Case Study

RS, a 37-year-old woman, comes to your office with her four children and elderly mother, who lives with them, for their routine check-ups. She says that her husband has to miss his appointment that day because of work. You see RS first.

Case Study Questions

1. Which one of the following recommendations is consistent with the U.S. Preventive Services Task Force (USPSTF) recommendation statement about screening for family violence?

• A. Do not screen RS for intimate partner violence.

• B. Be alert to physical and behavioral signs and symptoms associated with abuse or neglect.

• C. Screen RS for intimate partner violence only if she is at high risk for abuse.

• D. Screen RS's mother for elder abuse.

• E. Screen the four children for child abuse and neglect.

2. Which of the following statements about screening for family violence is/are accurate?

• A. No studies have assessed the accuracy of screening tools for identifying family and intimate partner violence in women or older adults in the general population.

• B. Evidence supports the effectiveness of interventions for family violence in older adults.

• C. Home-visit programs directed at high-risk mothers decrease the incidence of child abuse and neglect.

• D. Evidence shows that there are no harmful effects from screening or interventions for family and intimate partner violence.

3. During the physical examination, you discover several bruises on RS's back and legs. She says that she is a “klutz” and has fallen several times. You note that she has visited the emergency department twice during the past six months for falls or injuries. Which of the following actions should you consider?

• A. Document any suspicious physical findings.

• B. Treat any acute physical injuries.

• C. Give RS the phone numbers of local crisis centers, shelters, and protective agencies.

• D. Do nothing. She must be ready to tell you the truth about her injuries before you can help her.

Answers

1. The correct answer is B. The USPSTF found insufficient evidence to recommend for or against routine screening of parents and guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse.

2. The correct answers are A and C. No studies have determined the accuracy of screening tools for identifying family and intimate partner violence in children, women, or older adults in the general population. Limited evidence suggests that self-administered screening instruments have fairly high sensitivity but low specificity for identifying future child maltreatment, particularly when questionnaires are provided to pregnant mothers. No studies have evaluated the performance of screening instruments using verified outcomes of reported intimate partner abuse. Few screening instruments are available for older adults who are potential victims of abuse, and none are widely validated.

No studies have examined the effectiveness of interventions for family and intimate partner violence in older adults. Evidence that interventions reduce harm to women is limited. However, fair to good evidence indicates that interventions reduce harm to children when child abuse or neglect has been assessed. A randomized controlled trial with 15 years of follow-up indicated that nurse home-visit programs for low-income, first-time mothers during the prenatal and two-year postpartum periods (such as the Nurse-Family Partnership program) can improve the short-term and long-term outcomes of child abuse and neglect.

No studies have directly addressed the harms of screening and interventions for family and intimate partner violence. One possible harm of screening is a false-positive test result (most common in low-risk populations) that may compromise the physician- patient relationship. Additional harms may include loss of contact with established support systems, psychologic distress, and escalation of abuse.

3. The correct answers are A, B, and C. As part of diagnosis or case finding, any suspicious physical findings should be documented in the patient's chart. After any acute physical injuries have been treated, the physician should provide the phone numbers of local crisis centers, shelters, and protective agencies. Reporting child and elder abuse to protective services is mandatory in most states, and several states require reporting intimate partner violence.