Domestic Violence


Article Author:
Martin Huecker


Article Editor:
William Smock


Editors In Chief:
Bette Bogdan
Lori Kerley
Robin Geiger


Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Pritesh Sheth
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
10/27/2018 12:32:10 PM

Introduction

Family and domestic violence (including child abuse, intimate partner abuse, and elder abuse) is a common problem in the United States. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence.

Unfortunately, each form of family violence begets interrelated forms of violence, and the "cycle of abuse" is often continued from exposed children into their adult relationships, and finally to the care of the elderly.

Domestic and family violence include a range of abuse including economic, physical, sexual, emotional, and psychological toward children, adults, and elders.

Intimate partner violence includes stalking, sexual and physical violence, and psychological aggression by a current or former partner. In the United States, as many as one in four women and one in nine men are victims of domestic violence. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity.

The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The numbers of individuals affected is expected to rise over the next 20 years with the increase in the elderly population.

Domestic and family violence is difficult to identify, and many cases go unreported to health professionals or legal authorities. Due to the prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and physicians will at some point evaluate and possibly treat a victim or perpetrator of domestic or family violence.

Definitions

Family and domestic violence are abusive behaviors in which one individual gains power over another individual.

  • Intimate partner violence typically includes sexual or physical violence, psychological aggression, and stalking. This may include former or current intimate partners.
  • Child abuse involves the emotional, sexual, physical, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm.
  • Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an elder.

National

Center for Disease Control and Prevention (CDC)

Domestic violence, spousal abuse, battering, or intimate partner violence, is typically the victimization of an individual with whom the abuser has an intimate or romantic relationship. The CDC defines domestic violence as "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner."

Domestic and family violence has no boundaries. This violence occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referral.

Violence Abuse Types

The types of violence include stalking, economic, emotional or psychological, sexual, neglect, Munchausen by proxy, and physical. Domestic and family violence occurs in all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or geographic limitation. It may occur in individuals with different sexual orientations.

Etiology

Reason Abusers Need to Control

  • Anger management issues
  • Jealousy
  • Low self-esteem
  • Feeling inferior 
  • Cultural beliefs they have the right to control their partner
  • Personality disorder or psychological disorder
  • Learned behavior from growing up in a family where domestic violence was accepted
  • Alcohol and drugs, as an impaired individual may be less likely to control violent impulses

Risk Factors

Risk factors for domestic and family violence include individual, relationship, community, and societal issues. There is an inverse relationship between education and domestic violence. Lower education levels correlate with more likely domestic violence. Childhood abuse is commonly associated with becoming a perpetrator of domestic violence as an adult. Perpetrators of domestic violence commonly repeat acts of violence with new partners. Drug and alcohol abuse greatly increases the incidence of domestic violence.

Children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, the gender roles can be reversed.

Domination may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.

Epidemiology

Domestic violence is a serious and challenging public health problem. Approximate 1 in 3 women and 1 in 10 men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1500 deaths in the United States.

Domestic violence victims typically experience severe physical injuries requiring care at a hospital or clinic. The cost to individuals and society is significant. The national annual cost of medical and mental health care services related to acute domestic violence is estimated at over $8 billion. If the injury results in a long-term or chronic condition, the cost is considerably higher.

Financial hardship and unemployment are contributors to domestic violence. An economic downturn is associated with increased calls to the National Domestic Violence Hotline.

Fortunately, the national rate of nonfatal domestic violence is declining. This is thought to be due to a decline in the marriage rate, decreased domesticity, better access to domestic violence shelters, improvements in female economic status, and an increase in the average age of the population.

National

  • Most perpetrators and victims do not seek help.
  • Healthcare professionals are usually the first individuals with an opportunity to identify domestic violence.
  • Nurses are usually the first healthcare providers victims encounter.
  • Domestic violence may be perpetrated on women, men, parents, and children.
  • Fifty percent of women seen in emergency departments report a history of abuse, and approximately 40% of those killed by their abuser sought help in the 2 years before death.
  • Only one-third of police-identified victims of domestic violence are identified in the emergency department.
  • Healthcare professionals who work in acute care need to maintain a high index of suspicion for domestic violence as supportive family members may, in fact, be abusers.

Child Abuse

Age, family income, and ethnicity are all risk factors for both sexual abuse and physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse.

Each year there are over 3 million referrals to child protective authorities. Despite often being the first to examine the victims, only about 10% of the referrals were from medical personnel. The fatality rate is approximately two deaths per 100,000 children. Women account for a little over half of the perpetrators.

Intimate Partner Violence

According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men experience some form of sexual violence during their lifetimes. Intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year.

One in 6 women and 1 in 19 men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about 6 in 10 female victims and 4 in 10 male victims.

At least 5 million acts of domestic violence occur annually to women aged 18 years and older, with over 3 million involving men. While most events are minor, for example grabbing, shoving, pushing, slapping, and hitting, serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults occur. About 1 in 5 women have experienced completed or attempted rape at some point in their lives. About 1% to 2% of men have experienced completed or attempted rape.

The incidence of intimate partner violence has declined by over 60%, from about ten victimizations per 1000 persons age 12 or older to approximately 4 per 1000.

Elderly

Due to underreporting and difficulty sampling, obtaining accurate incidence information on elder abuse and neglect is difficult. Elderly abuse is thought to occur in 3% to 10% of the population of elders.

Elderly patients may not report due to fear, guilt, ignorance, or shame. Clinicians underreport elder abuse due to poor recognition of the problem, lack of understanding reporting methods and requirements, and concerns about physician-patient confidentiality.

Pathophysiology

There may be some pathologic findings in both the victims and perpetrators of domestic violence. Certain medical conditions and lifestyles make family and domestic violence more likely.

Perpetrators

While the research is not definitive, a number of characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:

  • Have a higher consumption of alcohol and illicit drugs and assessment should include questions that explore drinking habits and violence
  • Be possessive, jealous, suspicious, and paranoid
  • Be controlling of everyday family activity including control of finances and social activities
  • Suffer low self-esteem
  • Have emotional dependence which tends to occur in both partners, but more so in the abuser

Children

Domestic violence at home results in emotional damage which exerts continued effects as the victim matures.

  • Approximately 45 million children will be exposed to violence during childhood.
  • Approximately 10% of children are exposed to domestic violence annually, and 25% are exposed to at least 1 event during their childhood.
  • Ninety percent are direct eyewitnesses of violence.
  • Males who batter their wives batter the children 30% to 60% of the time.
  • Children who witness domestic violence are at increased risk of dating violence and have a more difficult time with partnerships and parenting.
  • Children who witness domestic violence are at an increased risk for post-traumatic stress disorder, aggressive behavior, anxiety, impaired development, difficulty interacting with peers, academic problems, and they have a higher incidence of substance abuse.
  • Children exposed to domestic violence often become victims of violence.
  • Children who witness and experience domestic violence are at a greater risk for adverse psychosocial outcomes.
  • Eighty to 90% of domestic violence victims abuse or neglect their children.
  • Abused teens may not report abuse. Individuals 12 to 19 years of age report only about one-third of crimes against them, compared with one-half in older age groups

Pregnant and Females

The American College of Obstetricians and Gynecologists (ACOG) recommends all women be assessed for signs and symptoms of domestic violence, during regular and prenatal visits. Providers should offer support and referral information.

  • Domestic violence affects approximately 325,000 pregnant women each year.
  • The average reported prevalence during pregnancy is approximately 30% emotional abuse, 15% physical abuse, and 8% sexual abuse.
  • Domestic violence is more common among pregnant women than preeclampsia and gestational diabetes.
  • Reproductive abuse may occur and includes impregnating against a partner's wishes by stopping a partner from using birth control.
  • Since most pregnant women receive prenatal care, this is an excellent time to assess for domestic violence.

The danger of domestic violence is particularly acute as both mother and fetus are at risk. Healthcare professionals should be aware of the psychological consequences of domestic abuse during pregnancy. There is more stress, depression, and addiction to alcohol in abused pregnant women. These conditions may harm the fetus.

Gay, Lesbian, Bisexual, and Transgender

Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the rates are thought to be similar to a heterosexual woman, approximately 25%.

  • There are more cases of domestic violence among males living with male partners than among males who live with female partners.
  • Females living with female partners experience less domestic violence than females living with males.
  • Transgender individuals have a higher risk of domestic violence. Transgender victims are approximately two times more likely to experience physical violence.

Gay, lesbian, bisexual, and transgender victims may be reticent to report domestic violence. Part of the challenge may be that support services such as shelters, support groups, and hotlines are not regularly available. This results in isolated and unsupported victims. Healthcare professionals should strive to be helpful when working with gay, lesbian, bisexual, and transgender patients.

Men

Usually domestic violence is perpetrated by men against women; however, females may exhibit violent behavior against their male partners.

  • Approximately 5% of males are killed by their intimate partners.
  • Each year, approximately 500,000 women are physically assaulted or raped by an intimate partner compared to 100,000 men
  • Three out of 10 women at some point are stalked, physically assaulted, or raped by an intimate partner, compared to 1 out of every 10 men.
  • Rape is primarily perpetrated by other men, while women engage in other forms of violence against men.

Although women are the most common victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.

Elderly

Elderly are often mistreated by their spouses, children, or relatives.

  • Annually, approximately 2% experience physical abuse, 1% sexual abuse, 5% neglect, 5% financial abuse, and 5% suffer emotional abuse.
  • The annual incidence of elder abuse is estimated to be 2% to 10% with only about 1 in 15 cases reported to the authorities.
  • Approximately one-third of nursing homes disclosed at least 1 incident of physical abuse per year.
  • Ten percent of nursing home staff self-report physical abuse against an elderly resident.

Elder domestic violence may be financial or physical. The elderly may be controlled financially. Elders are often hesitant to report this abuse if it is their only available caregiver. Victims are often dependent, infirm, isolated, or mentally impaired. Healthcare professionals should be aware of the high incidence of abuse in this population.

History and Physical

The history and physical exam should be tailored to the age of the victim.

Child Abuse

The most common injuries are fractures, contusions, bruises, and internal bleeding. Unexpected injuries to pre-walking infants should be investigated. The caregiver should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries should be investigated.

Children who are abused may be unkempt and/or malnourished. They may display inappropriate behavior such as aggression, or may be shy, withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. School attendance is usually poor.

Intimate Partner Abuse

Approximately one-third of women and one-fifth of men will be victims of abuse. The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. One should be suspicious if the history is not consistent with the injury. Defensive injuries may be present on the forearms and hands. The patient may have psychological signs and symptoms such as anxiety, depression, and fatigue.

Medical complaints may be specific or vague such as headaches, palpitations, chest pain, painful intercourse, or chronic pain.

Intimate Partner Abuse: Pregnancy and Female

Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions. There are a number of historical and physical findings that may help the provider identify individuals at risk.

If the examiner encounters signs or symptoms, she should make every effort to examine the patient in private, explaining confidentiality to the patient. Be sure to ask caring, empathetic questions and listen politely without interruption to answers.

Intimate Partner Abuse: Same Sex

Same-sex partner abuse is common and may be difficult to identify. Over 35% of heterosexual woman, 40% of lesbians, 60% of bisexual woman experience domestic violence. For men, the incidence is slightly lower. In addition to common findings of abuse, perpetrators may try to control their partners by threatening to make their sexual preferences public.

The provider should be aware there are fewer resources available to help individuals that are victims; further, the perpetrator and victim may have the same friends or support groups.

Intimate Partner Abuse: Men

Men represent as much as 15% of all cases of domestic partner violence. Male victims are also less likely to seek medical care so the incidence may be underreported. These victims may have a history of child abuse.

Elderly Abuse

Health professionals should ask geriatric patients about abuse, even if signs are absent.

Risk Factors

  • Dementia
  • Pathologic characteristics of perpetrators including dementia, mental illness, and drug and alcohol abuse
  • A shared living situation with the abuser
  • Social isolation

Evaluation

Domestic violence may be difficult to uncover when the victim is frightened, especially when he or she presents to an emergency department or healthcare practitioner's office. The key is to establish an assessment protocol and maintain an awareness of the possibility that domestic and family violence may be the cause of the patient’s signs and symptoms. Screening should be carried out in primary care, obstetric and gynecologic, psychiatric, pediatric, urgent care, and emergency departments.

Establishing that injuries are related to domestic abuse is a challenging task. Life and limb-threatening injuries are the priority. After stabilization and physical evaluation, laboratory tests, x-rays, CT, or MRI may be indicated. It is important that healthcare professionals first attend to the underlying issue that brought the victim to the emergency department.

  • The evaluation should start with a detailed history and physical examination. Clinicians should screen all females for domestic violence, and refer females who screen positive. This includes females who do not have signs or symptoms of abuse. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring patients for intimate partner violence. Protocols should include referral, documentation, and follow-up.
  • Health professionals and administrators should be aware of challenges such as barriers to screening for domestic violence: lack of training, time constraints, the sensitive nature of issues, and a lack of privacy to address the issues.
  • Although professional and public awareness has increased, many patients and providers are still hesitant to discuss abuse.
  • Patients with signs and symptoms of domestic violence should be evaluated. The obvious cues are physical: bruises, bites, cuts, broken bones, concussions, burns, knife or gunshot wounds.
  • Typical domestic injury patterns include contusions to the head, face, neck, breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more commonly involve the extremities of the body. Abuse victims tend to have multiple injuries in various stages of healing from acute to chronic.
  • Domestic violence victims may have emotional and psychological issues such as anxiety and depression. Complaints may include backaches, stomachaches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are more likely to experience asthma, irritable bowel syndrome, and diabetes.

Assessment

Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.

  • If there is no immediate danger, the assessment should focus on the mental and physical health and establish the history of current or past abuse. These responses determine the appropriate intervention.
  • During the initial assessment, a practitioner must be sensitive to the patient’s cultural beliefs. Incorporating a cultural sensitivity assessment with a history of being victims of domestic violence may allow more effective treatment.
  • Patients that have suffered domestic violence may or may not want a referral. Many are fearful of their lives and financial well-being and hence may be weighing the tradeoff in leaving the abuser leading to loss of support and perhaps the responsibility of caring for children alone. The healthcare provider needs to assure the patient that the decision is voluntary and that the provider will help regardless of the decision. The goal is to make resources accessible, safe, and to enhance support.
  • If the patient elects to leave their current situation, information for referral to a local domestic violence shelter to assist the victim should be given.
  • If there is a risk to life or limb, or evidence of injury, the patient should be referred to local law enforcement officials.
  • Counselors often include social workers, psychiatrists, and psychologists that specialize in the care of battered partners and children.

Testing

Children

A detailed history and careful physical exam should be performed. If head trauma is suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.

Laboratory

Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings similar to child abuse, as a consequence, they must be ruled out.

Urine

  • A urine test may be used as a screen for sexually transmitted disease, bladder or kidney trauma, and toxicology screening. 

Hematology

If bruises or contusions are present, there is no need evaluate for a bleeding disorder if the injuries are consistent with an abuse history. Some tests can be falsely elevated so a child abuse-specialist pediatrician or hematologist should review or follow-up these tests.

Gastrointestinal and Chest Trauma

  • Consider liver and pancreas screening tests such as AST, ALT, and lipase. If the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L, consider an abdomen and pelvis CT with intravenous contrast.
  • The highest-risk are those with abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15.

Imaging

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults such as cranial sutures and incomplete bone growth. A fracture can be misinterpreted. If there is a concern for abuse, consider consulting a radiologist.

Imaging: Skeletal Survey

A skeletal survey is indicated in children younger than 2 years with suspected physical abuse. The incidence of occult fractures is as high as 1 in 4 in physically abused children younger than 2 years. The clinician should consider screening all siblings younger than 2 years.

The skeletal survey should include 2 views of each extremity; anteroposterior and lateral skull; and lateral chest, spine, abdomen, pelvis, hands, and feet. A radiologist should review the films for classic metaphyseal lesions and healing fractures, most often involving the posterior ribs. A “babygram” that includes only 1 film of the entire body is not an adequate skeletal survey.

Skeletal fractures will remodel at different rates which are dependent on the age, location, and nutritional status of the patient.

Imaging: CT

If abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged six months or younger or children younger than 24 months if intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months.

CT of the abdomen and pelvis with intravenous contrast is indicated in children who are unconscious, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.

Special Documentation

Photographs should be taken before treatment of injuries.

Intimate Partner and Elder

Laboratory

Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, and malnutrition. 

Imaging

  • X-rays of bruised of tender body parts to detect fractures
  • Head CT scan to evaluate for intracranial bleeding as a result of abuse or the causes of altered mental status

Other

  • Pelvic examination with evidence collection if sexual assault

Evidence Collection

Domestic and family violence commonly results in legal prosecution of the perpetrator. Preferably, a team specializing in domestic violence is called in to assist with evidence collection.

Each health facility should have a written procedure for how to package and label specimens and maintain a chain of custody. Law enforcement personnel will often assist with evidence collection, and provide specific kits.

It is important to avoid destroying evidence. Evidence includes tissue specimens, blood, urine, saliva, and vaginal and rectal specimens. Saliva from bites can be collected; the bite mark is swabbed with a water-moistened cotton-tipped swab.

Clothing stained with blood, saliva, semen, and vomit should be retained for forensic analysis.

Treatment / Management

The priority is the ABCs and appropriate treatment of the presenting complaints. However, once the patient is stabilized, emergency medical services personnel may identify problems associated with violence.

Emergency Department and Office Care

Interventions to consider include:

  • Make sure a safe environment is provided.
  • Diagnose physical injuries and other medical or surgical problems.
  • Treat acute physical or life-threatening injuries.
  • Identify possible sources of domestic violence.
  • Establish domestic violence as the diagnosis.
  • Reassure the patient that he is not at fault.
  • Evaluate the emotional status and treat.
  • Document the history, physical, and interventions.
  • Determine the risks to the victim and assess safety options.
  • Counsel the patient that violence may escalate.
  • Determine if legal intervention is needed and report abuse when appropriate or mandated.
  • Develop a follow-up plan.
  • Offer shelter options, legal services, counseling, and facilitate such referral.

Medical Record

The medical record is often evidence used to convict an abuser. A poorly document chart may result in an abuser going free and assaulting again.

Charting should include detailed documentation of evaluation, treatment, and referrals.

  • Describe the abusive event and current complaints using the patient's own words.
  • Include behavior of the patient in the record.
  • Include health problems related to the abuse.
  • Include the alleged perpetrator's name, relationship, and address.
  • The physical exam should include a description of the patient's injuries including location, color, size, amount, and degree of age bruises and contusions.
  • Document injuries with anatomical diagrams and photographs.
  • Include the name of the patient, medical record number, date, and time of the photograph, and witnesses on the back of each photograph.
  • Torn and damaged clothing should also be photographed.
  • Document injuries not shown clearly by photographs with line drawings.
  • With sexual assault, follow protocols for physical examination and evidence collection.

Disposition

If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once the patient returns home.

  • A referral should be made to primary care or another appropriate resource.
  • Advise the patient to have a safety plan and provide examples.

Remember

  • Forty percent of domestic violence victims never contact the police.
  • Of female victims of domestic homicide, 44% had visited a hospital emergency department within 2 years of their murder.
  • Health professionals provide an opportunity for victims of domestic violence to obtain help.

Differential Diagnosis

The differential diagnosis varies with the injury type of injury and age.

Child

Head Trauma

  • Accidental injury
  • Arteriovenous malformations
  • Bacterial meningitis
  • Birth trauma
  • Cerebral sinovenous thrombosis
  • Hemophilia
  • Solid brain tumors

Bruises and Contusions

  • Accidental bruises
  • Birth trauma
  • Bleeding disorder
  • Coining
  • Cupping
  • Congenital dermal melanocytosis (Mongolian spots)
  • Erythema multiforme
  • Hemangioma
  • Hemophilia

Burns

  • Accidental burns
  • Atopic dermatitis
  • Contact dermatitis
  • Impetigo
  • Inflammatory skin conditions
  • Sunburn

Fractures

  • Accidental
  • Birth trauma
  • Congenital syphilis
  • Malignancy
  • Osteogenesis imperfecta
  • Osteomyelitis
  • Rickets
  • Scurvy
  • Toddler’s fracture

Prognosis

Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity.

  • Of those injured by domestic violence, over 75% continue to experience abuse.
  • Over half of battered women who attempt suicide will try again; often they are successful with the second attempt.

In children, the potential for poor outcomes is particularly high as abuse inflicts lifelong effects. In addition to dealing with the sequelae of physical injury, the mental consequences may be catastrophic. Studies indicate a significant association between child sexual abuse and increased risk of psychiatric disorders in later life. The potential for the cycle of violence to continued from childhood is very high.

Children raised in families of sexual abuse may develop:

  • Attention deficit hyperactivity disorder (ADHD)
  • Conduct disorder
  • Depression
  • Bipolar disorder
  • Panic disorder
  • Sleep disorders
  • Suicide attempts
  • Post-traumatic stress disorder (PTSD)

Health Outcomes

There are multiple known and suspected negative health outcomes of family and domestic violence. There are long-term consequences to broken bones, traumatic brain injuries, and internal injuries.

Patients may also develop multiple comorbidities such as:

  • Asthma
  • Insomnia
  • Fibromyalgia
  • Headaches
  • High blood pressure
  • Chronic pain
  • Gastrointestinal disorders
  • Gynecologic disorders
  • Depression
  • Panic attacks
  • PTSD

Pearls and Other Issues

Pearls

  • Healthcare professionals should document all findings and recommendations in the medical record, including statements made denying abuse
  • If domestic violence is admitted, documentation should include the history, physical examination findings, laboratory and radiographic finds, any interventions, and the referrals made.
  • If there are significant findings that can be recorded, pictures should be included.
  • The medical record may become a court document; be objective and accurate.
  • Healthcare professionals should provide a follow-up appointment.
  • Reassurance that additional assistance is available at any time is critical in to protect the patient from harm and break the cycle of abuse.

Screening

Screening: Reporting Family and Domestic Violence

Over 80% of victims of domestic and family violence seek care in a hospital; others may seek care in health professional offices, including dentists, therapists, and other medical offices. Routine screening should be conducted by all healthcare practitioners including nurses, physicians, physician assistants, dentists, nurse practitioners, and pharmacists. Screening is a critical component protecting victims and minimizing negative health outcomes.

Health professional interventions reduce the incidence of morbidity and mortality associated with domestic violence.

Screening: Tools

  • The American Academy of Pediatricians has free guides for the history, physical, diagnostic testing, documentation, treatment, and legal issues in cases of suspected child abuse.
  • The Center for Disease Control and PRevention (CDC) provides several scales assessing family relationships, including child abuse risks.
  • The physical examination is still the most significant diagnostic tool to detect abuse. A child or adult with suspected abuse should be undressed, and a comprehensive physical exam should be performed. The skin should be examined for bruises, bites, burns, and injuries in different stages of healing. Examine for retinal hemorrhages, subdural hemorrhages, tympanic membrane rupture, soft tissue swelling, oral bruising, fractured teeth, and organ injury.

Screening: Recommendations

  • Evaluate for organic conditions and medications that mimic abuse.
  • Evaluate patients and caregivers separately
  • Clinicians should regularly screen for family and domestic violence and elder abuse
  • The Elder Abuse Suspicion Index can be used to assess for elder abuse
  • Screen for cognitive impairment before screening for abuse in the elderly
  • Pattern injury is more suspicious

Risks

  • Failure report child abuse is illegal in most states.
  • Failure to report intimate partner and elder abuse is illegal in many states.

Legal

It is important to be aware of federal and state statutes governing domestic and family abuse. Remember that reporting domestic and family violence to law enforcement does not obviate detailed documentation in the medical record.

  • Battering is a crime, and the patient should be made aware that help is available. If the patient wants legal help, the local police should be called.
  • In some jurisdictions, domestic violence reporting is mandated. The legal obligation to report abuse should be explained to the patient.
  • The patient should be informed how local authorities typically respond to such reports and provide follow-up procedures. Address the risk of reprisal, need for shelter, and possibly an emergency protective order (available in every state and the District of Columbia).
  • If there is a possibility the patient’s safety will be jeopardized, the clinician should work with the patient and authorities to best protect the patient while meeting legal reporting obligations.
  • The clinical role in managing an abused patient goes beyond obeying the laws that mandate reporting; there is a primary obligation to protect the life of the patient.
  • The clinician must help mitigate the potential harm that results from reporting, to provide appropriate ongoing care and preserve the safety of the patient.
  • If the patient desires, and it is acceptable to the police, a health professional should remain during the interview.
  • The medical record should reflect the incident as described by the patient and any physical exam findings. Include the date and time the report was taken and the officer's name and badge number.

National Statutes

Federal Child Abuse Prevention and Treatment Act (CAPTA)

Each state has specific child abuse statues. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure recent act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation.

Elder Justice Act

The Elder Justice Act provides strategies to decrease the likelihood of elder abuse, neglect, and exploitation. The Act utilizes three significant approaches:

Patient Safety and Abuse Act

The Violence Against Woman Act makes it a federal crime to cross state lines to stalk, harass, or physically injure a partner; or enter or leave the country violating a protective order. It is a violation to possess a firearm or ammunition while subject to a protective order or if convicted of a qualifying crime of domestic violence. The victim also has a right to:

Resources

National

The following agencies provide national assistance for victims of domestic and family violence:

  • Centers for Disease Control and Prevention (800-CDC-INFO (232-4636)/TTY: 888-232-6348
  • Childhelp: National Child Abuse Hotline: (800-4-A-CHILD (2-24453))
  • The coalition of Labor Union Women (cluw.org): 202-466-4615
  • Corporate Alliance to End Partner Violence: 309-664-0667
  • Employers Against Domestic Violence: 508-894-6322
  • Futures without Violence: 415-678-5500/TTY 800-595-4889
  • Love Is Respect: National Teen Dating Abuse Helpline: 866-331-9474 /TTY: 866-331-8453
  • National Center on Domestic and Sexual Violence
  • National Center on Elder Abuse
  • National Coalition Against Domestic Violence (www.ncadv.org)
  • National Network to End Domestic Violence: 202-543-5566
  • National Organization for Victim Assistance
  • National Resource Center on Domestic Violence: 800-537-2238 
  • National Sexual Violence Resource Center: 717-909-0710

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE courses, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Domestic Violence - Questions

Take a quiz of the questions on this article.

Take Quiz
Which is most associated with violence in the home?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female who is 20-weeks pregnant presents with bruising on her breasts and alcohol on her breath. What is the most likely cause of these findings?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has a history of physical and emotional abuse that is causing anxiety. Which of the following techniques would be best to encourage expression of feelings?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female is admitted to the psychiatric unit for evaluation after an episode of domestic violence. The police had been called to her home, where she and her husband were engaged in a physical fight. The husband was arrested. Initially, the patient stated that she wanted a divorce but now she wants to reunite and is crying. How should the provider respond?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following techniques for victims of abuse would be best to assist in expressing anger?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female patient is brought to OT by her husband who is quite solicitous. The patient has chronic pain and findings that would warrant treatment but she often skips appointments and does not do her home exercises. Which of the following may be causing this behavior?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is referred for physical therapy for low back pain after a fall. The patient has multiple bruises on her arms, hips, and back. What should the therapist do if domestic abuse is suspected?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a true regarding domestic violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is not the responsibility of a medical professional for patients involved in domestic violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 25-year-old female presents to the emergency department (ED) with complaints of dyspnea and chest pain. Chest x-rays reveal two fractured ribs. A review of her records shows that she has visited the ED many times in the last several months for various injuries. When asked how she may have fractured her ribs, she replies, "I fell onto the banister as I tripped down the stairs." What should be the next course of action?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is appropriate when dealing with a case of suspected domestic violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 24-year-old pregnant female is at 28 weeks of gestation. She has just moved to the area and is presenting for care. She states that the pregnancy has gone well, but she has a long history of headaches. Vital signs and fetal heart tones are normal. The patient has bruises at various stages on her arms, legs, and torso. She states that she is clumsy and bumps into things. Which of the following questions is most appropriate?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents to the emergency department with complaints of pain and trouble breathing after falling down the stairs at her home. During the initial assessment, the nurse notes swelling, bruising, and a laceration to the patient's face and forehead, bruising to her upper chest area, and bruising in various stages of healing to her body. The nurse is concerned that the patient may be a victim of domestic violence and consults the forensic nurse. During the forensic nurse examination, the patient states her husband has been abusing her for many years and the abuse is getting worse. The forensic nurse asks the patient if she has reported the abuse to law enforcement and she states, "No, I do not want law enforcement involved." Due to mandatory reporting laws, is the forensic nurse mandated to report the abuse to law enforcement regardless of the patient's wishes?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 36-year-old female presents to the primary care setting complaining of vague abdominal pain. During the evaluation, the clinician notes poor eye contact and multiple bruises in various stages of healing. Which of the following statements is true regarding domestic violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common form of physical interpersonal violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not typically described as being part of the cycle of abuse and violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
You are playing a game of "liar liar, pants on fire" where players draw cards, and three cards contain true statements, and one card contains a false statement. Which of the following is the false statement?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a true statement regarding child abuse?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following may be mistaken for child abuse?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a common barrier to screening for domestic violence?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is an incorrect association?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is noted to have multiple contusions. When asked how they occurred, the patient is evasive but eventually states they fell down the steps. What is appropriate in providing care to this patient if you are concerned about possible domestic violence? Select all that apply.

(Move Mouse on Image to Enlarge)
  • Image 4309 Not availableImage 4309 Not available
    Contributed by Wikimedia Commons (CC-BY-2.0)
Attributed To: Contributed by Wikimedia Commons (CC-BY-2.0)



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Domestic Violence - References

References

Intimate partner violence., Cronholm PF,Fogarty CT,Ambuel B,Harrison SL,, American family physician, 2011 May 15     [PubMed]
Patterns of intimate partner violence and their associations with physical health, psychological distress, and substance use., Carbone-López K,Kruttschnitt C,Macmillan R,, Public health reports (Washington, D.C. : 1974), 2006 Jul-Aug     [PubMed]
Intimate Partner Violence., Dicola D,Spaar E,, American family physician, 2016 Oct 15     [PubMed]
Intimate partner violence and physical health consequences: policy and practice implications., Plichta SB,, Journal of interpersonal violence, 2004 Nov     [PubMed]
ACOG issues technical bulletin on domestic violence. American College of Obstetricians and Gynecologists.,, American family physician, 1995 Dec     [PubMed]
The danger assessment: validation of a lethality risk assessment instrument for intimate partner femicide., Campbell JC,Webster DW,Glass N,, Journal of interpersonal violence, 2009 Apr     [PubMed]
Differentiating among Attempted, Completed, and Multiple Nonfatal Strangulation in Women Experiencing Intimate Partner Violence., Messing JT,Patch M,Wilson JS,Kelen GD,Campbell J,, Women's health issues : official publication of the Jacobs Institute of Women's Health, 2018 Jan - Feb     [PubMed]
Risk factors for femicide in abusive relationships: results from a multisite case control study., Campbell JC,Webster D,Koziol-McLain J,Block C,Campbell D,Curry MA,Gary F,Glass N,McFarlane J,Sachs C,Sharps P,Ulrich Y,Wilt SA,Manganello J,Xu X,Schollenberger J,Frye V,Laughon K,, American journal of public health, 2003 Jul     [PubMed]
State Intimate Partner Violence-Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015., Díez C,Kurland RP,Rothman EF,Bair-Merritt M,Fleegler E,Xuan Z,Galea S,Ross CS,Kalesan B,Goss KA,Siegel M,, Annals of internal medicine, 2017 Oct 17     [PubMed]
Mental disorders associated with subpopulations of women affected by violence and abuse., Cavanaugh CE,Martins SS,Petras H,Campbell JC,, Journal of traumatic stress, 2013 Aug     [PubMed]
The association between child exposure to intimate partner violence (IPV) and perpetration of IPV in adulthood-A systematic review., Kimber M,Adham S,Gill S,McTavish J,MacMillan HL,, Child abuse & neglect, 2018 Feb     [PubMed]
Using Reoffenders' Experiences and Perspectives to Improve Intimate Partner Violence Treatment., Portnoy GA,Murphy CM,, Journal of interpersonal violence, 2017 Jun 1     [PubMed]
Flawed Theories to Explain Child Physical Abuse: What Are the Medical-Legal Consequences?, Leventhal JM,Edwards GA,, JAMA, 2017 Oct 10     [PubMed]
Constructive and Unproductive Processing of Traumatic Experiences in Trauma-Focused Cognitive-Behavioral Therapy for Youth., Hayes AM,Yasinski C,Grasso D,Ready CB,Alpert E,McCauley T,Webb C,Deblinger E,, Behavior therapy, 2017 Mar     [PubMed]
Prenatal Substance Exposure and Reporting of Child Maltreatment by Race and Ethnicity., Putnam-Hornstein E,Prindle JJ,Leventhal JM,, Pediatrics, 2016 Sep     [PubMed]
Elder abuse: Paucity of data hampers evidence-based injury prevention., Crandall M,Duncan T,Mallat A,Greene W,Violano P,Christmas AB,Cooper Z,Barraco RD,, The journal of trauma and acute care surgery, 2016 Sep     [PubMed]
Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies., Pillemer K,Burnes D,Riffin C,Lachs MS,, The Gerontologist, 2016 Apr     [PubMed]
Development and Implementation of a Child Welfare Workforce Strategy to Build a Trauma-Informed System of Support for Foster Care., Kerns SE,Pullmann MD,Negrete A,Uomoto JA,Berliner L,Shogren D,Silverman E,Putnam B,, Child maltreatment, 2016 May     [PubMed]
Building Capacity for Trauma-Informed Care in the Child Welfare System: Initial Results of a Statewide Implementation., Lang JM,Campbell K,Shanley P,Crusto CA,Connell CM,, Child maltreatment, 2016 May     [PubMed]
PTSD and Daily Co-Occurrence of Drug and Alcohol Use Among Women Experiencing Intimate Partner Violence., Sullivan TP,Weiss NH,Flanagan JC,Willie TC,Armeli S,Tennen H,, Journal of dual diagnosis, 2016     [PubMed]
Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse., Rosen T,Bloemen EM,LoFaso VM,Clark S,Flomenbaum NE,Lachs MS,, The Journal of emergency medicine, 2016 Mar     [PubMed]
Attention bias and anxiety in young children exposed to family violence., Briggs-Gowan MJ,Pollak SD,Grasso D,Voss J,Mian ND,Zobel E,McCarthy KJ,Wakschlag LS,Pine DS,, Journal of child psychology and psychiatry, and allied disciplines, 2015 Nov     [PubMed]
Potential Impact of a Validated Screening Tool for Pediatric Abusive Head Trauma., Hymel KP,Herman BE,Narang SK,Graf JM,Frazier TN,Stoiko M,Christie LM,Harper NS,Carroll CL,Boos SC,Dias M,Pullin DA,Wang M,, The Journal of pediatrics, 2015 Dec     [PubMed]
Barriers and Facilitators to Detecting Child Abuse and Neglect in General Emergency Departments., Tiyyagura G,Gawel M,Koziel JR,Asnes A,Bechtel K,, Annals of emergency medicine, 2015 Nov     [PubMed]
Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused., Adams JA,Kellogg ND,Farst KJ,Harper NS,Palusci VJ,Frasier LD,Levitt CJ,Shapiro RA,Moles RL,Starling SP,, Journal of pediatric and adolescent gynecology, 2016 Apr     [PubMed]
Child maltreatment and risk patterns among participants in a child abuse prevention program., Duffy JY,Hughes M,Asnes AG,Leventhal JM,, Child abuse & neglect, 2015 Jun     [PubMed]
Trauma-Focused Cognitive Behavioral Therapy for Youth: Effectiveness in a Community Setting., Webb C,Hayes A,Grasso D,Laurenceau JP,Deblinger E,, Psychological trauma : theory, research, practice and policy, 2014 Sep 1     [PubMed]
Validation of a clinical prediction rule for pediatric abusive head trauma., Hymel KP,Armijo-Garcia V,Foster R,Frazier TN,Stoiko M,Christie LM,Harper NS,Weeks K,Carroll CL,Hyden P,Sirotnak A,Truemper E,Ornstein AE,Wang M,, Pediatrics, 2014 Dec     [PubMed]
Sexual abuse and assault in children and teens: time to prioritize prevention., Moles RL,Leventhal JM,, The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 2014 Sep     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Professional and Ethics. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Professional and Ethics, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Professional and Ethics, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Professional and Ethics. When it is time for the Nurse-Professional and Ethics board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Professional and Ethics.