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]

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.

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.

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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