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 Area:    Feminism
  Msg:    #386
 Date:    11-07-94 10:39 (Public) 
 From:    Kathy Gerber             
 To:      All                      
 Subject: NIMH:Violent Injuries 1/4
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From NIH gopher server:

Screening for Violent Injuries

Recommendation:


Routine screening interviews or examinations for evidence of violent
injuries are not recommended.  Children and adults presenting with unusual
injuries should be examined with attention to possible abuse or neglect,
and efforts should be made to prevent subsequent violent injury.
Counseling and referral should be offered to those persons at high risk
of becoming victims or perpetrators of violence (see Clinical
Intervention).


Burden of Suffering


Violent injury is a serious public health problem in the United States.
Millions of violent incidents occur each year, but because many cases
are unreported the true magnitude of the problem can only be estimated.
In 1986 there were over 830,000 reported incidents of aggravated assault
alone.[1] Victims of violence suffer psychological trauma, physical
injuries, disability, and death. In one year, aggravated assaults
accounted for 355,000 hospitalizations, 4 million lost workdays, and
$638 million in medical costs.[2] In addition to medical injuries,
violence can also produce fear, anxiety, and isolation in its
victims.[2] Assailants risk disrupted personal lives, damaging criminal
records, extended imprisonment, and, in some cases, capital
punishment.


Women are frequent victims of violence. About 90,000 rapes are reported
to the police each year, and 2-4 million women are abused each year by
their spouses.[1-6] Battering may occur in as many as 25% of couples,
and it is the cause of trauma injuries in 6% of women who visit the
emergency room.[7] Due to underreporting, the actual number of attacks
on women is thought to be considerably larger. In addition to the
physical injuries produced by such attacks, victims of spouse abuse can
also suffer psychological complications; they are more likely than are
other women to abuse alcohol and drugs, attempt suicide, and transfer
their aggression to children. Pregnant women are three times as likely
as nonpregnant women to be victims of abuse, and severe beatings can
endanger both mother and fetus.[8]


Between 1 and 2 million cases of child abuse are reported each year;
many additional cases are not reported.[4,5,9] Abused children
experience physical injuries such as bruises, burns, fractures, and
neurological and abdominal trauma. As many as 5000 die from their
injuries each year.[10] Child sexual abuse, which occurs in 100,000 to
500,000 children each year,[11] often results in severe psychological

trauma as well as in medical complications such as sexually transmit
diseases. Children who have been victims or witnesses of violence often
experience abnormal physical, social, and emotional development, and
many manifest violent behavior as adolescents and adults.[2,8] Elderly
persons are often as vulnerable as children; it is estimated that over
1.1 million persons over age 65 are victims of elder abuse, and in 86%
of cases the abuser is a relative.[12]


The most serious manifestation of violent behavior is homicide. Over
20,000 Americans were murdered during 1986.[1] Homicide is most common
in the young; along with suicide, it ranks fourth in causes of potential
years of life lost.[13] Studies indicate that about 56% of all murders
are committed by relatives (16%), friends (9%), or acquaintances
(31%).[1] In about 25% of homicides, either the victim or the killer has
a previous arrest record.[6,14] Persons at greatest risk of death by
homicide include minorities, young males, and those living in poor urban
communities.[4] Blacks are at especially increased risk.  One in 21
black males dies from homicide.[1] It is the leading cause of death in
black males aged 15-24.[4]


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 Area:    Feminism
  Msg:    #387
 Date:    11-07-94 10:40 (Public) 
 From:    Kathy Gerber             
 To:      All                      
 Subject: NIMH:Violent Injuries 2/4
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 Efficacy of Screening

The clinician can identify victims of violence through the patient
interview and the physical examination. The interview provides an
opportunity to ask the patient about previous experiences with violent
behavior, either as a perpetrator or victim, and about the presence of
risk factors for violence (e.g., firearms in the home). It has been
suggested that victims are more comfortable sharing this information
with physicians than with other professionals,[8] but the sensitivity
and specificity of such questions are not known. Many victims of
violence may be reluctant to expose details for fear of humiliation,
criticism, or punitive action directed at themselves or their loved
ones. Battered women may be fearful of terminating their relationship
with the abusive partner.[8] Children may be afraid of punishment, and
both young children and adults with cognitive impairment may be unable
to provide accurate details.  Other victims of violence may reveal
problems common in abused persons (e.g., substance abuse, headache,
fatigue, insomnia, and indigestion) which are not in themselves specific
for physical abuse. Some progress has been made in recent years in the
development of questionnaires to assess more precisely the risk of child
abuse,[15,16] but further validation of these instruments is needed.

The physical examination is a second means of detecting evidence of
abuse. Burns, bruises, and other lesions can be suggestive by their
appearance (e.g., patterns resembling hands, belts, cords, and other
weapons) or location (e.g., corporal punishment of children on buttocks,
lower back, upper thighs, and face). Multiple traumatic injuries without
a plausible explanation are also suspicious. The sensitivity and
specificity of this form of screening are not known, however. Physical
findings may not be apparent in many victims of abuse, such as sexually
abused children, and persons with suspicious injuries may not have been
victims of intentional injury. Errors in suspecting abuse are of great
concern because of the serious emotional, legal, and societal
implications of either failing to take action in cases of abuse or of
incorrectly accusing innocent persons.


Thus, there is currently no evidence on which to evaluate the accuracy
of the interview or the physical examination in detecting victims of
violence.  Some studies report that less than 10% of battered women are
accurately diagnosed by physicians, even in hospitals with an
established protocol for this problem.[6,8] It is not known, however,
how much of this high failure rate is due to patient reluctance to
disclose incidents, the types of questions or examination procedures
used, and/ or physician failure to consider violence as a possible
etiology.



Effectiveness of Early Detection


In addition to medical and psychiatric treatment for previous injuries,

potential victims of violence can be given information and counseling
from the clinician in an attempt to prevent future injuries or killings.
Specifically, patients can be advised about risk factors, such as
possession of firearms and substance abuse, that increase the likelihood
of serious harm in intentional injuries. About 60% of all homicides are
committed with firearms,[1] and at least 50% are associated with alcohol
use.[5] Psychological counseling, by either the primary care clinician
or a mental health professional, may help the patient terminate personal
relationships with violent individuals. The patient can also be provided
with telephone numbers and encouraged to contact community resources
such as crisis centers, shelters, protective service agencies, or the
police department if there is fear of injury. The clinician may also
identify individuals who are at increased risk of committing intentional
injuries in the future.  Such persons may be referred for psychiatric
counseling or family therapy to learn nonviolent alternatives to
conflict resolution and stress management. Finally, the clinician is
able (and, in many instances, required) to report suspected cases of
abuse and neglect to appropriate protective service and foster care
agencies. The efficacy of these measures is largely unstudied, however,
and the available evidence is inadequate to determine whether any of
these strategies are successful in preventing subsequent violent
injury.


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 Area:    Feminism
  Msg:    #388
 Date:    11-07-94 10:41 (Public) 
 From:    Kathy Gerber             
 To:      All                      
 Subject: NIMH:Violent Injuries 3/4
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Recommendations of Others


Although many groups advise counseling by clinicians to prevent
unintentional injuries (see Chapter 52), there are no specific
recommendations to screen patients for evidence of violent injury.
Legislation in all states requires health care professionals to report
suspected cases of child abuse,[10] and failure to report is a
prosecutable offense in 37 states.[9] Many states also require reporting
of abuse of elders and other adults. In addition to these regulatory
guidelines, recommendations for physicians on the detection and
treatment of child abuse have been issued by the American Medical
Association.[10] Guidelines for the prevention of sexual abuse have been
issued by the National Institute of Mental Health.[3] Recommendations
for clinicians on the identification of battered women have recently
been issued by the American College of Obstetricians and Gynecologists
and have been supported by the U.S. Surgeon General.[17] Finally,
recommendations for improved training of health care professionals in
the identification, treatment, and follow-up of victims of violence were
included in the 1986 report of the Secretary's Task Force on Black and
Minority Health.[4]


Discussion


The etiology of violent behavior is multifactorial; it is a function of
such variables as cultural attitudes toward violence, socioeconomic
conditions, biological factors, and the availability of weapons.[4]
Therefore, the clinician, as a single agent of change, will have
difficulty in preventing violent injury. There are also few data to
CPS Screening for Violent Injuries [21Apr94 15K] (p10
suggest that proposed interventions are efficacious in preventing
violence.  Nonetheless, efforts by clinicians to prevent violence are
justified because intentional injury and homicide are serious public
health problems in the United States; in young black males, homicide is
the leading cause of death. Although there is insufficient evidence to
support routine screening of all patients, it is important for
clinicians to maintain a high index of suspicion when examining persons
at increased risk of physical abuse (young children, pregnant women, and
the elderly), to assess potential risk factors for violent injury,
to refer potential victims and perpetrators to other professionals and
community services to help prevent future incidents.


Clinical Intervention


Routine screening interviews or examinations for evidence of violent
injuries are not recommended. Clinicians examining children should be
alert to the physical findings of child abuse.  Guidelines are available
to help clinicians interview children who are potential victims of
sexual abuse.[10,11] Suspected cases of child abuse or neglect must be

reported to local child protective services agencies. Both children and
adults who present with multiple injuries and an implausible explanation
should be evaluated with attention to possible abuse or neglect.
Specific guidelines are available for the evaluation of suspected
victims of spouse abuse.[6] Injured pregnant women and elderly patients
should receive special consideration for this problem.  Suspected case
of abuse should receive proper documentation of the incident and
physical findings (e.g., photographs, body maps); treatment of physical
injuries; arrangements for counseling by a skilled mental health
professional; and the telephone numbers of local crisis centers,
shelters, and protective service agencies. The safety of children of
victims of abuse should also be ensured.

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 Area:    Feminism
  Msg:    #389
 Date:    11-07-94 10:41 (Public) 
 From:    Kathy Gerber             
 To:      All                      
 Subject: NIMH:Violent Injuries 4/4
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Clinicians should ask adolescent and young adult males (aged 15-24) to
discuss previous violent behavior, current alcohol and drug use, and the
availability of handguns, shotguns, and rifles.  Patients with evidence
of violent behavior should be counseled regarding nonviolent
alternatives to conflict resolution and about the risks of violent
injury associated with easy access to firearms and intoxication with
alcohol or other drugs.


Note:  See also the relevant U.S. Preventive Services Task Force
background paper: Stolley P. Preventing homicide. In: Goldbloom RB,
Lawrence RS, eds.  Preventing disease: beyond the rhetoric. New York:
Springer-Verlag (in press).


References:
 1. Federal Bureau of Investigation. Uniform crime reports for
    the United States, 1986. Washington D.C.: Government Printing Office, 
    1987.
 2. Rosenberg ML, Gelles RJ, Holinger PC, et al. Violence:
    homicide, assault, and suicide. In: Amler RW, Dull HB, eds.
    Closing the gap: the burden of unnecessary illness. New York:
    Oxford University Press, 1987:164-78.
 3. National Institute of Mental Health. The evaluation and
    management of rape and sexual abuse: a physician's guide.
    National Center for Prevention and Control of Rape. Rockville,
    Md.: National Institute of Mental Health, 1985.  (Publication 
    no.DHHS (ADM) 85-1409.)
 4. Department of Health and Human Services. Report of the
    Secretary's Task Force on Black and Minority Health. Volume V:
    Homicide, suicide, and unintentional injuries. Washington D.C.:
    Government Printing Office, 1986.
 5. Silverman MM, Lalley TL, Rosenberg ML, et al. Control of stress and 
    violent behavior: mid-course review of the 1990 health objectives. 
    Public Health Rep 1988; 103:38-49.
 6. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in
    the medical setting: an introduction for health personnel. Monograph 
    Series No. 7. Rockville, Md.: National Clearinghouse on 
Domestic Violence, 
    1981.
 7. McLeer SV, Anwar R. A study of battered women presenting in an emergency 
    department. Am J Public Health 1989; 79:65-6.
 8. Mehta P, Dandrea LA. The battered woman. Am Fam Physician 1988; 37:193-9.
 9. Cupoli JM. Is it child abuse? Patient Care 1988; April:28-51.
10. American Medical Association. AMA diagnostic and treatment guidelines 
    concerning child abuse and neglect. Chicago,Ill.: American Medical 
    Association, 1985.
11. Schuh SE, Ralston ME. Medical interview of sexuallyabused children. 
    South Med J 1985; 78:245-51.
12. Council on Scientific Affairs. Elder abuse and neglect.JAMA 1987; 
    257:966-71.
13. Centers for Disease Control. Years of potential life lost before age 
    65-United States, 1987. MMWR 1989; 38:27-9.

14. Police Foundation. Domestic violence and the police:
    studies in Detroit and Kansas City. Washington, D.C.: Police Foundation, 
    1977.
15. Milner JS, Gold RG, Ayoub C, et al. Predictive validity of the Child 
    Abuse Potential Inventory. J Consult Clin Psychol 1984; 62:879-84.
16. Milner JS, Gold RG, Wimberley RC. Prediction and explanation of child 
    abuse: cross-validation of the Child Abuse Potential Inventory. J Consult 
    Clin Psychol 1986; 54: 865-6.
17. Raymond C. Campaign alerts physicians to identify, assist victims of 
    domestic violence. JAMA 1989; 261:963-4.

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