Early identification of family violence must become a standard of care. One in every four Americans is a victim, witness to, or perpetrator of family violence. Healthcare professionals – often the first to see signs of abuse -have a unique opportunity to identify victims early and send a strong message that family violence is unacceptable.

Warning Signs for Adult Victims of Abuse

Since most instances of abuse are not reported, healthcare professionals like you need to become familiar with the following warning signs:

• Failure to keep medical appointments
• Delay between an injury and seeking medical treatment
• A history of multiple unscheduled visits or unexplained injuries inconsistent with the history
• A partner or caregiver, who controls the interview, is overly concerned or will not leave the patient alone with the provider.
• Injury to head, neck, chest, breasts, abdomen or genitals
• Bilateral or multiple injuries, especially injuries in different stages of
• Physical injury during pregnancy, especially on breasts and abdomen
• High number of sexually transmitted diseases, pregnancies, miscarriages, abortions, or repeat vaginal and urinary tract infections.
• Multiple bruises or decubitus ulcers in various stages of healing, often seen in

Screening for Family Violence

• The only way to know for sure if the patient is a victim of abuse is to
• Identification begins with routine screening and monitoring of all patients – adults, adolescents and children

Victims may be reluctant to disclose abuse, or attempt to deny or hide it. Reasons vary, but often victims fear:

• The perpetrator will find out and violence will escalate, or children will be
• Placement in a nursing home
• Caregivers will report the incident to the
• Loss of child custody or immigration status
• Caregivers will pressure them into doing something they are not ready or able to

Studies show that many patients are willing to discuss abuse experiences with caregivers and are often relieved when the subject is introduced.

• Discuss any mandatory reporting requirements for child or elder abuse before screening
• Interview patients in private, without friends or family members present.
• Ask simple, direct
• Avoid making judgments and giving
• If victims deny abuse, your concern may reinforce their desire to seek help when they are ready and increase the  likelihood  of  future

Types of Abuse/Neglect

Abuse and neglect of older adults can take many forms, including physical, emotional, financial, sexual, and spiritual.

Physical abuse includes violence or rough treatment, even if it does not leave an injury. It can also be a threat of physical force. A push that might not hurt a younger person can be very harmful to an older adult. Physical abuse also includes inappropriate use of medications or restraints.

Emotional abuse includes name calling, intimidation, threats, yelling, ignoring, or socially isolation the older person. Emotional abuse is often a form of control. Treating an elder adult “like a child” is another form of emotional abuse. Emotional abuse can cause emotional pain, anguish, or distress. It can undermine an older person’s sense of dignity and self-worth. Emotional abuse is also known as verbal, mental, or psychological abuse.

Financial abuse is the most common form of abuse of older adults. It can involve illegally or improperly using a person’s money, assets, or property without the person’s permission or knowledge. It is often a form of theft or fraud. Examples of financial abuse includes:

• Pressuring for money, goods or property; using property or money without the person’s knowledge and consent; and misusing a power of

Sexual abuse is sexual contact with an older adult without that person’s consent. It can include pressuring an older adult for intimacy, fondling, touching, and sexual assault. Sexual abuse can also include sexual comments or jokes, or leering.

Neglect can be physical, emotional, or financial. It refers to situations where a person has a responsibility to provide care or assistance to an older adult, but does not. For example, a neglectful caregiver might stop paying the bills or providing food, shelter, medication, medical attention, or to her forms of assistance that the older adult needs and cannot get on his or her own. Abandoning the person is another form of neglect.

Types of Child Abuse

The four main types of child abuse are:

Sexual Abuse/Sexual Misconduct – Any sexual act or sexual threat imposed on a child or young person. For example: suggestive behavior, inappropriate touching.

Physical abuse – Non-accidental injury and/or harm to a child or young person, caused by another person such as a parent, care-giver or even an older child. For example: physically punishing, pushing or shoving.

Emotional abuse – Behaviors that may psychologically harm a child or young person. For example, threatening language, bullying, ridicule, personal abuse and comments designed to demean and humiliate.

Neglect – Failing to provide a child or young person with basic physical and emotional necessities, harming them or putting them at risk of harm. For example: physical, educational or emotional neglect.

Once abuse is identified, assess the situation immediately. Your goal is to gather information about health problems associated with the abuse and assess the patient’s immediate and long-term health and safety needs. Because of the sensitive nature of abuse, provide privacy.

Elder:

• Interview elders in private, well-lit
• Position yourself directly in front of elders and speak slowly and clearly in a low tone of voice.
• Even if an elder victim has a cognitive impairment, ask about abuse or neglect. Diminished cognitive capacity does not necessarily negate the eider’s ability to describe

Children:

• Children who are abused or neglected must be identified for their own If possible, interview children without parents or caregivers present.
• Tailor your questions to the child’s developmental level and be sensitive to possible fears and apprehension when discussing the home
• When talking with younger children, sit at the child’s eye level. Questions that begin with “how come” are more productive than questions beginning with “why.”
• Keep in mind that children may deny abuse because of threats of retaliation or a fear of losing a