Transcript family violence 2011

Family Violence: 2011
Cecily Cosby FNP/PA-C, PhD
Study Guide Questions
What are some indicators that a family
member is at risk of becoming violent?
Which elders are at greatest risk of abuse?
What is the role of the FNP when a patient
confides he/she has recently been sexually
assaulted?
List 4 different categories of elder abuse.
What questions can the FNP ask to explore
intimate partner violence?
Study Guide Questions
How does the FNP report suspected
child abuse and/or neglect?
Discuss the pros and cons of
mandated DV reporting.
Identify important elements of the
“Rape Trauma Syndrome”
What areas should be discussed with
your teen patient to clarify their risks
of violence?
Objectives: Children/Adolescents
Identify the scope of ‘child abuse &
neglect’ and adolescent violence in
the United States
Define child abuse & adolescent
violence
Discuss the role of the FNP
Discuss reporting requirements
Objectives: Intimate Partner
Identify the scope of DV problem
Define DV
List 6 indicators of DV
Discuss the role of the FNP
Discuss reporting requirements
Objectives: Elder abuse
Identify the scope of elder abuse
Define elder abuse
List 6 indicators of elder abuse
Discuss the role of the FNP
Discuss reporting requirements
Definition
An all-inclusive expression referring to
threatening or overt behaviors
presumed to have harmful
consequences for those against
whom it is directed (eg. children,
adults, elders).
Public Health
Violence in the United States is a major
public health problem (impulsive
aggression, “anger attacks”)
http://www.ojp.usdoj.gov/bjs/intimate/ipv.ht
m
Genetic, environmental and biologic factors
?seasonal variations (Norway)
Most death row inmates have a history of
physical, emotional or sexual abuse
Indicators of Risk
Attitudes approving of violence
Anger
Significant life stresses
Witnessing abuse as a child
History of violence outside the family
Marital conflict over power and control
Economic stresses
Antisocial personality characteristics
Psych diagnosis, mood disorders, psychosis
Alcohol and drug abuse, previous probs
Violence
Profound association with alcohol and
drug abuse, psychiatric disorders
Guns in the United States
200 million
Nicholas
You are seeing 8 yo Nicholas for a
soccer pre-participation exam. You
notice strap marks on his back and
when you inquire Mom tells you that
Nicholas was disrespectful yesterday
and Dad had to discipline him.
How do you handle this?
Is this abuse?
Child Abuse & Neglect
…any recent act or failure to act
resulting in imminent risk of serious
harm, death, serious physical or
emotional harm, sexual abuse, or
exploitation of a child (age varies) by
a parent or caretaker who is
responsible for the child’s welfare
(Child abuse prevention & treatment act,
1996)
Scope of Problem: Kids
1962 “battered child syndrome” JAMA
> 3 million cases reported to CPS annually
(90% were caregivers)
3-5 kids die each day, 2008: >1700
18,000 permanently disabled from nearfatal abuse
97% of US children experience physical
punishment
Lin
You notice that 4 year old Lin is very
quiet and subdued at her pre-school
screening appointment. She clings to
her mother and is noticeably timid,
with dirty hair and clothing and is
sucking her fingers.
Resource
Skin signs of child abuse
Walter Lambert, MD
http://cme.medscape.com/viewarticle/432571_3
Scope of Problem: Kids
Physical abuse: 19%
Shaken baby syndrome
Sexual abuse: 10%
Emotional abuse:8%
Neglect: 63%
Munchausen-by-proxy
Risk Factors for Abuse
Parental abuse of drugs or alcohol
Young maternal age
Low family income
Four or more children in the family
Single-parent household
Other household abuse (DV)
Socially isolated caretaker
Adult family member abused as child
No high school graduation
Don’t forget foster care kids
Who are the abusers?
63% female,
white (40%)> Hispanic (33%) >
black (19%) > other (3%)
80% natural parents
Average age of perpetrator is 31
Rosie
15 yo Rosie comes in for dysuria.
During your interview she tells you
her 17 yo boyfriend is really cute, he
will be graduating from high school
this year, and will turn 18 next month.
She discloses that she is sexually
active with him, he uses a condom
most of the time, and they are in love.
What are your concerns?
A patient asks you……
I have a friend who is 21 years old
and is dating a 17 year old. there has
been speculation that people could
turn her in, even though the 17 year
olds parents know the circumstances.
is she at risk? what would be an
outcome to this?
Related Laws
http://www.sexlaws.org/sexting_teens_fa
cing_felony_charges_for_misuse_of_cell
_phones
http://www.sexlaws.org/california_statuto
ry_rape
http://aspe.hhs.gov/hsp/08/SR/StateLaw
s/summary.shtml
Sexual Abuse: under age
…employment, use, persuasion,
inducement, enticement, or coercion of any
child to engage in, or assist any other
person to engage in, any sexually explicit
conduct; any simulation of such conduct for
the purpose of producing any visual
depiction of such conduct; or rape, and in
cases of caretaker or interfamilial
relationships, statutory rape, molestation,
prostitution, or other form of sexual
exploitation of children, or incest with
children
Margaret
14 yo brought in by police for a
forensic evaluation. Found ‘parking’
with 23 yo ‘boyfriend’ by police.
When notified, parents wanted to
press charges.
What are Margaret’s rights?
What is practitioner responsibility?
What are possible outcomes?
Associated Syndromes
Rape Trauma Syndrome
Burgess 1974
“Compound” & “silent” reactions
Post-traumatic stress
Sexual abuse
At age 14, the age at which girls are
most likely to be victimized, the risk of
abuse is 10 times that of boys
Who must report?
All licensed health care providers
Prehospital care providers
Teachers, school employees
Counselors including clergy
Photo lab employees
Sexual Assault: adult
In your evaluation of new patient 22
yo Rebecca, she discloses that 6
months ago she was the victim of
“date rape” . She is a college student
living in the dorm at a nearby campus.
She did not report the event.
What are your concerns?
How do you counsel her?
Louise
26 yo Louise is your neighbor. She
confides to you one day while visiting
that she and her husband Rick had an
argument last night and he slapped
her in the face. She was shocked,
and he felt very badly afterwards. She
is confident it will never happen again.
What do you tell her?
What is your “duty”?
Definition:
Penal Code 1000.6;13700
DV (IPV) is abuse committed against an
adult or fully emancipated minor who is a
spouse, former spouse, cohabitant of the
abusing individual(s); or a person who has
a child or is dating or has an engagement
relationship with the abusing individual.
Abuse means intentionally or recklessly
causing or attempting to cause bodily
injury, placing another person in
reasonable apprehension of imminent
serious bodily injury…
Scope of Problem: DV
In US 2-6 million relationships are
affected
1 million women are assaulted
annually
Half of these result in (physical) injury
50% of females are battered at some
time in their lives: 33% repeatedly
Data limited by private and sensitive
nature, immigration concerns,
language & cultural barriers…
Scope of Problem
Annual US rates 12/1000 for marital
rape to 116/1000 for any act of
domestic violence
43,000 women: GSW, stab wounds,
broken bones, internal injuries or LOC
57,000 women: raped or sexually
assaulted
390,000 women: minor injuries
Scope of Problem
1/3 of these women seek medical
care
Of the 1800 murders attributable to
intimates in 1996, 75% were female
victims
30% of all murdered women are killed
by intimates (average of 4 per day)
20% of ED visits from trauma involve
DV
Scope of Problem
In mixed gender DV, the female is
30% more likely to be killed than the
man
Men comprise 15% of victims- some
reports suggest the frequencies of
male and female victims of DV are
equal
Same gender partners also at risk
One in ten is appropriately identified
Lucy
Lucy is a 33 year old who comes to the
clinic for a routine appointment. During the
process of the interview you inquire as to
her “safety” concerns and she states her
boyfriend has “pushed me around a little”
in the past. This seems to happen only
when she is reluctant to have sex with him.
She denies recent abuse or injuries.
What are your concerns and appropriate
actions?
Lucy
Danger assessment: Identify
immediate risks
(patient/children/family) or ongoing
violence (Physical Abuse Ranking
Scale & Lethality Checklist)
Gather specific information
surrounding the events and document
them- use exact words and quotation
marks when possible
May include psychological, physical,
sexual, verbal abuse
Lucy
Evaluate for psychological and or
somatic complaints that may be
associated
Screen for any evidence of physical
injuries
Assess support systems
Provide educational
information/resources/ appropriate
referrals/confidentiality limits
Barriers to Recognizing
Time constraints
Lack of training
Discomfort
Sense of powerlessness
Embarrassment
Denial
Fear
Indicators
Patient discloses physical abuse
Unexplained injury or vague/evasive
explanation
Discrepant history
Alleged self-inflicted injury
Delay in seeking medical care
Indicators
History of repeated suspicious injuries
Incorporate into routine prenatal and
postpartum care
Psychiatric symptoms of abuse
include
Isolation, inability to cope/PTS
Suicide attempts or gestures
Depression/panic/anxiety
Substance abuse
Indicators
An abusive partner’s use of control in a
violent relationship may result in:
Limited access
Non-adherence
Missed appointments
Lack of transportation, access to finances or
phone
Failure to use condoms or other contraception
Not being told by partner of HIV or other STI
Indicators
Other findings
Partner accompanies patient, answers
questions, insists on staying close
Reluctance to speak or disagree in front
of partner
Jealousy or possessiveness expressed
Denial or minimization by partner
Self-blame for partner violence
Richard
Richard is a 28 year old who comes to the
acute care clinic for repair of an eyebrow
laceration. He states he fell and bumped
his head against the wall this evening. You
find out he is in a new relationship with a
male partner, named Gordon. Gordon is
jealous of Richard’s previous boyfriend
who called earlier today, and after a few
glasses of wine tonight, Gordon started an
argument.
What are your concerns and actions?
Richard
Danger assessment
Need for emergency housing, legal, and
social service consultations
Assess support systems
Gather specifics and document
Evaluate and treat physical injuries
Provide information, resources,
referrals
File a report?
REMEMBER
DV is typically recurrent and
progressively escalates in both
severity and frequency
It is about POWER and CONTROL
Circle of violence: tension buildingacute battering-reconciliation
The distinction between your ethical
obligation and legal duty
REMEMBER
Common presentations include
complaints with no visible evidence of
injury
The patient may not want a report
filed
Safety on the job
Risks increase with chronic
disease/pregnancy/HIV/ substance
use
DV Mandatory Reporting
California
New Mexico
Colorado
Mississippi
Kentucky
Pennsylvania
New Hampshire
Rhode Island
Most states have laws re: reporting
deadly weapon injuries, criminal acts
or violence
Reporting Outcomes--PRO
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Increased institutional commitment
Increased professional training & education
Improved identification, treatment, documentation
Clear message to society, victim, suspect
Enhanced patient safety
Maintain refusal to ‘interact’ but not report
Patient education
Professional and ethical imperative
Clear provider protection
Mandatory Reporting- Con
Places patient at risk for retaliation
Serves as deterrent to seeking medical
care
Does not improve care
Creates expectation of service and
protection
Results in inconsistent and biased
reporting
Violates the doctrine of nonmaleficence
Undermines patient autonomy
Violates confidentiality and trust
California AB1652
Any health practitioner employed in a
health facility, clinic, physician’s office,
local or state public health department, or a
clinic or other type of facility operated by a
local or state public health department,
who in his/her professional capacity or
within the scope of employment, provides
medical services for a physical condition to
a patient who s/he knows or reasonably
suspects is a person who:
AB1652
Any person suffering from any wound
or other injury inflicted by his/her own
act or inflicted by another where the
injury is by means of a firearm
Any person suffering from any wound
or other physical injury inflicted upon
the person where the injury is the
result of assaultive or abusive
conduct
Report
The report is made as follows:
A report by telephone shall be made
immediately or as soon as practically
possible
A written report shall be prepared and
sent to a local law enforcement agency
with 2 working days of receiving the
information
Liability
Any required reporter is granted
immunity from liability for reporting as
well as reimbursement for expenses
associated with defending a suit
based upon the required reporting
Confidentiality
The information recorded by a
required report IS NOT covered by
the physician or psychotherapistpatient privilege in any court
proceeding or administrative hearing.
The reports are to be kept confidential
except as needed for investigation or
prosecution of the batterer
Failure to Report
A misdemeanor, punishable by a fine
of $1000 and/or jail term of six
months
Reporting forms, protocol:
http://www.sacdhhs.com/article.asp?Con
tentID=160
Nursing/FNP Strategies
Primary vs. Secondary Prevention
Guns, media, “games”
Pay attention
Trust yourself
Educate parents
Early and regular screening
Every child, every woman, every family
Referrals early: peri-natal support…
Home visitation programs
Family support services
Document
Report
Characteristics of Abused Elders
who Died
> 75 years old
Male
Lower education level
Multiple chronic health conditions
Low body weight
Limited activity levels
Poor social network
Cognitive impairment
Depression
Scope of Problem: Elders
1985 Elder Abuse Prevention,
Identification & Treatment Act
Difficult to estimate, but increasing
> 2 million per year ?
Collecting data since 1986
Categories
Physical (15%)
Sexual (0.3%)
Emotional (8%)
Financial/material exploitation (12%)
Neglect (55%)
Abandonment
Self-neglect
Mrs. Watkins
Mrs. Watkins has come to clinic today
to refill her medications. She is 73
years old and lives alone. She tells
you she has to sell her home, where
she has lived for 51 years, because
she can no longer afford the upkeep.
Her children have taken many of her
belongings and jewelry to sell in order
to help pay her bills.
Resources
www.emedicine.com/emerg/index.shtml
www.medscape.com review
National Coalition Against Domestic
Violence
http://www.amaassn.org/ama1/pub/upload/mm/386/domes
ticviolence.pdf
http://www.amaassn.org/ama/upload/mm/386/exesum.pdf
Resources
Adult Protective Services
510-5676894
http://www.elderabusecenter.org/
/Elder
abuse
http://nccanch.acf.hhs.gov/index.cfm
National clearinghouse on child abuse
http://www.rainn.org/publicpolicy/legal-resources/mandatoryreporting-database
Rape, abuse & incest national network