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Elder Abuse, University of Tulsa Medical School, Oklahoma City 2009 Dr. Norman Simon, Sue Ann

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OU Med School "Screen to Save" Presentation

  1. 1. “Healthcare and Screening for Domestic Violence” Raising Awareness; Inspiring Action Families and Communities Empowered for Safety (918) 519-3698 :: faces.sherry@gmail.com :: www.faces.tulsa.org
  2. 2. Rhianna with her abuser, Chris Brown
  3. 3. Definition of IPV • A pattern of assaultive and coercive behaviors used in the context of dating or intimate relationships • May take the form of physical, sexual, and/or psychological abuse, is generally repeated, and often escalates within relationships • May be occurring despite end of intimate relationship Ganley A: Family Violence Prevention Fund 1995
  4. 4. Domestic violence is about… Physical Social & physical abuse isolation POWER AND CONTROL Sexual Emotional & abuse Economic verbal abuse abuse
  5. 5. 2006 Data on Homicides • Oklahoma ranks fourth (2008) highest in the nation in homicides of women per 100,000 population • 92% of the victims knew their killer and of these 60% were wives or intimate partners of the perpetrator
  6. 6. U.S. Statistics • 1 to 3 million women abused per year • 1 in 4 (25%) lifetime prevalence in primary care study • 1 in 7 women (15%) seen in GIM clinics • 1 in 9 women seen in ED • 1 in 2 (54%) lifetime prevalence in women seen in ED Bachman R: US Dept. of Justice, 1998 Freund KM: JGIM 1996 Gin NE: JGIM 1991 Abbott J: JAMA 1995
  7. 7. The Reality of Abuse
  8. 8. This is Often What We See  Sleep and appetite  Abdominal and GI disturbances complaints  Fatigue  Irritable bowel syndrome  Sexual dysfunction  Dyspepsia  Headaches  Depression  Chronic pelvic pain  Anxiety disorders  Atypical chest pain  Suicide attempts  Somatization
  9. 9. Physical Health Consequences of Physical and Psychological IPV • 1152 women screened from 2 FP clinics • Used 2 screening tools to assess both types of IPV (ISA- P and WEB scale) • 54% had experienced IPV of any kind • 40% physical violence hx • 14% psychological without physical – More likely to report physical and mental health as ―poor‖ – Increased disabilities, chronic neck or back pain, arthritis, migraines, STDs, pelvic pain, PUD, and IBS • Psychologic IPV hx as strongly related to poor health outcomes as physical IPV Coker et al Arch Fam Med 2000
  10. 10. Physiologic Responses to IPV • Spanish study tested physically and psychologically abused women compared to controls • Saliva sampled at 8am and 8pm • IPV victims had higher levels of evening cortisol and morning and evening DHEA • Differences remained after controlling for age, smoking, medications and lifetime history of victimization Pico-Alfonso et al. Biol Psychiatry 2004
  11. 11. Stress-related Chronic Illness » Stress of living in abusive situation may cause or worsen physical symptoms: • ―Thick Chart Syndrome‖ — frequent visits, comprehensive exams with extensive testing, no known physical cause for complaints • ―Medically Unexplained Symptoms‖ – MUS common in victims of violence
  12. 12. Post-traumatic Stress Disorder (PTSD) • Exposure of traumatic event(s) • Re-experiencing the traumatic event • Persistent avoidance of stimuli and numbing of responsiveness • Persistent symptoms of increased arousal • Symptoms > 1 month • Symptoms cause significant distress or impairment DSM-IV 1994
  13. 13. PTSD • Many but not all victims will develop PTSD • More likely in victims of sexual assault • Requires mental health professional for diagnosis and treatment • Commonly associated with patients with multiple somatic complaints • Relationships and exams can be difficult Violence Against Women, Liebschutz, Frayne and Saxe, Eds., ACP 2003
  14. 14. Effects of Childhood Abuse in Adults • Adverse Childhood Experiences (ACE) Study • Questionnaire returned by 9500 HMO patients • Adjusted for demographic factors • Graded relationship between no. of ACE and adult risk behaviors and diseases, such as CAD, cancer, chronic lung disease and liver disease Felitti et al Am J Prev Med 1998
  15. 15. Effects of Abuse on Children • Of the 2-4 million women battered each year , one half live with children under 12 • 62% of children living in a home with domestic violence are also abused • Boys who witness violence against their mothers are ten times more likely to abuse their female partners as adults • 63% of boys aged 11-20 arrested for murder were arrested for murdering the man assaulting their mother
  16. 16. Health Care Utilization in IPV Victims • History of DV predictor of hospitalizations, general clinic use, mental health services and out-of-plans referrals • Net costs $1775 more annually* • Being IPV victim associated with 1.6 to 2.3-fold increase in total health care utilization and costs** *Wisner et al J Fam Pract 1999 **Ulrich et al Am J Prev Med 2003
  17. 17. Costs of IPV in US • Exceeds $5.8 billion per year – $4.1 billion in direct medical and mental health care costs • $900 million from lost productivity from paid work and household chores • $900 million from lifetime earnings lost by victims of IPV homicide Costs of Intimate Partner Violence Against Women in the United States, CDC report, 2003
  18. 18. Why Don’t Victims Tell? Could be: • Fear of Retribution • Shame and humiliation • Protecting their relationship with: – Partner – Friend or parent – Church • Lack of trust in others
  19. 19. Why Don’t Victims Leave? • Fear • Children • Finances (no job and /or few skills) • Denial • Shame and embarrassment • Guilt and low self-esteem • Lack of resources • Sex-role conditioning • Religious beliefs & values • Love • Hope
  20. 20. Circle of Violence
  21. 21. The Physician’s Role
  22. 22. The Role of the Healthcare Provider
  23. 23. How Are We Doing on Screening? • Recent survey of clients at Family Safety Center* – Of 38 women, 27 had seen a physician in last year – 9 stated physician asked about personal safety in relationships – 4 were referred to DV advocacy organization – 5 were given information on where to receive services *Ann Patterson Dooley Family Safety Center 2008
  24. 24. Interviewing the Patient Recommendations from American Medical Association 1. Physicians should routinely screen all women patients 2. Interview patient alone, without partner
  25. 25. Is This ―Our‖ Job? • JCAHO standards: – PE.1.9: ―Possible victims of abuse are identified using criteria developed by the hospital.‖ – PE.8: ―Patients who are possible victims of alleged or suspected abuse have special needs relative to the assessment process.‖
  26. 26. Physician Barriers to Screening • Lack of education and experience • Fear of offending patients • Lack of effective interventions • Limited time • Not appropriate in health care setting • Patient will not make changes • Blaming the victim • “Pandora’s Box” ?
  27. 27. Patient Barriers to Identification • Fear that revelation will jeopardize safety • Shame and humiliation • Thinking she deserved the abuse • Protection of partner • Lack of awareness that physical symptoms are caused by stress of living in an abusive relationship • Belief that injuries not severe enough to mention
  28. 28. Screening Questions Examples 1. ―Because violence is so common in women’s lives, I’ve begun to ask about it routinely.‖ 2. ―Do you ever feel afraid of your partner?‖ 3. ―We all disagree at home. What happens when you and your partner disagree?‖ 4. ―Are you in a relationship in which you have been physically hurt or threatened by your partner?‖
  29. 29. Examples When Abuse Suspected • ―Often when I see a person with this kind of problem, it is because someone has hurt them. Has this happened to you?‖ • ―Many women who have physical problems like yours have suffered from violence in their homes. Could this have happened to you?‖
  30. 30. Screening question on new pt. Hx form: Have you ever experienced violence or abuse from a family member or partner?
  31. 31. Safety Planning • Don’t say: ―You need to leave now!‖ • Options should be given • If victim has no safe place to go, leaving may increase chance of severe injury or death • 70% of severe injuries and deaths occur when the victim is trying to leave • Ask about weapons in home, threats of murder, thoughts of suicide, strangulation
  32. 32. How You Can Help • Don’t tell her what to do • Be careful about saying ―I know just how you feel…‖ • Help her explore her options • Reinforce her reasons for leaving • Encourage calling DVIS, getting counseling and financial help • Tell her you will be available no matter what she decides to do
  33. 33. What to Say to a DV Victim 1. I fear for your safety. 2. I fear for the safety of your children. 3. It will likely get worse. 4. I support you and I am here for you. 5. You deserve better. 6. There is considerable help available. 7. Nothing you did (or didn’t do) makes you deserve this. 8. I am sorry this has happened to you. 9. I believe what you are telling me.
  34. 34. Reporting Domestic Abuse for Health Care Professionals • Current Oklahoma law • Old law was confusing and required mandatory reporting, now considered risky for the victim • Old law did not provide sufficient guidance to doctors on how to comply and how to avoid liability Rules are different for suspected abuse of children, incapacitated and elderly
  35. 35. Reporting Domestic Abuse 1-2-3 1. Report DV and criminally injurious conduct to a non-incapacitated adult victim only when the victim makes the request for you to do so; at that time, a report to county law enforcement must be made. 2. You must clearly and legibly document the incident and injuries observed and treated, whether or not a report is made. Document your actions in the patient’s record: assess, report, and refer. 3. In all cases whether reported or not, you must give the victim a referral to a DV violence service program and the 24-hour Oklahoma statewide help line number: 1-800-522-SAFE. Local DV victim advocacy services can be found on the Oklahoma Coalition Against Domestic Violence & Sexual Abuse website under “help”: www.ocadvsa.org.
  36. 36. Domestic Abuse Screening 1. Screen female patients for domestic violence. 2. Report when patient makes the request for you to do so. 3. Refer patient to Oklahoma state hotline: 1-800-522-SAFE. Refer patient to local domestic violence victim advocacy agency: www.ocadvsa.org 4. Legibly document findings and actions in patient’s chart.
  37. 37. When Reporting is Mandatory 1. Any case of suspected child abuse – victim under the age of 18 2. When a victim of domestic violence, age 18 and older requests a medical practitioner to make a report to local law enforcement. 3. Abuse of a vulnerable adult, a person age 18 or above who has physical or mental conditions which cause the need for a guardian as defined by law, or whose impairments are less disabling but still prevent the adult from independently managing all of his or her own affairs or protecting him or herself from maltreatment by others 4. Any case of elder abuse, 62 years or over.
  38. 38. Elder Abuse • Elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm to a vulnerable adult. • Elder abuse can consist of physical abuse, financial exploitation, emotional abuse, neglect and domestic violence. • Elder abuse frequently consists of self-neglect, rather than abuse by a second party. • The definition of self-neglect excludes a situation in which a mentally competent older person, who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety as a matter of personal choice. (NCEA)
  39. 39. Elder Abuse and Neglect Tulsa Lifespan Abuse Information • FY 05- 1850 DHS Adult Protective Services confirmed cases in Tulsa • Tulsa -- 8.6% of all state referrals (16,804) • 38% increase of elder abuse by adult children since 2005 • 116% increase over past 10 years (Source: Adult Protective Services (APS) w/ the Oklahoma Department of Human Services, 2005) To compare • In FY 04, Tulsa’s child abuse case investigations--1,228 confirmed cases of 16,000 state calls (Source: S. Arnold de Berges. Prioritization of System Issues, Child Protection System of Tulsa County Report, 2005 )
  40. 40. Reporting Elder Abuse 1. In the case of abuse of a vulnerable adult, or elder abuse the health care provider must report to either DHS-local office or 1-800-522-3511, or to local law enforcement. 2. Suspected child abuse must be reported to DHS at local office or 1-800-522-3511.
  41. 41. Reporting Abuse • You must provide copies of medical records relating to abuse if requested by law enforcement invest- igating reports. • If you treat a victim of abuse, you have statutory immunity from any liability, civil or criminal, if you report or don’t report in good faith as well as exercise due care.
  42. 42. To schedule a presentation or for more information, contact: Sherry Clark at f.a.c.e.s. faces.sherry@gmail.com or (918)519-3609 Raising Awareness; Inspiring Action

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