Transcript Recognize the Signs Intimate Partner Violence & Child

Recognize the Signs
Intimate Partner Violence & Child Abuse
What the Family Physician Can Do
NJAFP Scientific Assembly
Ping-Hsin Chen, PhD
Abbie Jacobs, MD
Sue Rovi, PhD
UMDNJ - New Jersey Medical School, Department of Family Medicine
NYMC Family Medicine Residency, Hoboken University Medical Center
Disclosure
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The speaker have nothing to disclose
relevant to this presentation.
Learning Objectives
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Define Intimate Partner Violence (IPV),
and Child Abuse and Neglect
Demonstrate knowledge of the dynamics
and risk factors in abuse
Recognize the signs and symptoms of
adults and children affected by abuse
Discuss the role of Family Physicians in
addressing the health and safety of victims
and their families
Incidence and Prevalence
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7.7 million IPV victimizations each year
35.6% women experience IPV during their
lifetime
For men, the lifetime prevalence is 15.9%
In clinical settings, the rate of IPV in the
past year among women:
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33.6% for physical abuse
44% for psychological abuse
26% for sexual abuse
Definition of IPV
Physical, sexual or psychological harm by a
current or former partner or spouse.
- Physical: pushing, grabbing, slapping, use
of a weapon, restraints, or one’s own body
strength.
- Sexual: A verbal or physical act, and may or
may not result in the completion of a sexual
act.
- Psychological: Coercive tactics, threats, and
harm such as isolation, humiliation, denial of
resources, and stalking.
Dynamics of IPV
Developed by
Domestic
Violence
Intervention
Project.
Duluth:MN.
Case #1
Karen Smith presents with a
complaint of chronic pelvic pain
and insomnia. You remember
learning that IPV can cause
health problems and are
concerned that she is a victim
of IPV.
Health Consequences
of IPV (1)
General Health conditions Reproductive
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Asthma
Bladder/Kidney infections
Circulatory conditions
Cardiovascular disease
Fibromyalgia
Irritable bowel syndrome
Chronic pain syndromes
Central nervous system disorders
Gastrointestinal disorders
Joint disease
Migraines/headaches
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Gynecological disorders
Pelvic inflammatory disease
Sexual dysfunction
Sexually transmitted infections
HIV/AIDS
Delayed prenatal care
Preterm delivery
Low birth weight babies
Perinatal deaths
Unintended pregnancy
Health Consequences
of IPV (2)
Psychological
• Anxiety
• Depression
• Post-traumatic
stress
Physical Indicators
disorder (PTSD)
Unexplained
• Antisocial
behavior
• bruises
and welts,
• Suicidal
behavior
in females
• burns,
• Low
self-esteem
• fractures
and/or
• Inability
to trust
others, and
lacerations
or abrasions
in •intimate
relationships
• Fear of intimacy
• Emotional detachment
• Sleep disturbances
• Flashbacks
• Replaying assault in the mind
Health Behaviors
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Unprotected sex
Decreased condom use
Early
sexual initiation
Behavioral
Indicators
Choosing unhealthy sexual partners
Wary ofsex
adult
contacts
Multiple
partners
Apprehensive
other children
cry
Trading
sex for when
food, money,
or other
items
Behavioral
extremes:
Smoking
cigarettes
•Aggressiveness
Drinking
alcohol, drinking alcohol and driving
•Withdrawal
Illicit
drug use
Frightened
of parents
Fasting
Afraid to go home
Vomiting
Reports injury by parents
Abusing diet pills
Overeating
Lower cancer screening compliance
Overuse of health services
Individual Risk Factors
of IPV
Medical and personal history
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Depression
Heavy alcohol and drug use
Low income
Young age
Unemployment
Low academic Achievement
Victim of physical or psychological abuse
History of physical offense
History of psychological aggression
Delinquent behavior as a youth
Experiencing physical discipline as a child
Experiencing poor parenting as a child
Personal traits
• Low self-esteem
• Borderline personality
traits
• Emotional insecurity
• Anger and hostility
• Antisocial personality
traits
• Belief in strict gender
roles
• Desire for power and
control in relationships
• Having few friends
Relationship and
Community Factors of IPV
Relationship
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Depression
Marital conflict-fights
Divorces or separations
Dominance of the relationship
Economic stress
Unhealthy family relationships
Community
• Poverty
• Low social capital
• Weak community
sanctions against IPV
Case #2
Mary Jones is 35 yr old and comes
to your office for her annual checkup. She screens positive for
depression. You recall USPSTF also
recommends screening for IPV and
you wonder what should be your
next step.
Current Recommendations
for IPV Screening
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In 2013, USPSTF recommended:
Screen women of childbearing age for IPV and
provide or refer women who screen positive to
intervention services. (B recommendation)
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In 2011, the IOM recommended that women’s preventive services
include:
Screening and counseling for all women and
adolescent girls for interpersonal and domestic
violence in a culturally sensitive and supportive
manner.
USPSTF. http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm.
IOM. http://www.iom.edu/Reports/2011/Clinical-Preventive-Services-for-WomenClosing-the-Gaps.aspx
Use your “RADAR”
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Routinely screen every patient
Ask directly, kindly, nonjudgmentally in
a private setting
Document findings
Assess patient’s safety
Review options and provide referrals
Massachusetts Medical Society, 1992
Screening Tools for IPV
Tool
Questions
Scoring
Method
HITS
(hurt,
insult,
threaten,
scream)
How often does your
partner:
1. Physically hurt
you?
2. Insult or talk
down to you?
3. Threaten you
with harm?
4. Scream or curse
at you?
(1)
(2)
(3)
(4)
(5)
Self report,
Reliability:
provider
0.76-0.8
administered, Validity:
mobile
0.75-0.85
Sensitivity:
86%-96%
Specificity:
91%-99%
Never
Rarely
Sometimes
Fairly often
Frequently
Cutoff score
for positive
IPV: 10.5
Accuracy
Documenting IPV
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Ask permission to document.
Use IPV documentation forms, including
body maps and photos of injuries.
Include quote marks of what the patient
says, avoid prejudicial terms, e.g, ‘alleged’.
Document options discussed, referrals,
follow-up.
Ensure confidentiality of all documentation.
Assessing patient’s safety
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Evaluate immediate danger
(e.g., weapons in the home)
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Likelihood of perpetrator harming self or
others
Check safety of children
Reporting of IPV in NJ
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New Jersey requires a police report if
injuries are the result of a weapon
(e.g., a gun or knife, not fists)
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Otherwise, respect the autonomy of adult
victims
If you think a child is in danger, report or
if possible, ask the non-offending parent
to report
Advocacy - Empowerment
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Victim is decision maker
Aim is to increase safety, access services,
reduce abuse, improve health
Assist victims in developing sense of
control
FPs can provide information cards and
referrals to community resources
Case #3
Mary brings her daughter Julie in for
her 14 year old check-up. You notice
that Julie is more withdrawn than
previously. Mary mentions that Julie’s
behavior has changed. What are the
consequences to a child exposed to
abuse?
Cycle of Violence
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The co-occurrence of IPV and child abuse is 60%.
Children exposed to IPV are
3.8 times more likely to be IPV perpetrators
3.5 times more likely to be IPV victims
in their adulthood.
Child Abuse and Neglect
NJ Definitions
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ABUSE is the physical, sexual or emotional harm
or risk of harm to a child under the age of 18
caused by a parent or other person who acts as a
caregiver for the child.
NEGLECT occurs when a parent or caregiver fails
to provide proper supervision for a child or
adequate food, clothing, shelter, education or
medical care although financially able or assisted
to do so.
New Jersey Department of Children and Families, http://www.nj.gov/dcf/reporting/defining/
Child Abuse and Neglect
US and NJ, 2011
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In the US, an estimated 681,000 children were
found to be victims of maltreatment by CPS; and
there were over 1500 child deaths.
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Most cases (4/5) are from neglect
In NJ, there were 8,752 substantiated victims of
child abuse and neglect and 25 deaths.
USDHSS: Child Maltreatment 2011 at http://www.acf.hhs.gov/sites/default/files/cb/cm11.pdf
NJ DCF http://www.nj.gov/dcf/reporting/fatalities/
For Victimization:
Risk Factors
• Younger than 4 yrs
• Special needs
•disabilities
•chronic illness
•Behaviors problems
For Perpetration
Individual
Family and Community
• Young age
Family
• Low education/income
• Social Isolation
• Single parent
• Lack of social support
• Lack of parenting skills
• Relationship problems, incl IPV
• HX of abuse as a child
• Substance abuse
Community
• Mental health problems • Neighborhood disadvantage:
• Non-biologic parent
poverty, unemployment,
• Criminal history
residential instability
• Community violence
Child Abuse and Neglect
Indicators (1)
Physical Abuse Indicators:
Physical Indicators
Unexplained
• bruises and welts,
• burns,
• fractures and/or
• lacerations/abrasions
Behavioral Indicators
• Wary of adult contacts
• Apprehensive when other
children cry
• Behavioral extremes:
•Aggressiveness
•Withdrawal
• Frightened of parents
• Afraid to go home
New Jersey Department of Children and Families.
http://www.nj.gov/dcf/reporting/indicators/
• Reports
injury by parents
Child Abuse and Neglect
Indicators (2)
Physical Neglect Indicators:
Physical Indicators
• Consistent hunger, poor
hygiene, inappropriate dress
• Consistent lack of
supervision,
• Constant fatigue or
listlessness
• Unattended physical
problems or medical needs
• Abandonment
Behavioral Indicators
• Begging, stealing food
• Extended stays at school
• Constantly falls asleep in
class
• Alcohol or drug abuse
• Delinquency
• States there is no caregiver
Child Abuse and Neglect
Indicators (3)
Sexual Abuse Indicators:
Physical Indicators
Behavioral Indicators
• Difficulty in walking or sitting
• Torn, stained or bloody
underclothing
• Pain or itching in genital area
• Bruises or bleeding in external
genitalia, vaginal or anal areas
• STI, especially in pre-teens
• Pregnancy
• Unwilling to change for gym or
participate in PE
• Withdrawn, fantasy or infantile
behavior
• Bizarre, sophisticated or unusual
sexual behavior or knowledge
• Poor peer relationships
• Delinquent or run away
• Reports sexual assault by
caregiver
Child Abuse and Neglect
Indicators (4)
Emotional maltreatment Indicators:
Physical Indicators
• Habit disorders (sucking,
biting, rocking, etc.)
• Conduct disorders
(antisocial, destructible, etc.)
• Neurotic traits (sleep
disorders, speech disorders,
inhibition of play)
Behavioral Indicators
Behavior extremes:
• Compliant, passive
• Aggressive, demanding
Overly adoptive behavior:
• Inappropriately adult
• Inappropriately infant
Reporting Child Abuse/Neglect
in New Jersey (1)
Any person having reasonable cause to believe
that a child has been subjected to abuse or
acts of abuse should immediately report this
information to the Child Abuse Hotline (State
Central Registry):
1-877 NJ ABUSE (1-877-652-2873).
If the child is in immediate danger,
call 911 as well.
Reporting Child Abuse/Neglect
in New Jersey (2)
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Who, what, when, where, how?
Reporter immune from criminal or civil liability
Proof not required and can report anonymously
Failure to report suspected abuse or neglect =
disorderly person
Division of Child Protection and Permanency*
(DCP&P) investigates within 24 hours
* Formerly the Division of Youth and Family Services (DYFS)
Preparing Your Practice
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Develop Collaborative Relationships
with Agencies (DV, Law Enforcement)
Training and Education for MDs and
staff
Create a safe office environment
Protocols for screening, confidentiality
Referrals and Resources available