Patient care

All health care providers, teachers, and others who work with children are responsible for identifying and reporting abusive situations as early as possible. Risks for abuse may be assessed by identifying predisposing parental, child, and environmental characteristics, but these are not by themselves predictors of actual abuse. A detailed history and thorough physical examination should be carried out. Findings should be assessed not only in comparison to known indicators of maltreatment but also in light of diseases or cultural practices that can simulate abuse. Nurses play an important role in identifying child abuse since they often are the first health care contacts for child and family, e.g., in the emergency department, physician's office, clinic, or school.

Physical neglect may be evidenced by failure to thrive, signs of malnutrition, poor personal hygiene, dental neglect, unclean or inappropriate dress, frequent injuries from lack of supervision, enuresis, and sleep disorders.

Emotional abuse (belittling, rejection) and neglect may be suspected but are difficult to substantiate. Physical abuse is not always obvious and may be difficult to diagnose. Overt evidence of abuse includes bruises and welts, imprint burns (forming the shape of a cigarette tip or other item), immersion burns (socklike on feet and legs or donut-shaped on buttocks or genitalia), spiral fractures and dislocations of limbs, facial and rib fractures, abrasions and lacerations in various stages of healing, human bite marks (with tissue compression and contusion), and chemical poisonings. Behavioral indicators include self-stimulating behaviors; lack of social smile and stranger anxiety during infancy; withdrawal; unusual wariness; antisocial behavior (destructiveness, cruelty, stealing); being indiscriminately friendly or displaying unexpected affection; developing only superficial relationships; acting out to seek attention; being overly compliant, passive, aggressive, or demanding; delays in emotional, language, and intellectual developmental; and suicide attempts.

Symptoms in the older child include begging or stealing food, frequent school absences, vandalism, shoplifting, or substance abuse.

When sexual abuse is suspected, a thorough but gentle physical examination must be conducted. Physical indicators may include any injury to the external genitalia, anus, mouth, and throat; torn, stained, or bloody undergarments; pain on urination or recurrent urinary tract infections; pain, swelling, unusual odor, and itching of the genitalia; vaginal or penile discharge, vaginitis, venereal warts, or sexually transmitted diseases; difficulty with walking or sitting; or pregnancy in the young adolescent. In most cases, the child knows the sexual abuser; in about half the cases the abuser is a caregiver or parent.

Abuse should be suspected in the presence of physical evidence, including old injuries; conflicting stories about an accident or injury from parents or others; injury blamed on siblings or another party; injury inconsistent with the history given; a history inconsistent with the child's developmental age; a chief complaint not associated with physical evidence; inappropriate level of parental concern (absence or an exaggerated response); refusal of parents to sign for needed tests or treatments; excessive delay in seeking treatment; absence of parents for questioning; inappropriate response of the child (little or no response to pain, fear of being touched, excessive or deficient separation anxiety); previous reports of abuse in the family; and/or repeated visits to emergency facilities with injuries (this may require checking with other facilities). Suspicions may be aroused by a feeling that behaviors are “not right.”

The first priority of care for the abused child is prevention of further injury. This usually involves removing the child from the abusive situation by reporting the situation to local authorities. All U.S. states and Canadian provinces have laws for mandatory reporting of such mistreatment. If evidence of abuse is supported, further action is taken. Care consistent with that for a rape victim is provided when sexual abuse is present. All needs of the abused child are considered as they would be for any other child. Caregivers act as role models for parents, helping them to relate positively to their child and fostering a therapeutic environment: there is no accusation or punishment, only concern and treatment to help parents recognize and change abusive behavior. Referral to self-help groups, resources for financial aid, improved housing, and child care are important to help families deal with overwhelming stress.

Educational programs in the prenatal period, infancy home visits, and outpatient parent groups provide opportunities for health care providers to inform families about normal growth and development and routine health care. Families can also share their concerns, gain support from others, and obtain referrals to appropriate services when needs are identified. Prevention of sexual abuse focuses on teaching children about their bodies, their right to privacy, and their right to say no. Parents and school nurses can discuss such topics with children, using “what if” questions to explore potentially dangerous situations. Everyone ought to know that “nice” people can be sexual abusers and that a change in a child's behavior toward a person requires investigation. The child must always be reassured that whatever happened was not his or her fault. Prevention of false accusations is also important. Caregivers play an important role by carefully documenting all evidence of abuse and recording exactly what they observed on examination and what behaviors occurred without interpreting their meaning.

For further information on abuse or reporting abuse, contact: U.S. Department of Health and Human Services Children’s Bureau: Childhelp USA’s National Child Abuse Hotline at 1-800-4 A CHILD (http://www.acf.dhhs.gov/programs/cb/); Prevent Child Abuse America at 1-800-CHILDREN or 312-663-3520 (http://www.preventchildabuse.org); or National Clearinghouse on Child Abuse and Neglect Information at 1-800-394-3366 or 703-385-7565 (http://nccanch.acf.hhs.gov).

Patient care

Domestic violence should be considered in any patient who presents with unexplained bruises, lacerations, burns, fractures, or multiple injuries in various stages of healing, esp. in areas normally covered by clothing; delays seeking treatment for an injury; has a partner who is reluctant to leave the patient alone or is uncooperative or domineering; indicates that he or she has a psychiatric history or drug or alcohol problems; presents with injuries inconsistent with the “accident” reported; expresses fear about returning home or for the safety of children in the home; or talks about harming himself or herself. Professional health care providers should screen such patients privately to ensure confidentiality and patient safety. “Do you feel safe at home?” may elicit a history of abuse. A sympathetic and nonjudgmental manner helps victims communicate. Scrupulous documentation of evidence of abuse is critical. Reporting is mandatory in many states.

Health care workers, many of whom have easy access to narcotics, are at high risk of abusing analgesics. Increased awareness of this problem has led hospitals to establish special programs for identifying these individuals, esp. physicians, nurses, and pharmacists, in order to provide support and education in an attempt to control the problem and prevent loss of license.

In the U.S., the abuse or misuse of prescription drugs has been identified by the Centers for Disease Control and Prevention (CDC) as a growing problem. In 2007, for example, the CDC reported that more than 27,500 Americans died of drug overdose, an increase of more than 100% in the preceding ten years. More than five times as many people died from misuse of prescribed opioids as from heroin.

Patient care

The assessment of older people thought to have been abused includes looking for evidence of impairment in caregiver relationships to the aged and in finding unusual patterns of injuries or illnesses unlikely to occur from disease. When abuse is suspected, questions such as “Do you feel safe and well cared for at home?” or “Has someone hurt you?” or “Did someone do this to you?” may elicit a history of abuse if the patient is mentally competent. Careful documentation of historical and physical findings (including discrepancies between patient and caregiver reports) and notification of legal authorities (such as a local adult protective services agency, long-term-care ombudsman, or the police) are mandated in most jurisdictions. Resources for health care providers include the National Center on Elder Abuse Phone (202-898-2586; www.elderabusecenter.org); Adult Protective Services (www.elderabusecenter.org/default.cfm?p=apsstate.cfm); The National Long Term Care Ombudsman Resource Center (202-332-2275; www.ltcombudsman.org); The U.S. Administration on Aging Elder Care Locator (1-800-677-1116; www.eldercare.gov/Eldercare/Public/Home.asp).

Health care providers can also help the elderly by educating them about the potential for abuse (such as in community education and outreach programs), explaining that abuse can be physical, emotional, or financial, and that even people who appear to be kind can be abusive. Talking points include recommendations that the elderly remain active and engaged with others in the community and that they get help and representation from ombudsmen or family lawyers who can be trusted to represent their interests.