should be investigated.

Children who are abused may be unkempt and/or malnourished. They may display
inappropriate behavior such as aggression, or maybe shy, withdrawn, and have poor
communication skills. Others may be disruptive or hyperactive. School attendance is
usually poor.

Intimate Partner Abuse

Approximately one-third of women and one-fifth of men will be victims of abuse. The
most common sites of injuries are the head, neck, and face. Clothes may cover injuries
to the body, breasts, genitals, rectum, and buttocks. One should be suspicious if the
history is not consistent with the injury. Defensive injuries may be present on the
forearms and hands. The patient may have psychological signs and symptoms such as
anxiety, depression, and fatigue.

Medical complaints may be specific or vague such as headaches, palpitations, chest

pain, painful intercourse, or chronic pain.

Intimate Partner Abuse: Pregnancy and Female

Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions.
There are a number of historical and physical findings that may help the provider
identify individuals at risk.
If the examiner encounters signs or symptoms, she should make every effort to
examine the patient in private, explaining confidentiality to the patient. Be sure to ask
caring, empathetic questions and listen politely without interruption to answers.

Intimate Partner Abuse: Same-Sex

Same-sex partner abuse is common and may be difficult to identify. Over 35% of
heterosexual women, 40% of lesbians, 60% of bisexual women experience domestic
violence. For men, the incidence is slightly lower. In addition to common findings of
abuse, perpetrators may try to control their partners by threatening to make their
sexual preferences public.

The provider should be aware there are fewer resources available to help victims;
further, the perpetrator and victim may have the same friends or support groups.

Intimate Partner Abuse: Men

Men represent as much as 15% of all cases of domestic partner violence. Male victims
are also less likely to seek medical care, so that the incidence may be underreported.
These victims may have a history of child abuse.

Elderly Abuse

Health professionals should ask geriatric patients about abuse, even if signs are
absent.

Risk Factors

● Dementia
 ● Pathologic characteristics of perpetrators including dementia, mental illness,
and drug and alcohol abuse
● A shared living situation with the abuser
● Social isolation

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Evaluation

Establishing that injuries are related to domestic abuse is a challenging task. Life and
limb-threatening injuries are the priority. After stabilization and physical evaluation,
laboratory tests, x-rays, CT, or MRI may be indicated. It is important that healthcare
professionals first attend to the underlying issue that brought the victim to the
emergency department.[1][16][17][18]

● The evaluation should start with a detailed history and physical examination.
Clinicians should screen all females for domestic violence and refer females
who screen positive. This includes females who do not have signs or symptoms
of abuse. All healthcare facilities should have a plan in place that provides for
assessing, screening, and referring patients for intimate partner violence.
Protocols should include referral, documentation, and follow-up.
● Health professionals and administrators should be aware of challenges such as
barriers to screening for domestic violence: lack of training, time constraints,
the sensitive nature of issues, and a lack of privacy to address the issues.
● Although professional and public awareness has increased, many patients and
providers are still hesitant to discuss abuse.
● Patients with signs and symptoms of domestic violence should be evaluated.
The obvious cues are physical: bruises, bites, cuts, broken bones, concussions,
burns, knife or gunshot wounds.
● Typical domestic injury patterns include contusions to the head, face, neck,
breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more
 commonly involve the extremities of the body. Abuse victims tend to have
multiple injuries in various stages of healing, from acute to chronic.
● Domestic violence victims may have emotional and psychological issues such
as anxiety and depression. Complaints may include backaches, stomachaches,
headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are
more likely to experience asthma, irritable bowel syndrome, and diabetes.

Assessment

Assuming the patient is stable and not in pain, a detailed assessment of victims should
occur after disclosure of abuse. Assessing safety is the priority. A list of standard
prepared questions can help alleviate the uncertainty in the patient's evaluation. If
there are signs of immediate danger, refer to advocate support, shelter, a hotline for
victims, or legal authorities.

● If there is no immediate danger, the assessment should focus on mental and

physical health and establish the history of current or past abuse. These
responses determine the appropriate intervention.
● During the initial assessment, a practitioner must be sensitive to the patient’s
cultural beliefs. Incorporating a cultural sensitivity assessment with a history of
being victims of domestic violence may allow more effective treatment.
● Patients that have suffered domestic violence may or may not want a referral.
Many are fearful of their lives and financial well-being. They hence may be
weighing the tradeoff in leaving the abuser leading to loss of support and
perhaps the responsibility of caring for children alone. The healthcare provider
needs to assure the patient that the decision is voluntary and that the provider
will help regardless of the decision. The goal is to make resources accessible,
safe, and enhance support.
● If the patient elects to leave their current situation, information for referral to a
local domestic violence shelter to assist the victim should be given.
● If there is a risk to life or limb, or evidence of injury, the patient should be
referred to local law enforcement officials.
● Counselors often include social workers, psychiatrists, and psychologists that
specialize in the care of battered partners and children.
Testing

Children

A detailed history and careful physical exam should be performed. If head trauma is
suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.

Laboratory

Laboratory studies are often important for forensic evaluation and criminal
prosecution. On occasion, certain diseases may mimic findings similar to child abuse.
As a consequence, they must be ruled out.

Urine

● A urine test may be used as a screen for sexually transmitted disease, bladder
or kidney trauma, and toxicology screening.

Hematology

If bruises or contusions are present, there is no need to evaluate for a bleeding

disorder if the injuries are consistent with an abuse history. Some tests can be falsely
elevated, so a child abuse-specialist pediatrician or hematologist should review or
follow-up these tests.

Gastrointestinal and Chest Trauma

 ● Consider liver and pancreas screening tests such as AST, ALT, and lipase. If
the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L,
consider an abdomen and pelvis CT with intravenous contrast.
● The highest-risk are those with abusive head trauma, fractures, nausea,
vomiting, or an abnormal Glasgow Coma Scale score of less than 15.

Imaging

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as
there are subtle differences from adults, such as cranial sutures and incomplete bone
growth. A fracture can be misinterpreted. If there is a concern for abuse, consider
consulting a radiologist.

Imaging: Skeletal Survey

A skeletal survey is indicated in children younger than 2 years with suspected physical
abuse. The incidence of occult fractures is as high as 1 in 4 in physically abused
children younger than 2 years. The clinician should consider screening all siblings
younger than 2 years.

The skeletal survey should include 2 views of each extremity; anteroposterior and
lateral skull; and lateral chest, spine, abdomen, pelvis, hands, and feet. A radiologist
should review the films for classic metaphyseal lesions and healing fractures, most
often involving the posterior ribs. A “babygram” that includes only 1 film of the entire
body is not an adequate skeletal survey.

Skeletal fractures will remodel at different rates, which are dependent on the age,
location, and nutritional status of the patient.

Imaging: CT
If abuse or head trauma is suspected, a CT scan of the head should be performed on
all children aged six months or younger or children younger than 24 months if
intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT
scan of the head when abuse is suspected, especially in an infant younger than 12
months.

CT of the abdomen and pelvis with intravenous contrast is indicated in unconscious

children, have traumatic abdominal findings such as abrasions, bruises, tenderness,
absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have
elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.

Special Documentation

Photographs should be taken before treatment of injuries.

Intimate Partner and Elder

Laboratory

Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance

abuse, improper medication administration, and malnutrition.

Imaging

● X-rays of bruised of tender body parts to detect fractures

● Head CT scan to evaluate for intracranial bleeding as a result of abuse or the
causes of altered mental status

Other
 ● Pelvic examination with evidence collection if sexual assault

Evidence Collection

Domestic and family violence commonly results in the legal prosecution of the
perpetrator. Preferably, a team specializing in domestic violence is called in to assist
with evidence collection.

Each health facility should have a written procedure for how to package and label
specimens and maintain a chain of custody. Law enforcement personnel will often
assist with evidence collection and provide specific kits.

It is important to avoid destroying evidence. Evidence includes tissue specimens,

blood, urine, saliva, and vaginal and rectal specimens. Saliva from bites can be
collected; the bite mark is swabbed with a water-moistened cotton-tipped swab.

Clothing stained with blood, saliva, semen, and vomit should be retained for forensic
analysis.

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Treatment / Management

The priority is the ABCs and appropriate treatment of the presenting complaints.
However, once the patient is stabilized, emergency medical services personnel may
identify problems associated with violence.[19][20][21]

Emergency Department and Office Care

Interventions to consider include:

● Make sure a safe environment is provided.

● Diagnose physical injuries and other medical or surgical problems.
● Treat acute physical or life-threatening injuries.
● Identify possible sources of domestic violence.
● Establish domestic violence as a diagnosis.
● Reassure the patient that he is not at fault.
● Evaluate the emotional status and treat.
● Document the history, physical, and interventions.
● Determine the risks to the victim and assess safety options.
● Counsel the patient that violence may escalate.
● Determine if legal intervention is needed and report abuse when appropriate or
mandated.
● Develop a follow-up plan.
● Offer shelter options, legal services, counseling, and facilitate such referral.

Medical Record

The medical record is often evidence used to convict an abuser. A poorly document
chart may result in an abuser going free and assaulting again.

Charting should include detailed documentation of evaluation, treatment, and

referrals.

● Describe the abusive event and current complaints using the patient's own
words.
● Include the behavior of the patient in the record.
● Include health problems related to the abuse.
● Include the alleged perpetrator's name, relationship, and address.
● The physical exam should include a description of the patient's injuries
including location, color, size, amount, and degree of age bruises and
contusions.
 ● Document injuries with anatomical diagrams and photographs.
● Include the name of the patient, medical record number, date, and time of the
photograph, and witnesses on the back of each photograph.
● Torn and damaged clothing should also be photographed.
● Document injuries not shown clearly by photographs with line drawings.
● With sexual assault, follow protocols for physical examination and evidence
collection.

Disposition

If the patient does not want to go to a shelter, provide telephone numbers for domestic
violence or crisis hotlines and support services for potential later use. Provide the
patient with instructions but be mindful that written materials may pose a danger once
the patient returns home.

● A referral should be made to primary care or another appropriate resource.

● Advise the patient to have a safety plan and provide examples.

Remember

● Forty percent of domestic violence victims never contact the police.

● Of female victims of domestic homicide, 44% had visited a hospital emergency
department within 2 years of their murder.
● Health professionals provide an opportunity for victims of domestic violence
to obtain help.

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Differential Diagnosis

The differential diagnosis varies with the injury type of injury and age.

Child

Head Trauma

● Accidental injury
● Arteriovenous malformations
● Bacterial meningitis
● Birth trauma
● Cerebral sinovenous thrombosis
● Hemophilia
● Solid brain tumors

Bruises and Contusions

● Accidental bruises
● Birth trauma
● Bleeding disorder
● Coining
● Cupping
● Congenital dermal melanocytosis (Mongolian spots)
● Erythema multiforme
● Hemangioma
● Hemophilia

Burns
 ● Accidental burns
● Atopic dermatitis
● Contact dermatitis
● Impetigo
● Inflammatory skin conditions
● Sunburn

Fractures

● Accidental
● Birth trauma
● Congenital syphilis
● Malignancy
● Osteogenesis imperfecta
● Osteomyelitis
● Rickets
● Scurvy
● Toddler’s fracture

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Prognosis

Without proper social service and mental health intervention, all forms of abuse can
be recurrent and escalating problems, and the prognosis for recovery is poor. Without
treatment, domestic and family violence usually recurs and escalates in both
frequency and severity.[3][22][23]

● Of those injured by domestic violence, over 75% continue to experience abuse.

 ● Over half of battered women who attempt suicide will try again; often they are
successful with the second attempt.

In children, the potential for poor outcomes is particularly high as abuse inflicts
lifelong effects. In addition to dealing with the sequelae of physical injury, the mental
consequences may be catastrophic. Studies indicate a significant association between
child sexual abuse and increased risk of psychiatric disorders in later life. The
potential for the cycle of violence to continued from childhood is very high.

Children raised in families of sexual abuse may develop:

● Attention deficit hyperactivity disorder (ADHD)

● Conduct disorder
● Depression
● Bipolar disorder
● Panic disorder
● Sleep disorders
● Suicide attempts
● Post-traumatic stress disorder (PTSD)

Health Outcomes

There are multiple known and suspected negative health outcomes of family and
domestic violence. There are long-term consequences to broken bones, traumatic
brain injuries, and internal injuries.

Patients may also develop multiple comorbidities such as:

● Asthma
● Insomnia
 ● Fibromyalgia
● Headaches
● High blood pressure
● Chronic pain
● Gastrointestinal disorders
● Gynecologic disorders
● Depression
● Panic attacks
● PTSD

Go to:

Pearls and Other Issues

Screening: Tools

● The American Academy of Pediatricians has free guides for the history,
physical, diagnostic testing, documentation, treatment, and legal issues in cases
of suspected child abuse.
● The Center for Disease Control and Prevention (CDC) provides several scales
assessing family relationships, including child abuse risks.
● The physical examination is still the most significant diagnostic tool to detect
abuse. A child or adult with suspected abuse should be undressed, and a
comprehensive physical exam should be performed. The skin should be
examined for bruises, bites, burns, and injuries in different stages of healing.
Examine for retinal hemorrhages, subdural hemorrhages, tympanic membrane
rupture, soft tissue swelling, oral bruising, fractured teeth, and organ injury.

Screening: Recommendations
 ● Evaluate for organic conditions and medications that mimic abuse.
● Evaluate patients and caregivers separately
● Clinicians should regularly screen for family and domestic violence and elder
abuse
● The Elder Abuse Suspicion Index can be used to assess for elder abuse
● Screen for cognitive impairment before screening for abuse in the elderly
● Pattern injury is more suspicious

Risks

● Failure to report child abuse is illegal in most states.

● Failure to report intimate partner and elder abuse is illegal in many states.

Legal

It is important to be aware of federal and state statutes governing domestic and family
abuse. Remember that reporting domestic and family violence to law enforcement
does not obviate detailed documentation in the medical record.

● Battering is a crime, and the patient should be made aware that help is
available. If the patient wants legal help, the local police should be called.
● In some jurisdictions, domestic violence reporting is mandated. The legal
obligation to report abuse should be explained to the patient.
● The patient should be informed how local authorities typically respond to such
reports and provide follow-up procedures. Address the risk of reprisal, need for
shelter, and possibly an emergency protective order (available in every state
and the District of Columbia).
● If there is a possibility the patient’s safety will be jeopardized, the clinician
should work with the patient and authorities to best protect the patient while
meeting legal reporting obligations.
 ● The clinical role in managing an abused patient goes beyond obeying the laws
that mandate reporting; there is a primary obligation to protect the life of the
patient.
● The clinician must help mitigate the potential harm that results from reporting,
provide appropriate ongoing care, and preserve the safety of the patient.
● If the patient desires, and it is acceptable to the police, a health professional
should remain during the interview.
● The medical record should reflect the incident as described by the patient and
any physical exam findings. Include the date and time the report was taken and
the officer's name and badge number.

National Statutes

Federal Child Abuse Prevention and Treatment Act (CAPTA)

Each state has specific child abuse statutes. Federal legislation provides guidelines for
defining acts that constitute child abuse. The guidelines suggest that child abuse
includes an act or failure recent act that presents an imminent risk of serious harm.
This includes any recent act or failure to act on the part of a parent or caretaker that
results in death, physical or emotional harm, sexual abuse, or exploitation.

Elder Justice Act

The Elder Justice Act provides strategies to decrease the likelihood of elder abuse,
neglect, and exploitation. The Act utilizes three significant approaches:

Patient Safety and Abuse Act

The Violence Against Woman Act makes it a federal crime to cross state lines to stalk,
harass, or physically injure a partner; or enter or leave the country violating a
protective order. It is a violation to possess a firearm or ammunition while subject to a
protective order or if convicted of a qualifying crime of domestic violence.
 Go to:

Enhancing Healthcare Team Outcomes

Domestic violence may be difficult to uncover when the victim is frightened,

especially when he or she presents to an emergency department or healthcare
practitioner's office. The key is to establish an assessment protocol and maintain an
awareness of the possibility that domestic and family violence may be the cause of the
patient’s signs and symptoms.

Over 80% of victims of domestic and family violence seek care in a hospital; others
may seek care in health professional offices, including dentists, therapists, and other
medical offices. Routine screening should be conducted by all healthcare practitioners
including nurses, physicians, physician assistants, dentists, nurse practitioners, and
pharmacists. Interprofessional coordination of screening is a critical component of
protecting victims and minimizing negative health outcomes. Health professional
team interventions reduce the incidence of morbidity and mortality associated with
domestic violence. Documentation is vital and a legal obligation.

● Healthcare professionals including the nurse should document all findings and
recommendations in the medical record, including statements made denying
abuse
● If domestic violence is admitted, documentation should include the history,
physical examination findings, laboratory and radiographic finds, any
interventions, and the referrals made.
● If there are significant findings that can be recorded, pictures should be
included.
● The medical record may become a court document; be objective and accurate.
● Healthcare professionals should provide a follow-up appointment.
● Reassurance that additional assistance is available at any time is critical to
protect the patient from harm and break the cycle of abuse.
 ● Involve the social worker early
● Do not discharge the patient until a safe haven has been established.

Resources

National

The following agencies provide national assistance for victims of domestic and family
violence:

● Centers for Disease Control and Prevention (800-CDC-INFO (232-4636)/TTY:

888-232-6348
● Childhelp: National Child Abuse Hotline: (800-4-A-CHILD (2-24453))
● The coalition of Labor Union Women (cluw.org): 202-466-4615
● Corporate Alliance to End Partner Violence: 309-664-0667
● Employers Against Domestic Violence: 508-894-6322
● Futures without Violence: 415-678-5500/TTY 800-595-4889
● Love Is Respect: National Teen Dating Abuse Helpline: 866-331-9474 /TTY:
866-331-8453
● National Center on Domestic and Sexual Violence
● National Center on Elder Abuse
● National Coalition Against Domestic Violence (www.ncadv.org)
● National Network to End Domestic Violence: 202-543-5566
● National Organization for Victim Assistance
● National Resource Center on Domestic Violence: 800-537-2238
● National Sexual Violence Resource Center: 717-909-0710

Go to:

Review Questions
 ● Access free multiple choice questions on this topic.
● Comment on this article.

Go to:

References

1.

Sapkota D, Baird K, Saito A, Anderson D. Interventions for reducing and/or

controlling domestic violence among pregnant women in low- and middle-income
countries: a systematic review. Syst Rev. 2019 Apr 02;8(1):79. [PMC free article]
[PubMed]

2.

Klein LB, Chesworth BR, Howland-Myers JR, Rizo CF, Macy RJ. Housing
Interventions for Intimate Partner Violence Survivors: A Systematic Review.
Trauma Violence Abuse. 2021 Apr;22(2):249-264. [ PubMed]

3.

Marie-Mitchell A, Kostolansky R. A Systematic Review of Trials to Improve Child

Outcomes Associated With Adverse Childhood Experiences. Am J Prev Med. 2019
May;56(5):756-764. [PubMed]

4.
 Lewis NV, Dowrick A, Sohal A, Feder G, Griffiths C. Implementation of the
Identification and Referral to Improve Safety programme for patients with
experience of domestic violence and abuse: A theory-based mixed-method process
evaluation. Health Soc Care Community. 2019 Jul;27(4):e298-e312. [PMC free
article] [PubMed]

5.

Sarkar R, Ozanne-Smith J, Bassed R. Systematic Review of the Patterns of

Orofacial Injuries in Physically Abused Children and Adolescents. Trauma
Violence Abuse. 2021 Jan;22(1):136-146. [PubMed]

6.

Gao S, Assink M, Liu T, Chan KL, Ip P. Associations Between Rejection

Sensitivity, Aggression, and Victimization: A Meta-Analytic Review. Trauma
Violence Abuse. 2021 Jan;22(1):125-135. [PubMed]

7.

Zeppegno P, Gramaglia C, di Marco S, Guerriero C, Consol C, Loreti L, Martelli

M, Marangon D, Carli V, Sarchiapone M. Intimate Partner Homicide Suicide: a
Mini-Review of the Literature (2012-2018). Curr Psychiatry Rep. 2019 Feb
21;21(3):13. [PubMed]

8.

Hackenberg EAM, Sallinen V, Handolin L, Koljonen V. Victims of Severe Intimate

Partner Violence Are Left Without Advocacy Intervention in Primary Care
 Emergency Rooms: A Prospective Observational Study. J Interpers Violence. 2021
Aug;36(15-16):7832-7854. [PubMed]

9.

Gottlieb A, Mahabir M. The Effect of Multiple Types of Intimate Partner Violence

on Maternal Criminal Justice Involvement. J Interpers Violence. 2021
Jul;36(13-14):6797-6820. [PubMed]

10.

Roscoe LA, Schenck DP. Victim of Abuse, or Bully? The Case of the 800-Pound
Man. Narrat Inq Bioeth. 2018;8(3):261-271. [PubMed]

11.

Wahi A, Zaleski KL, Lampe J, Bevan P, Koski A. The Lived Experience of Child
Marriage in the United States. Soc Work Public Health. 2019;34(3):201-213.
[PubMed]

12.

Harland KK, Peek-Asa C, Saftlas AF. Intimate Partner Violence and Controlling
Behaviors Experienced by Emergency Department Patients: Differences by Sexual
Orientation and Gender Identification. J Interpers Violence. 2021
Jun;36(11-12):NP6125-NP6143. [PMC free article] [PubMed]

13.
 Jiang Y, DeBare D, Colomer I, Wesley J, Seaberry J, Viner-Brown S.
Characteristics of Victims and Suspects in Domestic Violence-Related Homicide -
Rhode Island Violent Death Reporting System, 2004-2015. R I Med J (2013). 2018
Dec 03;101(10):58-61. [PubMed]

14.

Stone LB, Amole MC, Cyranowski JM, Swartz HA. History of childhood
emotional abuse predicts lower resting-state high-frequency heart rate variability in
depressed women. Psychiatry Res. 2018 Nov;269:681-687. [PMC free article]
[PubMed]

15.

Hansen JB, Killough EF, Moffatt ME, Knapp JF. Retinal Hemorrhages: Abusive
Head Trauma or Not? Pediatr Emerg Care. 2018 Sep;34(9):665-670. [PubMed]

16.

Skott S. Disaggregating Violence: Understanding the Decline. J Interpers Violence.

2021 Aug;36(15-16):7670-7694. [PubMed]

17.

Lifflander AL. Hard Times and Hard Stops. JAMA. 2019 Mar 05;321(9):837-838.
[PubMed]

18.
 Saywitz KJ, Wells CR, Larson RP, Hobbs SD. Effects of Interviewer Support on
Children's Memory and Suggestibility: Systematic Review and Meta-Analyses of
Experimental Research. Trauma Violence Abuse. 2019 Jan;20(1):22-39. [PubMed]

19.

Jordan KS, Steelman SH, Leary M, Varela-Gonzalez L, Lassiter SL, Montminy L,

Bellow EF. Pediatric Sexual Abuse: An Interprofessional Approach to Optimizing
Emergency Care. J Forensic Nurs. 2019 Jan/Mar;15(1):18-25. [PubMed]

20.

US Preventive Services Task Force. Curry SJ, Krist AH, Owens DK, Barry MJ,
Caughey AB, Davidson KW, Doubeni CA, Epling JW, Grossman DC, Kemper AR,
Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW,
Wong JB. Interventions to Prevent Child Maltreatment: US Preventive Services
Task Force Recommendation Statement. JAMA. 2018 Nov 27;320(20):2122-2128.
[PubMed]

21.

Wardle D, Finnerty F. Work of the BASHH Sexual Violence Special Interest Group.
Sex Transm Infect. 2018 Dec;94(8):552. [PubMed]

22.

Hawcroft C, Hughes R, Shaheen A, Usta J, Elkadi H, Dalton T, Ginwalla K, Feder

G. Prevalence and health outcomes of domestic violence amongst clinical
populations in Arab countries: a systematic review and meta-analysis. BMC Public
Health. 2019 Mar 18;19(1):315. [PMC free article] [PubMed]
23.

Berhanie E, Gebregziabher D, Berihu H, Gerezgiher A, Kidane G. Intimate partner

violence during pregnancy and adverse birth outcomes: a case-control study.
Reprod Health. 2019 Feb 25;16(1):22. [PMC free article] [PubMed]

Copyright © 2021, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution, and
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Bookshelf ID: NBK499891PMID: 29763066

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In this Page

​ Continuing Education Activity

​ Introduction
​ Etiology
​ Epidemiology
​ Pathophysiology
​ History and Physical
​ Evaluation
​ Treatment / Management
​ Differential Diagnosis
​ Prognosis
​ Pearls and Other Issues
​ Enhancing Healthcare Team Outcomes
​ Review Questions
 ​ References

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