Violence and Abuse

Abstract

This chapter reviews conditions that are among the leading causes of morbidity and mortality throughout the life cycle, yet remain under-recognized and under-addressed in clinical practice.

Appendices

Appendix A: Tables with Possible Answers to the Vignettes

7.1.1 Case Vignette 7.1: Mary Infante

Learning issue Table 7.1

Facts	Hypotheses	Information needed	Learning issues
Mary Infante is a 32-year-old married woman who is 20 weeks pregnant and having severe cramps	Medical conditions	Comprehensive medical evaluation and physical exam	Previous laboratory tests were unremarkable
She has had two miscarriages in the past and is worried that she may be having another one	Substance use disorder	Laboratory tests	Upon physical examination, she has bruising on the upper arms and abdomen. The bruising is not noticeable on any areas of the body that are not covered by her clothing
Ms. Infante is a secretary at a local law firm. Her husband was recently laid off from his position with a construction company and is seeking another company to work with	Domestic violence	Obstetric evaluation and prenatal care	Physicians should be aware of physical and emotional signs of violence and abuse
He has apparently been let go from a number of positions since they have been together	Abuse	A psychiatric consultation was requested by her physician to evaluate the situation (information required from patient and husband)	It is the responsibility of the physician to make the initial identification and refer the patient to an appropriate specialist
They have been married for approximately 3 years, but have not yet been able to have children	The perpetrator of abuse may have experienced abuse while growing up	–	What are certain risk factors and signs/symptoms of domestic violence the physician needs to consider?
After further inquiry, Ms. Infante reveals that the miscarriages might have been caused by spousal abuse while she was pregnant	Psychosocial stressors	–	Physicians need to be aware of other specific types of abuse among adults, including rape or sexual assault and elder abuse
You then call the husband into the room to discuss your concerns with the current pregnancy	–	–	You interview the patent and husband, together and independently
Overall, he is cordial and polite, and seems attentive to his wife	–	–	You note that he often interrupts his wife while she is attempting to answer a question
–	–	–	You politely ask him to refrain from answering questions directed at his wife, but he continues to answer questions for her
–	–	–	What are common physician-related reasons why the victim may not disclose information to the physician?
–	–	–	You decide to admit Ms. Infante for threatened miscarriage and for further assessment and intervention for domestic violence
–	–	–	A safety plan is formulated
–	–	–	A social worker assists Ms. Infante with a referral to legal counsel

7.1.2 Case Vignette 7.2: Nicholas Head

Learning issue Table 7.2

Facts	Hypotheses	Information needed	Learning issues
An ER physician refers Nicholas Head, a 5-year-old boy, to your care	Medical and/or psychiatric illness of patient and parents	Comprehensive behavioral health and medical evaluation	Upon examination, it was clear that Nick’s left eye and the left side of his face are badly bruised
Nick’s mother reported that he was running in the house and tripped and hit his head on the corner of their dining room table	Parent substance abuse	Physical and neurological examination	During the complete full-body examination, the ER doctor saw bruising on his upper arm and tenderness when palpating his abdomen
His mother reports that he was roughhousing on the playground with some other children at school and fell off the jungle gym	Abuse, neglect, and maltreatment	Baseline labs	The ER physician orders several X-rays, one of which indicates that Nick has a healing fractured humerus
Nick’s mother is a single parent and is forced to work two jobs to make ends meet	If abuse is determined, what is the likelihood that Nick experienced repeated episodes of abuse?	Diagnostic imaging (X-ray)	You are called to join the case to perform a psychiatric consultation
While she is at her second job in the evenings, the mother’s live-in boyfriend watches over her son	Domestic violence	Psychiatric consultation	The clinician must be aware of identified risk factors for child abuse and neglect (categorized by caregiver, child, and family/environmental factors)
When asked about his home Nick says that he usually goes to school without eating breakfast and is lucky to have dinner at night	Psychosocial stressors	–	You and a hospital social worker interview Nick (independently) and his mother
On certain mornings, Nick will see his mother getting ready for work and inquire if any breakfast is available	Single parent		Because of the apparent neglect and abuse, the assessment of Nick requires both medical and legal investigation, what is the physician’s role in the investigation; notification of CPS?
When probed on what her response is, he looks down at the floor and states that occasionally his mother will become angry at his question so recently he has stopped asking	Limited parent resources and supports	–	What are the general guidelines for interviewing and examining youth who are possible victims of abuse or neglect?
Nick won’t answer any more questions about the boyfriend	Nick is experiencing behavioral (aggression) and school problems	–	Nick is admitted to the hospital pediatrics unit for his safety and to ensure that his immediate medical needs are addressed first, such as possible malnutrition
The social worker calls CPS and expects a return call			You hope that Nick, a victim of violence, does not go on to become a perpetrator of violence as an older child or adolescent. You wonder what interventions could prevent such an outcome
You learn from an “auntie” that Nick has been more disruptive and aggressive in school	–	–	–

Appendix B: Answers to Review Questions

Answers

• 1. a

• 2. d