Child abuse and partner abuse: diagnosis and intervention
Recently, the "Violence and Public Health" lecture series
focused on how physicians can identify victims of domestic
violence and intervene appropriately.
Dr. Joseph Schwab described the magnitude of the child abuse
problem, with 1.4 million abuse cases per year, 160,000 serious
injuries, and 1,000 to 2,000 deaths per year. He gave a litany
of sequelae: victims have an increased risk of aggression,
anxiety, depression, and substance abuse, and 30% of them later
become abusers.
Schwab described a list of injury patterns commonly found in
child abuse, as opposed to accidental trauma. For shaken baby
syndrome, these include retinal hemorrhage, intracranial bleeding
and "bucket-handle" fractures at the ends of bones, caused by
bones colliding. Normal children have bruises on bony
projections from falling and bumping into hard objects, but
abused children may have bruises on fleshy parts of the body;
however, purplish bruise-like discolorations of the skin that
remain stable for months may be due to "Mongolian spots," not
abuse. Bite marks inflicted by an adult generally have a 3-cm or
greater distance between the canines. An accidental burn will
have a non-uniform shape, and degree will vary across the burn;
an abusive burn may have sharp outlines, uniform thickness, and
uniform degree across the burn. In "hot tub" scalding, hot water
is placed in a tub and the child is forced to sit in the water:
the buttocks are pressed against the cool porcelain tub surface
and are thus protected, leading to a distinctive burn pattern.
Cigarette burns are easily mistakable for impetigo at a first
glance, and are often present on the soles of the foot. Thirty
percent of abused children have fractures, most commonly of the
ribs and humerus. Abusive skull fractures often are multiple,
with fractures crossing skull suture lines.
According to Schwab, when a physician is confronted with
"abusive" patterns of injury, s/he should perform an interview
with the following goals: determine the history of the child's
situation, assess the plausibility of the reported cause of the
injury, determine ongoing risk to the child, take a medical
history, form a relationship with the family, and explain the
case and the process that the physician will follow if abuse is
suspected. Doctors, as well as nurses, teachers, and social
workers, are legally required to report their suspicions of child
abuse.
Schwab also stressed that documentation of the injuries and
of the doctor's interpretation of the injuries is helpful
evidence to establish a pattern of abuse, since the injuries
themselves disappear over time. Such documentation can include a
simple written statement of suspicion of abuse, description of
the patterns of the injuries, or drawings and photographs of the
injuries. Illustrations should be accompanied by a reference for
size comparison, such as a coin or ruler placed on the skin next
to the injury.
Schwab said that seventy-five percent of sexual abuse is
done by a "father figure" who is not the child's biological
father, that less than 10% of sexual abuse disclosures are false,
and that children as young as 3 "can accurately observe and
recount things happening to and around them."
The problem of partner abuse was addressed by Kathryn
Fisher, a coordinator at New Jersey Women's Services, who
described the development of an abusive relationship: a
commitment to the relationship, followed by the normal
"honeymoon" period, then a tension-building phase, and then an
"explosion" involving a physically or mentally abusive event; the
cycle can then return to the "honeymoon" phase. Fisher cited
statistics: domestic violence is the leading cause of injury to
women; and about 25% of women seeking various forms of medical
help are abused. US Healthcare requires that all participating
physicians take a test on domestic violence knowledge, to avoid
unnecessary testing and misdiagnosis.
Partner abuse can be signalled by injury, illness, or
isolation of the victim. Suspicion-arousing factors include
substance abuse and suicide attempts. Other health-related signs
include: repeated injuries, substantial delay between the time
of injury and presentation, evidence of old or untreated
injuries, implausibility of explanations for injuries, strokes in
young women, and fear of disobeying or displeasing the partner.
Social indicators include isolation from family and friends,
references to the partner's temper and jealousy, reluctance to
speak or disagree in the partner's presence, frequent fleeing of
home, and frequent missing of appointments. Suspicions should be
aroused if the partner accompanies the patient closely, speaks
for her, bullies her in public, snatches children, makes jealous
accusations of sexual infidelity, abuses children, or accuses her
of being mentally ill. Fisher also gave some suggestions for
ways that doctors can phrase questions when discussing partner
abuse with a patient, such as saying "I notice you have bruises.
How did they happen? Did someone hit you?", or "You seem
frightened of your partner. Has he ever hurt you?" or "Your
partner seems very concerned and anxious. Was he responsible for
your injuries?" or, after abuse has been substantiated, "Do you
feel safe to return home?"
Unlike child abuse, partner abuse is not subject to
mandatory reporting. If partner abuse is confirmed, said Fisher,
a doctor can stress the "ABCDE'S": the victim is not "A", alone;
the doctor "B", believes that violence is wrong; "C",
confidentiality is assured; and the doctor should "D", document
the abuse, "E", educate the patient, and ensure the "S", safety,
of the patient. However, the doctor should allow the patient to
decide whether her domestic situation is safe to return to, since
the risk of injury increases 75% upon separation from an abusive
partner.
For information about "CORTS," a service for sexual abuse,
contact Peggy Foster at United Hospital.
Schwab described the procedure an MD should go through
before reporting the suspicion.
an adult immersing a child's hands in hot water as punishment
(which qualifies as child abuse) results in both hands being
severely and evenly burned, with a sharp demarcation at the wrist
between burned and non-burned skin. (
geocities.com/soho)