This column briefly reviews several critical areas in emergency psychiatry: domestic violence, sexual dangerousness, elder abuse, and child abuse. The epidemiology and risk factors of victims and perpetrators for each manifestation of violence are discussed, and advice is offered on clinical screening procedures in the emergency psychiatry department.
Nearly 2 million women per year are reported to be physically assaulted by their male partners, and one in four women in the United States will be physically abused during her lifetime (1). The demographic risk factors for domestic violence include age between 12 and 30; unmarried status, especially if cohabiting; presence of children in the home; previous disability; pregnancy; and homelessness (2). In addition, substance abuse increases risk substantially; up to 45 percent of female alcoholics and 50 percent of female drug abusers have been battered (2). However, women are not the only victims of domestic violence. Although men are less likely to have a history of abuse than women, they are more likely to be attacked by their partners with knives, guns, or thrown objects and to suffer serious injury or death as a result (2).
The victim can also be a perpetrator. In a committed relationship, when a woman assaults a man, the man has nearly always abused the woman (2). Other risk factors for domestic aggression include attitudes of patriarchy, which is defined as males having power over females in the home with respect to money, social interactions, and sex; exposure as a victim or witness to abuse in the family during childhood; unemployment; and current substance abuse (2). The strongest single predictor of injury to a victim of domestic assault is a history of alcohol abuse by the perpetrator (1).
Although many standardized measures of partner violence exist, including the Index of Spouse Abuse (3) and the Conflict Tactics Scale (4), they tend to be impractical for use in the emergency setting. However, newer measures such as the Spousal Assault Risk Assessment Guide (5) are quite promising in identifying domestic abusers. For victims, most clinicians find that the use of open-ended questions that are specific about typical behaviors yet nonjudgmental is effective in eliciting a history of domestic abuse (2). Others prefer to use the question, "Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?" (1). Whatever screening method is used, it is important to keep in mind that the greatest impediment to effectively identifying victims of violence is not that they conceal their status but that clinicians do not ask them to reveal it (2).
In the United States, between 300,000 and 700,000 adult women annually are victims of sexual assault. Thirteen to 18 percent of women will be raped in their lifetime, and of those, nearly 40 percent will be sexually assaulted more than once (6). In addition, up to a third of rape victims develop posttraumatic stress disorder, and a third suffer at least one major depressive episode in the year after the rape (6). Although sexual assault is most common among young women, men and older women also are victims of sexual assault. Men constitute 5 to 10 percent of noninstitutional assault victims, and older (postmenopausal) women constitute 2 to 3 percent of sexually assaulted women (6).
In 78 percent of cases of rape, the assailant is known to the victim. Most perpetrators of a sexual assault against both men and women are men who define their sexuality as heterosexual (6).
Although most identified rape victims will be triaged directly to a rape crisis treatment team, unreported victims may first present to a psychiatric emergency room. Screening for rape can be a difficult task, in part because the victim may feel too ashamed or guilty to talk about what happened or may not define the violation as rape—for example, in cases of spousal or date rape. Indeed, only 16 percent of rapes are reported to the police (6). Men, because they are more likely to exhibit reactions of control and denial, and older women, because they often harbor long-held biases against sexual assault victims, may present the clinician with particular difficulties in the attempt to elicit a history of sexual assault (6). However, by being alert for victims of sexual assault and by eliciting a sexual assault history in a calm, nonjudgmental, and impartial yet compassionate and supportive manner, the clinician can facilitate the transition from victim to survivor.
In evaluating a perpetrator, psychometric instruments such as the Psychopathy Checklist-Revised are warranted as part of the empirically guided clinical risk assessment (7).
In the United States the prevalence of abuse of people over 65 years old is 32 per 1,000 (8,9). The most common form of abuse is neglect, which accounts for 55 percent of reported cases, although physical abuse (14.6 percent) and financial exploitation (12.3 percent) are also common (10). The literature suggests that risk factors for abuse include advanced age, dependency, physical or cognitive impairment, conflicts, history of past abuse, and difficult or provocative behavior, such as wandering or being overly demanding (9,10,11).
However, the characteristics of the caregiver and not those of the victim are the stronger predictors of abuse. Perpetrator risk factors include substance abuse, psychiatric illness, psychosocial stressors, emotional or financial dependency, history of abuse, social isolation, inexperience in caregiving, and disinclination to provide care (9,10,11). The single most predictive factor for elder abuse is alcohol abuse by the caregiver (9,10). Although adult children are most commonly viewed as the major perpetrators of elder abuse, they constitute only 30 to 33 percent of the total (9). Spouses constitute 14 to 15 percent, and other relatives 9 to 20 percent.
Screening for elder abuse can be a challenging task because elderly persons often conceal the abuses they suffer. Victims may feel humiliated or responsible, they may worry about further abuse, or they may be concerned about being forced out of their homes. In addition, elderly persons often are loath to press charges against a family member (10). Numerous elder abuse assessment tools are available, and some newer tools such as the Indicators of Abuse screen are clinician-friendly and highly sensitive (84.4 percent), specific (99.2 percent), and reliable (11).
Nonetheless, to elicit an accurate history, most clinicians prefer simply to develop a strong rapport in the interview with either the person thought to be a victim or the potential abuser. Clinicians who are most successful ask direct and simple questions in a plain manner without being disparaging or intimidating (10). They often establish a nonconfrontational atmosphere by starting with general questions about safety in the home and caretaking concerns and then proceed to more direct queries about maltreatment—for example, exploring neglect and the use of physical violence and restraints (10).
Of the 3 million cases of child abuse reported annually, nearly 1 million are confirmed by child protective service agencies (12). Of those, 52 percent are cases of neglect, 24 percent of physical abuse, 12 percent of sexual abuse, and 6 percent of emotional mistreatment (12). Risk factors associated with maltreated children include residence in a single-parent household, especially if the father is the sole caretaker; age between three and 12; behavioral problems; large family size; and poverty (12,13). Of all the risk factors, poverty is the most strongly associated with abuse and with neglect in particular (13).
Caretaker factors that have been found to be associated with or contributory to child abuse and neglect include younger age, poverty, personal history of abuse, large family size, unplanned pregnancies, illicit drug and alcohol abuse, inadequate parenting skills, high incidence of low-birth-weight babies, and social isolation (12,13,14). Except in cases of sexual abuse, most abusers are parents (77 percent), are between 20 and 40 years of age (70 percent), and are slightly more likely to be female (12,13). Men are more likely to commit sexual abuse (13).
Assessing a parent or any adult for child abuse requires exquisite sensitivity and skillful questioning. Numerous risk assessment tools are available that can make the task easier. The Child Abuse Potential Inventory (15) is one of the most commonly used to measure aspects of parental functioning thought to contribute to child maltreatment, and it is considered both reliable and valid (12). However, use of an interview instrument alone cannot replace a thorough clinical interview. When confronted with a potential abuser, clinicians find that approaching the interview in a nonaccusatory, unbiased manner most effectively elicits a history of child abuse (13).
Evaluating a child who may be a victim of maltreatment presents clinicians with similar difficulties, especially if the child is reticent. Clinicians who are most successful interview the child alone, sit at the child's eye level, explain the purpose of the interview, use open-ended questions when possible, and do not display shock or horror at the child's descriptions (13). Rather, they demonstrate compassionate understanding and assure the child that he or she is in no way at fault (13).
Mental health clinicians generally advocate for their patients. It is an unsettling reality that our patients are not only the victims of domestic abuse, sexual assault, elder abuse, or child abuse but also the perpetrators of aggression. Sometimes they are both victim and victimizer. Patients may not be withholding a history of violence; rather, clinicians may not be asking about this important area in patients' lives. To give excellent care and prevent further harm, clinicians must explore why patients withhold information and why clinicians do not seek it.
Dr. Rudolph is a psychiatric resident at Boston University School of Medicine, 850 Harrison Avenue, Dowling 7 South, Boston, Massachusetts 02118-2394 (e-mail, firstname.lastname@example.org).Dr. Hughes, who is editor of this column, is associate professor of psychiatry at Boston University School of Medicine and director of the Solomon Carter Fuller Mental Health Center in Boston.