“My holy of holies is the human body, health, intelligence … and the most absolute freedom imaginable, freedom from violence and lies …” Anton Chekov wrote in a letter to Alexei Pleshcheev on October 4, 1888. His hope rings true, but remains unrealized more than a century later. In clinics, schoolrooms, emergency departments, ICUs — in every sort of health care setting in Puerto Rico as well as the rest of the world, nurses still see the effects of violence in children and adults of all ages. The very essence of their profession, along with ethical guidelines and laws, calls upon nurses to prevent the manifestations of domestic violence and to assess, intervene, protect, and care for those who remain burdened by its sometimes life-threatening effects.

Clinical literature uses the term domestic violence when describing abuse of spouses or other adult partners in close relationships, and refers to violence against children, dating adolescents, and the elderly in separate categories. This educational offering will use these subdivisions in describing violence within close relationships.

Domestic Violence

Maria arrived at the ED after a minor car accident. Her boyfriend, Carlos, who had been the driver, walked away with only a few scratches. He refused treatment.

When the nurse helped Maria slip into a hospital gown, she noticed symmetrical bruises on her upper arms. The marks seemed to be a few days old. At that moment, the nurse decided to accompany Maria to the radiology department.

Carlos stayed by Maria’s side, holding her hand as the nurse pushed the stretcher. A radiology technician asked the boyfriend to sit in the waiting area. Carlos said nothing, but before he walked away, he squeezed Maria’s hand so hard she winced.

Nurses encounter victims of domestic violence or intimate partner violence (IPV) regardless of where they work. Those who practice in offices, hospitals, clinics, homes, or hospices must be aware that living with domestic violence may be part of any of their patients’ daily lives. Even though education for health care professionals and routine screening of patients in EDs are mandated, many abused people will slip through the cracks.

Crisis Proportions

Seven out of 10 women killed in the world’s wealthiest counties are from the U.S. Women are more likely to be killed by husbands, boyfriends, or past lovers, and half of those murdered American women are killed with a gun.¹ Strangers kill only 3% of women who are murdered in their homes.² According to the U.S. Department of Justice, in 2004 of those offenders victimizing females, 21% were described as intimates.³ Criminal homicides, aggravated assaults, and simple assaults are among acts of physical violence that victimize women.

Unfortunately, domestic violence is no stranger to Puerto Rico. For example, between 1995 and 2005, there were 19,000 to 22,000 incidents of domestic violence per year.⁴ After a period of decline between 1997 and 2001, the number of incidents has been escalating annually.⁵ More recently, 22,718 incidents of domestic violence were reported in 2005 in Puerto Rico.⁶ The rate of incident of domestic violence for every 10,000 inhabitants rose from 48 in 2000 to 59 in 2005.⁷ While emotional abuse is hard to track, offenses can include threats or intimidation and simple and aggravated stalking of spouses or cohabitants. Reported forcible sexual offenses include rape, sodomy, and forcible fondling.

The nagging persistence of domestic violence has compelled the American Nurses Association (ANA) to form its own domestic violence advocacy policy. The ANA believes there is a need to increase awareness of violence against women to reduce injuries and psychological misery.⁸ The association supports objectives related to surveillance, prevention, and intervention for violent behavior as a priority issue. With education, nurses can learn effective assessment skills, develop a nonjudgmental attitude, and make appropriate community referrals. They can identify and support the 700,000 women who will present across the U.S. annually with overt injuries caused by physical abuse.⁹

Abuse Defined

Domestic violence advocacy means helping to stop the cycle of power and control that mounts a physical, sexual, and/or psychological assault against a spouse or intimate partner. Domestic violence or IPV can involve children and the destruction of personal property and pets. Abuse can be physical, emotional, or sexual, or any combination of the three. What begins as name calling and belittling can escalate to physical violence. What starts as a push into a wall can lead to a broken arm or a fatal injury. An abuser will use whatever it takes to control the situation, but the abuse need not occur regularly.

Not all victims of domestic violence present in an ED with physical marks of abuse. Some may not have abrasions or fractures, but have injuries or pain much harder to detect. Emotional abuse and degradation are more difficult to pinpoint. Words and threats of violence leave invisible wounds at first, then fulminate into depression, helplessness, and low self-esteem. Sexual abuse is more overt in forced, unwilling sexual acts, which often go unreported.

Abusers use violence because it works to keep their loved ones under control. The perpetrators, sometimes church-going community leaders, are often not violent toward anyone but the people they live with. For them, it is an issue of power and control over another person.

Power and Control

Abusers may control partners through finances by allowing victims no means to leave or to secure credit for a separate future. An abuser may refuse to allow the partner to work or attend school, complaining that the family will suffer from the woman’s absence. The abused may perceive the rationale as legitimate and quit all outside activities. Through gradual or sudden separation, victims can become isolated from family and friends. Removing outside support further places an abuser in a position of control.

Power and control can include threats of taking the children away if the woman leaves, so she may never see them again. Fear motivates the victim to stay, as she perceives the present situation as less frightening than the future, should she leave. The abuser may even convince the victim that she precipitates the violence, making battered women difficult for health care providers to identify.

Recognizing the Victims

Active domestic violence advocacy means nurses should look for historical indicators of abuse. For example, abuse in childhood can be predictive of later abuse as an adult. A survey of 1,931 women from four primary care practices showed that 22% of those surveyed experienced physical or sexual abuse as children, and of those, half reported being abused as adults.² If a woman admits to past injuries inflicted by a partner, the nurse needs to investigate further. Long before questioning patients, nurses may note that previous admissions or ED visits, sometimes by sheer volume alone, suggest abuse. Examine medical records for past injuries that may be clues to previous abuse. Health care workers often overlook abused women as “difficult patients” or “chronic complainers.” However, multiple visits for vague, somatic complaints can be triggered by brutal relationships. Chronic headaches, neck, stomach, pelvic, and abdominal pain may also be evidence of abuse.

Insomnia, a history of suicide attempts, and alcohol and drug abuse can all be the result of living with the stress of being battered or of psychological or sexual abuse. In fact, many women who abuse substances are adult or childhood victims of emotional, physical, or sexual abuse, including incest.¹⁰ Victims of domestic violence may have more sexually transmitted diseases because they are often unable to negotiate condom use with their partners. And abuse often begins or escalates during pregnancy. In fact, between 9% and 25% of pregnant women are battered¹¹ and few of them ever report it.¹²

Searching for Physical Evidence

Nurses need to be vigilant for subtle physical and psychological clues. Many abusers injure women in a “bathing suit pattern” by pinching, punching, and burning soft fleshy tissue normally covered by clothing and only revealed during a medical examination. Look for symmetrical bruises on the upper arms, wrists, and neck where a person might physically attempt to stop the victim from walking away. Check for nail marks or a swatch of hair missing from the woman’s head, which she might try to hide under a hat or long bangs.

Victims often have bruises in various stages of healing. Old fractures and injuries inconsistent with an explanation of how they occurred should trigger suspicion, for example, a patient reporting that symmetrical injuries resulted from “bumping into the bathroom sink.” Fractured mandibles, black eyes, ruptured tympanic membranes, lacerations around the eyes and lips, and subdural hematomas, as well as rib fractures and bruises on the breasts or genitalia, can indicate abuse.

Observation is key to recognizing patterns of abuse. Minor injuries often become extreme emergencies to a victim of abuse, while severe trauma may barely raise a concern. A victim may watch a partner for signs of approval before answering questions, or edge toward the opposite side of the stretcher when her partner walks near. A nurse may notice the patient’s heart rate accelerate when the abusive partner enters the room and moves closer. None of these observations alone indicate abuse, but their presence warrants further exploration.

Since perpetrators of domestic violence use power and control to manipulate their partners, they often continue with a subdued version in public. The abuser may object to a male nurse caring for his partner or may interrupt questions and answer for her. Many abusers refuse to allow their victims to be alone with nurses, therapists, or physicians, even for a few minutes. Strong objections to leaving the patient alone in your care by the partner, when you already suspect abuse, are warning signals. The abusive partner may be reluctant or even refuse to leave the room.

Abuse During Pregnancy

Violence commonly plagues pregnant women. Of those assaulted before pregnancy, almost half can expect to be attacked again afterward.^11,13 Although emotional distress, low self-esteem, teen pregnancy,¹⁴ single status, lower educational level, unemployment, and unplanned pregnancy may increase the risk of assault,¹⁵ every woman is potentially at risk.¹⁶

Battering occurs to pregnant women more frequently than hypertension, gestational diabetes, or any other antepartum complication.¹⁷ Although abuse may begin or accelerate during the prenatal period, few women ever report the phenomena to their providers.^11,15

Screen Teenagers Closely: Because teenagers tend to be at a higher risk for battering than their adult counterparts and the highest rate of abuse in pregnancy is found among teens,^18,19 nurses’ investigations should focus on this group. It is imperative to talk about abuse from the onset of pregnancy counseling and to develop rapport and trust with young women because teenagers often tell no one about the abuse and rarely report it to law enforcement agencies.²⁰

Nurses can be instrumental in uncovering abuse among pregnant women through contact at frequent prenatal visits. However, during the prenatal period, nurses should be alert for indirect indicators of abuse that could be overlooked and attributed to other physical or psychosocial problems. For example, patients who seek prenatal care far into pregnancy, or who present with symptoms of preterm labor, inadequate weight gain, poor nutrition, low-birth weight, or fetal-maternal injury could be victims of abuse.^12-23 Nurses should also realize that some normal hormonal or emotional variations of pregnancy, such as sadness, depression, anxiety about the pregnancy, or concerns for the baby or partner, can result from increased interpersonal stress caused by abuse.²¹

A systematic approach to the woman during pregnancy can increase the reporting of prenatal violence. One study found that the use of abuse screening during the initial prenatal visit, followed by multiple assessments during subsequent visits, augmented reporting of abuse by 22 times, compared with questioning about abuse solely at the initial visit.²⁴ Since mostly all abused women use well-baby care, screening for abuse during pediatric visits is also advised.

Just Ask the Question

All women should be routinely questioned for abuse. Victims may not spontaneously offer information, but many will admit to being in abusive relationships if asked. The question should be broached when the nurse feels the time is right, but the nurse must be alone with the woman. Close the door before starting the physical assessment or history, so that the patient’s safety is not compromised. Asking about abuse in front of a possible abuser may trigger an abusive episode. Even if an incident doesn’t occur at the time of the interview, the abuser may punish the woman when she returns home.

The nurse can incorporate questions within routine procedures or in an elevator on the way to another area. Broach the subject as routine, with no more concern than any other question regarding the patient’s care. Before asking questions about intimate partner violence, let the woman know it is routine to ask such questions, simply part of the process. Many nurses shy away from asking about abuse because of a lack of time, because of their own beliefs about asking such personal questions, or because some nurses themselves might have been in a similar situation. The cost of not asking these questions are tremendous in term of injuries and fatalities with more than 500,000 women injured as a result of domestic violence requiring medical treatment. Health care costs of intimate partner rape, physical assault, and stalking can exceed $5.8 billion each year, of which nearly $4.1 billion is for direct medical and mental health care services.²⁵

Asking the question is integral in helping to stop the violence. Still, the answer may come later. Sometimes just knowing that someone else knows about the abuse offers a victim some relief. Communicating support through a nonjudgmental attitude, or telling a woman that no one deserves to be abused, is the first step and requires little time from a nurse’s schedule. The social service department, local domestic violence shelter, or police victim advocate’s office can be contacted for further information, if the patient desires. See Sidebar 1 for a list of helpful questions.

When a woman discloses abuse, give her time to talk about it, particularly before beginning a physical assessment. It is not uncommon for a woman to understate or minimize the frequency and intensity of battering and its effects on her and the family. She may blame herself or indicate that the abuser could not help himself because of alcohol or other circumstances in his life.¹⁸ Always reassure the woman that she is not responsible for the perpetrator’s abusive behavior, nor does she deserve such treatment. Any hint of disapproval may keep a victim silent.

The Choice to Leave

By discussing safety plans with women and offering appropriate information and referrals to legal and social service systems, health care providers can greatly improve victims’ chances of change and relief from abuse.^26,27 Nurses must assess the danger by determining the pattern of violence and if it’s escalating. If the abuse is increasing and the victim is afraid of returning home, she may want to contact a local women’s shelter, a domestic violence agency, oar police to ensure safety and protection.

When assisting a woman to leave an abusive situation, a safety plan is the number one priority. A woman should keep a bag located somewhere outside the house with money for a bus or cab, phone numbers to call for assistance, a change of clothes for her and her children, and copies of important documents, such as children’s birth certificates, driver’s license, and Social Security cards. These are necessary tools for starting a life away from an abuser.

Nurses should only give out the phone numbers or hotlines of local abuse shelters if the patient wishes to accept them. Otherwise, let the woman know where the numbers are listed in the phone book. Those emergency numbers should already be posted in areas where women go without their abusers, such as x-ray dressing rooms and restrooms.

Women are at the highest risk of danger of violence when they try to leave an abusive relationship. If the woman cannot or is unwilling to immediately leave the relationship, she should be assisted in developing a plan to ensure her safety in the event of further harm.

If an abused woman plans to leave, she needs to settle many issues beforehand, for example, the timing and details of her departure, her destination, and the available resources.¹⁸ She should formulate a safety plan before the next battering incident. The American Bar Association has posted recommendations at www.abanet.org/tips/dvsafety.html. See Sidebar 2 on safety information for abused partners.

Recommendations for Practice

Although the first step to effective intervention at the primary care level involves identification of the problem and resources, responsibility does not end there. An abused woman must know how to access community resources and may need help with the coordination of these services.²⁸ Nurses can help break the cycle of violence and abuse by focusing on a few key areas.

Document Findings: Careful recording of the history and physical examination is an essential part of the process of treating alleged or suspected abuse.²⁹ In the patient’s own words, document the cause of the injury and a detailed description of all injuries. The record should also contain information about all medical and psychosocial interventions provided during the visits.

Nurses cannot choose a life of nonviolence for the victim. They can only offer choices. Many victims leave their abusers, who are also often their life-partner, father of their children, their lover, and financial supporter, as many as seven to eight times before they leave for good. This is not done with impunity: The time when a victim leaves is also the time when many victims are killed. Starting a new life is not easy for anyone, especially if the victim has been repeatedly told that she is ignorant, fat, and lazy, or that no one else could ever love her.

Nurses must guard against the feeling of failure, should a victim choose to remain in the abusive relationship. The choice to leave a violent relationship is strictly up to the victim, and her decision should not diminish the nurse’s efforts. Nurses must also guard against apathy or a judgmental attitude, should the person return to the hospital or ED numerous times for injuries sustained from abuse.

Medical-Legal Issues

Nurses are an important part of the medical-legal system, even if they never take a step through the courtroom door. They are in a position to use their documentation skills to affect social change.

Assessment observations, including injuries, signs and symptoms of possible abuse, and statements that victims and alleged abusers make should be documented. Be specific about shapes and sizes of bruises, for instance, if an injury appears in the shape of a horseshoe ring. Injury maps are perfect tools for pinpointing sites. Always place patients’ words or any statement made by a partner in quotation marks. Should the record be subpoenaed, the nurse cannot be held liable for recording actual statements.

One way to break the cycle of violence is to document injuries with a photograph, but have patients sign a consent form before taking photographs. Let victims know that like any medical photograph, the photo will stay with the medical record. Should the record be brought into court, the photos may provide legal evidence of abuse. There are special cameras for injury documentation in suspected domestic violence cases, but any quality camera will work. When taking photos, move in close to the wound or bruise and fill the frame with the area you are documenting. Both the patient and photographer should sign and date each photo.

Place evidence related to an assault, such as torn or blood- or semen-stained clothing, in a sealed paper bag or an envelope to present to the proper authorities.

Adolescent Dating Violence

Unlike domestic violence, the problem of violence within dating relationships remains somewhat unexplored. Yet, violence between adolescents in dating relationships has many of the same characteristics as those described in the section on domestic violence. Just as with domestic violence, dating violence occurs to people from all racial, social, cultural, and economic groups. It transpires in both heterosexual and homosexual relationships. Violence can include physical, sexual, and psychological acts. Victims of all three types of violence often feel as if they are to blame for the abuse and are reluctant to tell anyone that it is happening. While dating occurs within the context of an interpersonal relationship, dating relationships do not usually involve the legal and financial commitments of marriage. However, interpersonal relationships are afforded a degree of privacy within our society, and these factors contribute to the hidden nature of adolescent dating violence in our society. However, the nurse must take the unique aspect of this developmental stage into account when he or she assesses teens and provides interventions.

Violence occurs in about 33% of the dating relationships of adolescents.³⁰ Physical violence includes acts such as pushing, shoving, slapping, kicking, biting, hitting with fists or objects, beating, and use of or threats of using weapons. Most commonly reported are slapping, pushing, and shoving. Physical violence can also include pinching, hair pulling, or scratching. Common reasons adolescents give for hitting or being hit by a dating partner are real or perceived betrayal and jealousy. Many adolescents believe that abuse is justified if one feels betrayed. Boys and girls are just as likely to hit a dating partner as they are to be hit by a dating partner.³⁰ However, while adolescent girls do report injury from physical abuse, boys are less likely to report injury.³¹ This must be viewed with caution, as adolescent boys might not report injury in an attempt to appear more masculine.

Unlike physical violence where both boys and girls report being victims, girls are the usual victims of sexual violence, while boys are most often perpetrators.³² Sexual violence can refer to forced sexual activity, rough or painful sexual activity, gang rape, and sexual exploitation of younger or intoxicated victims.³² Teen sexual activity may be engaged by coercive methods, such as using emotional pressure or threatening violence. Emotional pressure can include threats of a breakup if sexual activity does not occur or calling a girl immature or inadequate if she does not agree to sexual activity. This emotional manipulation for sexual activity most commonly occurs with younger girls who are often insecure about their own sexuality.³²

Date rape or forced sexual activity can have long-term physical and emotional health consequences for victims, such as feelings of helplessness, powerlessness, anxiety, post-traumatic stress disorder, multiple physical complaints, and genital injuries.³²

Psychological abuse is important because it often precedes and serves as a predictor of physical abuse. Emotional abuse includes harsh or denigrating comments, remarks that belittle, or even cold and ignoring behavior. Adolescents also report threats and harassment from a partner after a breakup. Controlling behavior, extreme jealousy, possessiveness, and stalking are all forms of emotional abuse that increase the isolation and vulnerability of the victim.

Risk Factors

In identifying those at risk for dating violence, the nurse can explore factors that are related either to the person or to the relationship. Personal factors identified in victims and perpetrators include an attitude that justifies the use of aggression, substance abuse, and a history of violence.³³ Teens are at risk for being victims of dating violence if they are involved with an individual who demonstrates dominance, jealousy, poor anger management skills, and controlling behavior.³³

Initiating a Discussion

Effective identification of problems is rooted in an understanding of adolescent behavior. Because many adolescents believe that violence in relationships is normal, they may not report, or may minimize the effect of, the violence. The teen could feel that every other dating couple experiences violence.

Just as battered women don’t readily see themselves as battered, teens may not view their relationships as abusive. Therefore, nurses should avoid the use of emotionally loaded words, such as abuse, rape, or violence.³⁴ Additionally, date rape tends to be minimized or underreported. Many times, victims are uncertain as to whether rape occurred. An adolescent girl might feel that since she agreed to the date, it wasn’t really rape. Or she may feel that because she knows the boy, it cannot be rape. She could also believe that she is responsible for the rape, especially if she had been drinking or using drugs.

Assessing for Dating Violence

For example, a nurse might ask, “Does your partner tell you how to dress?” or “Does your partner ever follow you?” The inquiry should also focus on how conflict is handled within the relationship and how the adolescent feels about violence. Attitudes toward violence can be elicited by describing situations and then asking if hitting or slapping would be justified. Nurses could ask, “Is hitting appropriate when your partner…threatens to break up with you, flirts with someone else, observes you flirting with someone else, or hits you first?” For each situation, the teen can identify if violence would be justified as a reaction.

Both verbal and nonverbal clues may reveal a pattern of violence. Responses that would suggest an abusive relationship might include offering excuses for injuries; unwarranted delay between time of injury and seeking treatment; references to the partner’s having a temper; anxious affect or depressed mood; unexplained injuries; use of makeup, clothing, or hair to cover injuries; and fear of the partner.³⁴

A teen may feel afraid, yet not be able to trust his or her own instincts. Nurses should stress that they are listening and believe what teens are saying. Teen disclosure can be emotionally upsetting, so nurses have to work at supporting the self-esteem of victims. Trust and rapport are essential for effective intervention.

Planning for Safety

The goal is to provide support. Often, young women are at greater risk for abuse or violent acts after ending the relationship.³⁴ Key issues to discuss may include using a cell phone, having friends stay near, and dating only with a group present. Encourage the teen to plan for an emergency. By having the teen discuss past violent acts, the partner’s use of alcohol or illicit drugs, and the presence of weapons, the nurse can help the teenager problem solve to identify escape, if future violence occurs.

Depending on the severity of the situation, the criminal justice system may need to be involved. Dating violence in itself is not a crime. However, the acts that may be committed all constitute criminal activity. For example, physical violence is battery or assault, and forced sex is rape or sexual assault. Victims may not want to report date rape due to fears of being stigmatized, revictimized, or not believed.

Dating violence in an adolescent population can become complicated in the legal systems. In most states, adolescents are not considered adults and do not have the same legal rights. In some, adolescents may be unable to press charges and may need an adult guardian to do so. Many of the legal resources, such as restraining orders, may also be available to adolescents only through an adult. The nurse must carefully assess the adolescent’s family, support system, and school resources for an adult who can adequately represent the teenager. The nurse must know and follow the laws in the area that determine when child abuse or sexual assault must be reported.

Prevention Efforts

Nurses can intervene through primary and secondary prevention of dating violence. Primary prevention involves identifying stressors and teaching to provide skills to successfully manage or avoid stressors. Secondary prevention involves intervention after the stressor has occurred to return the person to the previous level of health. Primary prevention efforts can take the form of large- or small-group educational programs that present information on violence within relationships and ways to prevent, deter, and cope with aggression from a dating partner. Effective education challenges the belief that violence is a normal part of a loving relationship. Discussions of what constitutes appropriate or healthy, loving relationships and how love is demonstrated can provide a starting place for addressing violence in relationships.

Prevention efforts should also include parents. It is not uncommon for adults to dismiss dating violence as typical adolescent behavior, believing that “boys will be boys.” However, parents need to understand that dating violence can threaten the health of their children. They need to know the signs that may indicate an abusive relationship and be alert to changes from the usual behavior of their child, such as withdrawn behavior or signs of fear. Nurses can provide parents with information that can help them build an alliance with their children and the scripts that will assist them in discussing healthy relationships and developing conflict resolution skills in their teens.

Child Abuse and Neglect

The cycle of abuse often begins in early infancy. The child who learns about abuse as a victim grows up to become an abuser in close relationships as an adult. In 2003, state and local Child Protective Services (CPS) investigated an estimated 2.9 million referrals alleging child abuse and neglect. Approximately 906,000 children were victims of substantiated child abuse and neglect. Nationally, the rate of children reported for child abuse or neglect has been diminishing from 13.4 victims per 1,000 children in 1990 to 12.4 victims per 1,000 in 2003.³⁵ As a direct result of abuse and neglect, children often die by the hands of the people who are supposed to love and protect them — their families. For 2003, an estimated 1,500 children died due to child abuse or neglect.³⁵

Every year, thousands more children become permanently disabled and tens of thousands more are at risk for suffering lifelong psychological trauma. The odds are great that these youngsters will engage in future crime or domestic violence, perpetuating the abusive cycle. For all these reasons, it is vital to identify these children quickly. For starters, remember that in the eyes of the law, abuse can result from the acts of the parent or the person legally responsible for the child at the relevant time.

The abused or neglected child: An abused child is less than 18 years of age whose parent or legal custodian –

·         Inflicts or allows to be inflicted physical injury that could cause death, disfigurement, or impairment of health or function.

·         Creates or allows to be created a substantial risk of physical injury.

·         Commits or allows to be committed a sex offense against the child or permits or encourages a child to engage in acts such as incest or prostitution.

The neglected child is another category. Children deemed to be maltreated have been neglected. Social Services Law defines neglect as the failure to exercise a minimum degree of care in –

·         Supplying food, clothing, shelter, education, and medical and dental care when offered reasonable means to do so.

·         Providing proper supervision.

·         Misusing drugs and/or alcohol to the extent that the caretaker loses self-control.

·         While it may seem painfully obvious, abandonment of a child is considered neglect.

Emotional neglect is a subcategory that describes the impairment of good emotional health. In this situation, the impairment must be attributable to the unwillingness or inability of the caretaker to exercise a minimum degree of care toward the child in instances of failure to thrive, self-destructive impulses, and habitual truancy, for example.

Red Flags

A profile of those at risk has evolved. For example, a U.S. Department of Health and Human Services survey conducted between 1986 and 1993 indicated that children of single parents have an 87% greater risk of being harmed by physical neglect and an 80% chance of suffering serious injury or harm than those from two-parent families.³⁶ New findings will soon be available as a new wave of this research is currently being conducted. Abusers come from all socioeconomic backgrounds, but low-income parents are at higher risk: Children from families with annual incomes below $15,000 were 22 times more likely to experience maltreatment than those from families making more than $30,000 a year.^37,38 Girls are slightly more likely than boys to be victims. Pacific Islander, American Indian or Alaska Native, and African-American children had highest rates of victimization when compared to their national population. The age group victimized most frequently is from zero to 3 years old with the rates decreasing as age increases.³⁵

Certain factors put adults at risk for becoming abusers. For example, many abusive and neglectful adults were victims of abuse themselves. Although not everyone with these risk factors is an abuser, every caretaker at risk exhibits one or more of the following characteristics —

• Immaturity, lack of parenting skills, or unrealistic expectations of a child
• Unmet emotional needs, isolation, or poor impulse control
• A significant disruption of normal life, such as divorce, death of a loved one, loss of a job or source of income, or significant illness
• An accumulation of small stressors in combination with other risk factors that result in the parent or caretaker losing control
• Substance abuse^37,39,40

Any child can become a victim. However, certain characteristics can trigger abuse. Consider these cases that have been publicized. A child with cerebral palsy is abandoned in a hospital lobby by his overwrought parents. A colicky infant suffers massive brain injury as a result of shaken baby syndrome at the hands of an adolescent father. A caretaker locks a hyperactive, demanding child in his room every day after school. Children with special needs can be overwhelming for ill-equipped parents and abuse can take hold.

Many times, abusive caretakers have unrealistic expectations of the child’s physical and emotional needs. They may look at children as “miniature adults,” and expect them to behave that way. For example, they may feel that the child should be potty-trained before it is reasonable to expect this. When the child has an accident, the parent gets angry and abusive. Some parents consider corporal punishment as an unquestioned child-rearing practice. They may view the child as bad, evil, or different. They may fail to seek health care for injuries and illnesses and may skip routine check-ups and immunizations.⁴¹

Revealing Histories

Although the physical signs of child abuse vary and may be difficult to confirm, the patient’s history often yields clues. Medical records of previous admissions or ED visits for other siblings or a parent may reveal events that hint at family violence. Any history of domestic violence in a family puts the children at high risk for abuse. There is an increased likelihood that children of abused mothers will experience child abuse⁴². Be alert for parents who are reluctant to give an account of the injury or who offer a history of the occurrence that is inconsistent with the healing stage of the injury. And be wary when the type of injury does not correlate with the explanation of how it occurred.

For example, one mother reported that her child had “backed into a curling iron.” However, her story was improbable, because bumping into the iron would have likely left a horizontal burn, not a vertical one. The wound was consistent with an iron that had been held against the skin, and the disparity in the story raised a red flag. The absence or presence of wounds in areas that do not correspond to the account of the accident may be a sign of abuse. For instance, if a parent says that her child slipped and fell on the cement and hit his head, the palms of the hands would probably also be scraped.

Injuries are normal and typical during childhood. Active youngsters sustain scratches, cuts, and bruises from falling off bicycles, playing on monkey bars, and running. Nurses must look for injuries consistent with abuse, remembering that no one sign or symptom alone can indicate its presence.

Bruises in the shape of handprints or other identifiable patterns, welts, and abrasions in many stages of healing should stir suspicions. Pattern injuries often indicate the instrument of abuse, such as burns that are round from cigarette butts, cylindrical from a light bulb, or triangular from the tip of an iron. Contusions from belts, rings, and sharp objects may leave obvious, identifiable impressions on a child’s skin. Injuries to either eyes or cheeks should always raise eyebrows, as accidents typically cause only a unilateral injury. Linear whip marks and loop bruises may suggest the use of flexible objects, such as electrical cords. Look for “grab marks” on arms or shoulders, and check for bite marks. Absence of hair could be due to hair pulling, while tooth or frenulum injury might be a result of battering.

Fractures, especially those in multiple stages of healing, are a classic injury of child abuse. Broken long bones, ribs, skull, and vertebral bodies are highly suggestive of battering. Transverse fractures are due to direct trauma. Spiral and epiphyseal fractures of the long bones come from rotational and bending forces. Metaphyseal chip fractures are common in abuse. As with all injuries, if there is a changing explanation for the trauma or one that does not coincide with the injury, abuse may be involved.

Blunt trauma can affect the gastrointestinal, cardiopulmonary, and central nervous systems. Violent force can rupture a child’s spleen or intestines and cause massive shock and death. Fractured ribs can precipitate a pneumothorax, heart contusion, and pericardial tamponade. The leading cause of death in child abuse is head injuries. Infants or children with altered mental states, unresponsiveness, convulsions, or other neurological deficits may be victims of abuse.⁴³

Retinal bleeding, with no other overt signs of abuse, may be the result of violent shaking. When a child is under two years of age, the impact on the brain can be as much as 30 times the force of gravity. Nationally, 800 to 1,200 babies a year are admitted to EDs with subdural hematomas and other neurological trauma consistent with shaken baby syndrome.⁴⁴

Burns can be a life-threatening form of abuse. Stocking burns, which occur when a child’s limb is held forcibly in a burning liquid, are delineated, circumferential scalds that are usually inconsistent with any explanation of an accidental fall into water. Burns on the buttocks and genitalia can result from being immersed in hot water.

He May Be Telling You Something

The child’s behavior can be an indicator of abuse. The nurse may find that the child is wary of contact with the caretaker. He or she may become especially apprehensive when other children cry. You may witness behavioral extremes or wild mood swings. Perhaps you’ll observe signs of self-injurious behavior. The child may even have obsessions, phobias, compulsions, or hypochondria. He or she may be afraid to go home, threaten to run away, or mention suicide.

When you suspect neglect, consider these indicators. Is the child lagging in physical, mental, or emotional development? Is there a speech disorder or failure to thrive? Is there consistent hunger, poor hygiene, inappropriate dress for the season, lack of supervision, unattended medical needs, or chronic truancy? Perhaps there will be a history of stealing food, constant fatigue, delinquency, habit disorders, neurotic traits, or alcohol/drug abuse. Has the child ever run away or attempted suicide?

Abuse can move beyond the physical realm to involve excessive, aggressive, or unreasonable demands, such as making a child sit still for long periods of time without moving or expecting a youngster to carry out adult responsibilities. These acts place expectations on children that tax them beyond their capacity, retard their development, and damage their sense of self-worth. Constant criticizing, belittling, insulting, rejecting, and teasing rob children of the psychological nurturing needed for normal emotional development.

The Devastating “Secret”

The sad truth is that the vast majority of child molesters are family members or friends of the child. This makes it extremely difficult for the victim to report sexual abuse. Victims suffer shame and guilt and worry that they will be betraying a loved one. What’s so difficult for health care professionals is the fact that there is absolutely no profile of a child molester. Additionally, the signs and symptoms of incest and other sexual abuse can be subtle.

Victims of sexual abuse may suffer from stomach and abdominal pain, regressive bedwetting, recurrent urinary tract and yeast infections, and/or drastic weight fluctuations. Other indicators may be more obvious in children who present with sexually transmitted diseases; pregnancy; rectal bleeding and bruises; bite marks; or bruises in the soft palate or the rectal, thigh, or genital areas.⁴³ You may find torn, stained, or bloody underclothing. The child may have pain or itching in the genital area, painful discharge of urine, and/or repeated urinary tract infections.

Behavioral indicators could be as subtle as unwillingness to change for gym class. However, they may be as severe as forcing sexual acts on other children, seductive or promiscuous behavior, or prostitution. Withdrawal, fantasy, infantile behavior, extreme fear, and self-injurious behavior are all warning signals that must be taken seriously.

Fact or Fiction?

The interactions between the child and a parent are often most revealing when taking a history and performing a physical assessment. Watch the parent’s reaction to the child answering questions and observe the child’s response. Some abused children will cling to the abusive parent even after being injured, hoping to assure the parent that the secret is not being divulged. This behavior can also be an attempt to remain safe, to prevent further abuse, and to receive physical assurance that the abuser still loves the child. However, it is normal for children to cling to their parents in unfamiliar environments, especially if they are frightened.

Talk with the child as well as the parent or caretaker. He or she may have been coached before seeking medical attention; hence, their explanation may be identical to the parents’. Although questions are routine to the physical assessment of a child, a nurse should not appear to be interrogating the parent or child. By saying, “Is there anything I should know about your child or anything in particular you are concerned about with your child’s health?” you can avoid being perceived as accusatory.

Nurses should be careful to approach suspicious situations with equanimity. Children can enter an ED or clinic setting with signs and symptoms that suggest abuse when none has occurred; for example, an infant who sustained a fracture from a fall while being diapered or dressed. A child not yet diagnosed with osteogenesis imperfecta — a brittle bone disease characterized by bones that break easily —could also present a profile of a child who has been abused.^45,46 Or a child not yet diagnosed with Henoch-Schönlein purpura — a disease characterized in the early stages by multiple ecchymotic lesions on the lower extremities and buttocks — could be misdiagnosed as a victim until appropriate tests are able to differentiate between the two.⁴⁴

Although health care professionals are legally bound to report suspected abuse, good faith reporting typically protects them from prosecution if their suspicions are incorrect. However, nurses need to know what actions must be taken and find out about their legal responsibilities.

Reporting Abuse, Knowing When to Act

The key to differentiating between accidental and intentional injury lies in the history and physical examination of the child. Does the history explain the injuries? You may feel that it does not. But it’s easy to see why many health care professionals are reluctant to become involved. Abuse of a child is downright disturbing. Not only that, but dealing with abusers and victims creates anger and frustration.

The law in Puerto Rico outlines several situations in which nurses must file a report. Legally speaking, these apply when they are acting in their professional capacity:

1. You have reasonable cause to suspect or through personal knowledge, you know that a child is abused.
2. A parent or person legally responsible for the child comes to you and states from personal knowledge that the child is abused.
3. A staff member suspects abuse and notifies you, as the designated supervisor. It is then your responsibility to follow up on the information provided by the staff member and let an expert in child abuse determine if child abuse is present or not.
4. If working in any setting in which nurses normally work, such as schools, hospitals, communities, and private or public entities, you should report abuse by notifying the Family Department, Commonwealth of Puerto Rico, or the Division of Child Abuse with the police.⁴⁷

What to Do Next

It’s a good idea to keep careful notes for your own personal records indicating dates, times, places, and names of persons involved in any reporting incidents. Puerto Rican law allows the person who reports abuse to take pictures of the child’s body where there are signs of abuse or the immediate environment without the consent of parents or persons legally responsible for the child. Photos should be taken in such a way that will not aggravate the condition or harm the dignity of the child.⁴⁷

When filing a report of suspected abuse, you’ll need to name the “subject of the report.” This is the parent or person legally responsible for the child at the time. Of course, abuse may have been at the hands of a stranger, another child, or an acquaintance. In these situations, rather than calling in a case of suspected child abuse, law enforcement authorities or the Family Department need to be contacted. Include the following information in the report —

·         Names and addresses of the child, parents, and/or caretakers

·         Child’s age, gender, race

·         Nature and extent of injuries, including evidence of prior injuries or abuse to the child or siblings

·         Family composition

·         The source of the report

·         Person making the report and where to be reached

·         The actions taken — x-rays, photographs, and removal or keeping of the child

Any x-rays or photographs should be identified with the child’s name, date, and photographer’s name. It’s also helpful to list injuries by sites, and plot the location on a body diagram. These should accompany the written report or follow as soon as possible after its submission.

Any clothing torn or stained with blood, semen, or other fluids should be bagged in paper to preserve evidence and then set aside for authorities. Any lab specimens should be carefully labeled, handled by as few people as possible, and delivered directly to another department to ensure that the specimen is not tampered with or taken from the premises.

A Safe Haven

A child may be taken into protective custody without court order or parental consent if the parent or legal caretaker presents imminent danger to the child’s life or health. Those legally authorized to place a child into protective custody include law enforcement officials, a designated employee of the Department of Family, or a person in charge of a hospital, to name a few. Those individuals have to take certain actions once protective custody occurs. Unless the child is admitted to a hospital, the child must be brought to a location designated by the rules of the Family Court. Every reasonable effort must be made to inform the parent/caretaker about where the child has been taken. And written notice must be provided, as well. Local child protective services will take it from there.

The Investigation

The Department of Family uses the report itself as a starting point for an official investigation. This fact-finding process is used to determine whether evidence of abuse or maltreatment exists. The process will include interviewing, observing, and information gathering. Authorities will contact the source, the child, the parents, school personnel, health care professionals, neighbors, and others. As the mandated reporter, your testimony may be required during court proceedings, should it come to that.

The final step in the investigation is deciding whether the report is “indicated” or “unfounded,” which must take place within 90 d