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Domestic abuse refers to a behavior pattern in which a person repeatedly inflicts physical injury, pain, fear, or mental anguish on another family member. The trauma may be imposed through physical, psychological, sexual, or economic means. Neglect occurs when a caregiver fails to provide basic necessities for a family member.
Many victims of abuse and neglect come to the emergency department (ED) for treatment. Although as many as 2196 of all women who use emergency services are battered, only about 1 in 25 is recognized as such by hospital staff and receives care specifically for the abuse (Dickstein, 1988). Similarly, less than 20% of elder abuse incidents come to the attention of authorities (Jones et al 1988).
Given the frequency of the problem and the difficulty of identifying domestic abuse and neglect, clinicians and staff members should maintain a high index of suspicion. Knowing the signs that suggest domestic violence and neglect can help the clinician determine whether the injury resulted from a pattern of abuse, whether the abused or neglected patient should be separated from the abuser, and whether long-term treatment is necessary.
Treating domestic abuse patients can be stressful for the clinician and other staff members, who typically feel anger toward the abuser. These feelings intensify when the abused patient is helpless, such as a demented elderly patient. Furthermore, when a seemingly competent adult repeatedly returns to the abuser, staff members may become angry with the patient, their anger compounded by futility if they believe they cannot prevent future abuse. Finally, because many abusers have histories of nondomestic violence and threaten to harm anyone who helps the abused, staff members may be fearful of confrontation or of taking action that would anger the abuser.
To reduce their discomfort, some staff members develop myths about domestic abuse. For example, they may view violence as a part of the culture of emergency service patients, who are commonly from poorer socioeconomic groups, or they may come to believe that abused persons provoke violence and purposely choose abusive mates. Anger, fear, and denial are exacerbated if staff members are wrestling with unresolved issues in their own lives. Some staff members may have witnessed violence in their families or may have been victims of child or domestic abuse. Other staff members may provide care to their elderly parents and may feel guilty over a desire to be released from responsibilities, a wish that their parents would die, or anticipation of an inheritance (Lansky, 1985). Consequently, their feelings may influence their response to older abused patients.
Staff members need assistance in handling their feelings toward domestic abuse patients. Supervisors should expect occasionally strong negative reactions from staff members and try to maintain an honest, accepting, and supportive attitude. Realistic concerns of the staff must be separated from myths and distortions. Supervisors can also help staff members by discussing the complex interplay of factors that prevent a simple resolution of the patient's problems. A formal domestic abuse assessment protocol can minimize staff denial that leads to underreporting of abuse (McLeer et al., 1989).
The clinician can detect evidence of spouse abuse by thoroughly reviewing the patient's medical history and current symptoms and by carefully assessing the abuser. Inspect and treat the patient's injuries, observe the interaction between the abused and the abuser (if present), and hold separate discussions with each partner.
Treating the patient's physical injuries is the first priority. The clinician must then determine whether the injuries were caused by the patient's spouse or partner. Assess conditions surrounding the current episode, including information about threats preceding the abuse and whether economic, physical, verbal, or sexual abuse occurred. During the evaluation, ask the following questions:
Obtain a history of the current relationship, including previous types and conditions of abuse. Be especially alert for inconsistencies in the reported cause of the injury. In some cases, the patients description does not fit the nature of the injury; for example, the patient may attribute a broken bone to a slight shove. In other cases. descriptions taken separately from the patient and other family members are contradictory; for instance, a pregnant woman may claim that she injured her abdomen by falling down the stairs, yet her sister may report that the woman was fighting with her intoxicated boyfriend when she was hurt.
A history of spouse abuse or other domestic abuse in the abused or abuser's family may suggest a current episode of abuse. The abused or abuser may have been abused as a child or witnessed spouse abuse while growing up. Based on these earlier experiences. they may view such behavior as normal. Conditions that increase stress on a family also increase the risk of abuse. Financial difficulties, legal problems, and crowding are common stressors (Dick-stein, 1988), as are difficulties with childrearing and changes in family dynamics through birth, illness, marriage, or death.
According to Dickstein (1988), prolonged abuse can cause symptoms of post-traumatic stress disorder (PTSD). Thus, suspect abuse if the patient exhibits intrusive and fearful thoughts, numbing of normal responsiveness, social withdrawal, diminished interest in normal activities, irritability, and increased startle response (DSM-III-R, 1987).
Suicide attempts are also associated with domestic violence (Dickstein, 1988). When questioned, the abused patient may report previous suicide attempts or continual thoughts of suicide or self-harm. Other conditions commonly identified with abuse are depression, anxiety, and panic attacks (Dickstein, 1988: Tilden and Shepherd, 1987). A patient may say, "I've been really depressed lately," or report crying spells, suicidal thoughts, nervousness, dizziness, or palpitations. The patient may also have somatic complaints, such as headache and back pain (McLeer et al, 1989: Tilden and Shepherd, 1987).
Lacerations, contusions, and soft tissue injuries to the head and neck are commonly associated with abuse. Other common injuries include fractures, sprains, burns, intra-abdominal bleeding, and bruises around the wrists or ankles (the result of being physically restrained). You may note signs of a previous injury still healing: for example, an X-ray of a broken arm may reveal evidence of an earlier break.
The clinician usually obtains information about the abuser from the patient because the abuser may not accompany the patient to the ED. Although this information may not be completely accurate, it can be helpful in making clinical decisions about disposition. If the abuser is available for evaluation, the clinician should explore any history of violent behavior.
Abusers usually have diminished impulse control, suggested by a history of head injury or drug or alcohol abuse (Dickstein, 1988). Some psychiatric conditions-psychosis, sociopathy, paranoia, pathological jealousy, mania, and depression-are also associated with poor impulse control. Symptoms of these disorders include delusions (such as extreme, unwarranted jealousy) and auditory or visual hallucinations (for example, thoughts that the abused is 'the devil"). Signs of mania include grandiosity, rapid and continuous speech, and decreased need for sleep (DSM-III-R, 1987).
Also assess the abuser's attitude. The abuser may not take responsibility for the violent act, may admit committing the violence but feel justified, or may be extremely apologetic in hopes of reuniting with the patient, thus making possible the next incident of abuse. Such attitudes not only reinforce suspicion that abuse has occurred but also provide information about appropriate interventions and help determine whether abuse will continue.
Intervention in domestic abuse can be impeded by the abused patient, who may minimize the pain suffered from the attack or claim that the abuser did not really mean any harm. Such acceptance may be accompanied by nonverbal signs of low self-esteem, such as an unkempt appearance and poor eye contact. The patient may also apologize excessively, feel responsible for or deserving of the abuse, or feel unable to live without the abuser, despite the violence. This belief may stem from economic dependence or concerns about separation, especially if previous separations resulted in anxiety. loneliness, or depression. The patient may disguise such concerns with vague rationalizations, typically proclaiming love for the abuser despite believing that the abuser will not change and that abuse will continue.
The abused patient may not want to report the incident or separate from the abuser because of a fear of more serious physical harm. This fear of retaliation may be based on realistic expectations or previous experience. A critical aspect in deciding whether to encourage separation is the risk of continued abuse, which can be determined by evaluating current circumstances (severity of the patients injury, comorbid conditions in the abused and abuser-especially conditions related to impulse control, family stressors, attitude of the abused, and assessment of the abuser). past history of abuse (circumstances surrounding past episodes. severity of past injuries, frequency of abuse, and attitudes of abused and abuser toward past abuse), and past efforts to stop the abuse (treatment history, involvement with legal authorities, and previous separations). If the risk of further abuse is high, the clinician should encourage a separation.
In determining an appropriate referral placement, the clinician must try to minimize disruption for the family while maintaining adequate protection for the abused patient. The preferred approach is to remove the abuser from the household. Hospital staff may be required to initiate this intervention. To remove the abuser. staff members need to gain the cooperation of the couple, involve other family members to assist in the separation process, and possibly contact legal authorities. Efforts to remove the abuser are not appropriate when he is likely to injure the patient again or is unwilling to cooperate in the separation. Under these circumstances, the clinician should advise the patient to leave home.
ED members should help the patient find a suitable place to stay. Family or friends may be able to provide a temporary residence for the abused patient and any dependents, or the family may already be involved with a social service agency that can assist in residential placement. If no other alternatives exist, the clinician can refer the patient to a shelter. Although the shelter provides protection and ancillary services not available in other settings, moving to one is more disruptive to the family than other options. Staff members should have information about the shelters and their requirements for admission. Critical factors to consider are whether the shelter accepts children, whether its address is anonymous, and whether it offers social services or legal aid.
Educational interventions are more effective if separation seems unwarranted and the abuser is cooperative. Initially, try to discover the sequence of events that led to the abuse and help the victim and abuser develop strategies to avoid these situations, By reviewing several incidents of abuse with the couple, you can identify key events that typically precede the abuse. For example, the abuse may follow arguments over narrowly defined issues, such as childrearing, money, or drug abuse. The abuser may hit the a wall before striking a partner or spouse or may become violent at specific times during the month, such as just before the next paycheck is received. When the sequence of events is clear, attempt to change the pattern by asking the abused patient to leave before the abuse begins and by asking the abuser to stop using alcohol or illegal drugs. Although the latter suggestion may seem naive, sometimes the shock of recognizing that a loved one has been seriously hurt results in sobriety.
Recognize that the abused patient may have comorbid conditions, such as PTSD, depression, or anxiety disorders. In addition, the abuser may suffer from drug abuse, psychosis, or head trauma. If you suspect any of these conditions exists, refer the patient for treatment. For the patient in acute crisis, emphatic listening and medication may ameliorate symptoms. However, most patients with comorbid disorders require only referral for appropriate treatment. Because motivation to seek help usually increases during a crisis, the abuses and the abuser may be more likely to enter a treatment program.
Treatment options include private psychotherapists, clinics, and special abuse programs. Self-help and advocacy groups are available for abuse victims and abusers. Participants learn that others have had similar experiences and realize that they are not alone. Support for the couple can also come from extended family, religious organizations, or social agencies.
Become thoroughly familiar with reporting requirements and procedures for initiating legal action. Spouse abuse may constitute assault and battery. Although the victim must bring the charges personally in such cases, the clinician can provide support. For an otherwise physically and mentally fit spouse, the clinician is usually under no legal obligation to notify protective services.
When the abuser is dangerous and unlikely to stay away from the abused, consider involving legal authorities. Arresting the abuser can stop the violence and deter future episodes, especially if the abuser remains in jail. The abuser also learns that his actions have consequences. The courts can enforce a separation through a restraining order. Legal authorities sometimes order the abuser to be evaluated for mental illness or drug abuse and require participation in treatment.
Because legal enforcement of separation varies in different jurisdictions, the clinician and other staff members should know state and local laws regarding spouse abuse, evidence required to arrest and convict the abuser and the likely sentence, and requirements for a restraining order and the consequences if the order is violated
In some cases, involving the legal system can have negative consequences. The abuser is apt to be angry, which can lead (o retaliation - of special concern if the legal system is lenient toward spouse abusers.
Elderly persons can be the victims of passive neglect or physical abuse. The clinician must consider both possibilities when examining an elderly patient. Elder abuse can be difficult to confirm because many victims will not admit to violence or neglect for fear of losing support from the abuser. Sometimes, the elderly victim is too impaired to provide a history of the abuse. As with spouse abuse, the clinician's high index of suspicion is a critical component in making the diagnosis.
The first priority is to treat the physical consequences of the abuse or neglect. Then determine which medications have been prescribed and taken. Contact the patient's primary care physician for information about the medication regimen. Staff members should regulate current doses and examine any physical problems that have resulted from a lack of medication. Refer the patient for treatment of any physical problems that may be contributing to cognitive impairment or emotional instability. These efforts may help reduce the patient's dependency on family members and relieve family stress, thus lessening the risk of further abuse or neglect.
The attitude of the abused or neglected elderly patient is comparable to that of the abused spouse. The patient may minimize the problem, appear afraid of the caregiver, or express fears about returning home. When you suspect abuse or neglect, determine the history of such behavior. Ask the patient if he has been hit or otherwise physically harmed in the past or has been deprived of care or necessities. Such questions can reveal a pattern of abuse and allow the patient to report a previous incident, perhaps providing some distance from the current situation and relieving the patient's discomfort about reporting a child or caregiver. Asking about the past also taps the elderly patient's long-term memory, which may be more intact than short-term memory. Also gather information about previous incidents of verbal abuse, threats, restraints, or use of the patient's money without permission.
Mental status findings in elderly patients who are neglected or abused are the same as those for battered spouses. Withdrawal. depression, anxiety, confusion, suicidal thoughts, low self-esteem. and PTSD are common. The patient may also be disoriented and have an impaired memory.
Physical indicators of elder abuse are similar to those of spouse abuse. Clues to abuse include lacerations, soft tissue injuries, or burns; signs of old injuries at different stages of healing; injuries inconsistent with the explanation given; and delay in seeking medical attention. Signs of sexual abuse, such as evidence of a sexually transmitted disease or pain and bleeding in the genital area. may also be apparent (Bloom et al., 1989).
Signs of neglect differ somewhat from those of abuse. A neglected elderly person may be malnourished or dehydrated and have poor hygiene or pressure sores (Jones et al., 1988; O'Malley et al., 1983). Also be alert for misuse of drugs, including overdosing, underdosing, or inability to obtain medications. Sometimes, you can obtain additional evidence of neglect from the person who brings the elderly patient to the ED; this person may have seen the inside of the patient's home and can comment on the level of cleanliness, the functioning of utilities, and the adequacy of appliances such as walkers or commodes. You may need to speak with this person alone if he is reluctant to speak in front of the patient or other family members.
As with spouse abuse, the abuser may have an impaired impulse control. Impulsivity can result from drug or alcohol use or be a symptom of psychiatric illness. In addition, an elderly abuser may show evidence of dementia. The clinician can assess the specific attitudes of the abuser if he or she is present at the time of the examination. The abuser may be indifferent or angry, fail to assist the patient, show excessive concern about the costs of treatment. or not permit the patient to talk privately with emergency service staff members (Bloom et al., 1989).
Strive to reduce stress on the family by providing support and empathy. Helping the primary caregiver to involve other family members as interim caregivers may provide respite and lower family tension. Further, begin to identify interpersonal conflicts that underlie the abuse. Reactions to the presence of an older relative may vary, depending on the role of the patient and the abuser, the family's life-cycle stage, characteristics of each member, and family circumstances. For example, an adult child may want to care for an elderly parent at home, but the spouse may resent the emotional strains this would entail. Tension increases if the family is already strained by financial worries (such as college expenses) or illness in another member (such as substance abuse). Identifying and clarifying interpersonal conflicts can help determine appropriate referrals and may motivate the family to seek treatment.
Caring for a patient with Alzheimer's disease or another senile dementia is particularly difficult. As the disease progresses, the patient's impulse control and judgment deteriorate, and he cannot manage even the most basic activities of daily living. As a result. the caregiver must provide constant supervision for someone who becomes increasingly agitated, paranoid, and demanding. Not surprisingly, several characteristics of Alzheimer's disease—including dependency, cognitive impairment, and provocative behavior-are associated with elder abuse (Kosberg, 1988). Mounting stress may eventually overwhelm the caregiver, who may react by withholding care or by restraining or striking the patient (Yatzkan, 1988:0'Mallev et al., 1983).
Although usually initiated in the emergency setting, treatment for the patient, the abuser, and other family members must continue outside the hospital. Thus, the clinician and other staff should inform the family of appropriate community resources (such as individual counseling or family therapy) and make necessary referrals. These resources can provide emotional support, treatment of comorbid conditions (such as substance abuse, psychosis, depression, or dementia), and counseling to improve family communication and resolve interpersonal conflicts.
Other community resources, such as support groups for caregivers of Alzheimer's patients, offer family members the opportunity to share information and personal experiences. Visiting nurse or homemaker services, day programs, and senior citizen centers meet the needs of elderly persons at various levels of functioning and provide a social outlet to minimize isolation. These programs can reduce family tensions by providing care and attention to the patient and a much-needed respite for caregivers. Welfare or family service agencies can provide additional social support and financial assistance in coping with economic hardship or overcrowded living conditions, either of which may contribute to violent behavior.
As with spouse abuse, if the risk of severe or permanent injury' to an elderly patient is high, consider separating the patient from the abuser. Evaluate the family's stress level and interpersonal conflicts, severity of the patient's current injuries, and the abuser's past patterns of violence. Consider several alternative placements, although some are available only on a short-term basis. Relatives or friends may be able to provide care, sometimes for extended periods. Shelters offer another alternative, but the need to treat medical problems related to the abuse or neglect may preclude such a referral. Nursing home placement is another option. In some circumstances, the clinician may need to hospitalize the abused patient for medical management and protection.
Some states require clinicians (and other citizens) to report suspected or known cases of elder abuse or abuse of persons in boarding homes or institutions. Failure to report abuse can lead to criminal or civil penalties. The clinician should become familiar with the protocol for reporting such abuse and thoroughly document evidence of the abuse.