Module 2: Indicators of domestic violence

Sabrina is an accountant, 30 years old, married to a construction worker for 8 years now. She tells her primary care physician about her low energy level and headaches that have affected her for over a year. The headaches have gotten worse in the past month, affecting her mostly at the end of the day and she gets hopeless and feels down.

She has trouble sleeping and reports pain all over. She has been to several physicians in the past year but has not found anything that could help her. She has had blood tests, been prescribed painkillers, been advised to get more exercise and change her diet. She tells her physician that she desperately needs something to be done for her today as her husband is getting impatient with the lack of results.

Task for reflection
(1) Reflect on the importance of routinely screening patients for domestic violence, even when they present with seemingly unrelated symptoms.

When Elyse, a 28-year-old nurse developed debilitating irritable bowel symptoms (IBS), she went to a new primary care physician. In response to the physicians detailed questions as part of initial assessment, Elyse told her that work was okay but she was having a few problems with her boyfriend. Sex was sometimes painful, but she tried not to show it. She had occasional migraines, her periods were heavy and painful and she was treated with antidepressants for 3 years in her early twenties. She was a binge drinker as a teenager. She’d only ever had one Pap smear 8 years ago and it was excruciating.

Case adapted from The Medical Women’s International Association’s Interactive Violence Manual.

• Chronic conditions including headaches, pain and aches in muscles, joints and back ¹⁸
• Difficulty eating/sleeping
• Cardiologic symptoms without evidence of cardiac disease (heart palpitation, arterial hypertension, myocardial infarction without obstructive disease)

• Emotional distress, e.g., anxiety, indecisiveness, confusion, and hostility¹⁹
• Self-harm or suicide attempts ²⁰
• Psychosomatic complaints
• Sleeping and eating disorders (e.g. anorexia, bulimia, binge eating) ²¹
• Depression/pre-natal depression ²²
• Social isolation/no access to transport or money²³
• Submissive behaviour/low self-esteem ²⁴
• Fear of physical contact ²⁵
• Alcohol or drug abuse ^{26 27}

• Frequent use of medical treatment in various facilities
• The constant change of doctors ²⁸
• Disproportionately long-time interval between the occurrence of injury and treatment
• Faltering response when being asked about medical history
• Denial, conflicting explanations about the cause of the injury
• Overprotective behaviour of the accompanying person, controlling behaviour
• Frequent absence from work or studies
• Evasive or ashamed about injuries
• Seeming anxious in the presence of their partner or family members
• Nervous reactions to physical contact/quick and unexpected movements
• Easily startled behaviour
• Easily crying when being asked questions
• Extreme defensive reactions when asked specific questions

• Lack of basic hygiene
• Wet diapers
• Missing medical aids like walkers, dentures
• Bedsores, pressure ulcers
• Caregiver speaks about the elder as if he/she was a burden

• Injuries to the genitals, the inside of the thighs, the breasts, the anus
• Irritations and redness in the genital area
• Common infections in the genital area
• Pain in the lower abdomen and/or pelvic area
• Sexually transmitted diseases
• Bleeding in the vaginal or rectal area
• Pain when urinating or defecating
• Pain when sitting or walking
• Strong fears of examinations in the genital area; avoidance of examinations
• Severe cramps in the vaginal area during gynaecological examinations
• Sexual problems
• Self-harming behaviour
• Unwanted pregnancies/abortions (obstetrics)
• Complications during pregnancy (obstetrics)²⁹
• Miscarriages (obstetrics) ³⁰

• Physical injuries/bruises: legs and/or vaginal area of women (-> victim of domestic violence or of rape)
• Missed appointments and non-compliance with treatment
• Frequent presentations to health settings or delay in seeking medical treatment/advice
• Overbearing or overly solicitous partner who is always present
• Injuries at different stages of healing or that don’t fit with the explanation given
• Unwanted pregnancy or termination of pregnancy
• Sexually transmitted infections (STIs)
• Sexual dysfunction
• Gynaecological problems
• Menstrual cycle or fertility issues in women
• Low maternal weight-gain
• Victim appears evasive, socially withdrawn and is hesitant
• Children currently referred to other specialists for behavioural/emotional or developmental problems
• Known history of abuse in family of origin
• Chronic pelvic pain
• Chronic irritable bowel syndrome³³
• Miscarriage or other pregnancy complications
• Premature birth ³⁴
• Stillbirth
• Fetal growth restriction (FGR)

• Restlessness, nervousness, fear and pain (specifically in connection with vaginal examination)
• Suicide attempts and thoughts
• Inadequate/delayed prenatal care
• Frequent hospital or clinic visits, especially when presenting with varied or unexplainable injuries or symptoms
• Substance use
• Presence of justified trauma with a confusing and contradictory history
• Continuous undefined health concerns and an anxious state that cannot be sedated with health reassurance
• Difficulty following health prescriptions, failure to respond to prescribed treatments
• Missing appointments
• Refusal of home visits by social workers, family or paediatric counselling staff

• Controlling partner behaviours: overprotective/speak for the woman
• The accompanying partner is e.g. nervous, bad-tempered, aggressive, impetuous, arrogant, pushy

• Postpartum depression of mother
• Maternal death
• Difficulties bonding with the new-born
• Babies with low birthweight/injury/death

Mandy was a 23-year-old patient currently 28 weeks pregnant. I attended her birth and have been her doctor since then. I knew her quite well as she had asthma and spent more than the usual time in my office. I also looked after her mother and sister and grandmother.

She did not do well in school and hung with the rough crowd. Although we had talked about contraception on previous visits, she was unreliable taking her birth control pills. Therefore, it was not a surprise to find her presenting to my office for pregnancy care. Her relationship was unstable but at present she was living with the baby’s father, an El Salvadorian immigrant involved in the drug trade. The pregnancy was progressing uneventfully until one day Mandy presented with facial bruising and abdominal pain.

Case adapted from The Medical Women’s International Association’s Interactive Violence Manual.

• Victims of domestic violence receive radiological examinations more often, especially for physical trauma
• Unexplained or multiple injuries
• Especially head, neck, and facial injuries
• Bruises of various ages
• Injuries do not fit the history given
• Bite marks, unusual burns
• Injuries on parts of the body hidden from view (including breasts, abdomen and/or genitals), especially if pregnant
• Chapped lips
• Teeth knocked out
• Uncomfortable/unusual atmosphere, fear, hierarchy
• The accompanying persons answers all questions
• The history about the injury does not fit to the injuries

• Described history is not consistent with injuries.
• Unusual injuries, e.g.
  • Severe injuries of any kind
  • Frequent fractures
  • Very pronounced injuries of any kind
  • Unusual appearance (e.g., patterned injuries, such as bite marks)
  • Unusual (“protected”) localisation of injuries (including lips, teeth, oral cavity, eyelids, earlobes, buttocks, genitals, fingertips, etc.)
  • Untreated (old) injuries
  • Unexplained injuries in non-mobile children
  • Injury “inappropriate” for the child’s age; healthy /infants do not have bruises. Even small, medically irrelevant bruises indicate inappropriate handling of the child

Caution: Severe internal injuries (e.g., fractures) may lack external injuries! Shaking an infant is life-threatening – and also not externally visible.

• Contusions affecting the inner arms, inner thighs, palms, soles, scalp, ear (pinna), mastoid area, buttocks
• Multiple and clustered contusions
• Abrasions to the axillary area (from restraints) or the wrist and ankles (from ligatures)
• Nasal bridge and temple injury (from being struck while wearing eyeglasses)
• Periorbital ecchymoses
• Oral injury
• Unusual alopecia pattern
• Untreated pressure injuries or ulcers in non-lumbosacral areas
• Untreated fractures
• Fractures not involving the hip, humerus, or vertebra
• Injuries in various stages of evolution
• Injuries to the eyes or nose
• Contact burns and scalds
• Scalp haemorrhage or hematoma

A patient on my list for over 10 years, aged 87 years, lived after her daughter’s death with her son-in-law in a detached family house. The patient was suffering from cardiac insufficiency and repeatedly she came with injuries and excoriations on her legs to my private practice. “She is always running down the stairs too quickly!” said the son-in-law who accompanied her. His behaviour was then rather uncooperative and “strange”. The patient insisted that she was kindly well nursed by him and a niece with a nurse living nearby looked after her.”

Case from The Medical Women’s International Association’s Interactive Violence Manual

• Injuries to the reproductive organs (also during pregnancy, e.g., chorionic hematoma)
• Acute fractures (especially in the facial region, e.g., nasal bone fracture, orbital floor fracture; but also fractures of the extremities)
• Subacute and temporally indeterminate fractures (especially face, extremities, and spine)
• Soft tissue injuries (e.g., hematoma and laceration)

• Radiological findings and imaging data contribute to the documentation of the extent of physical injuries.
• However, the injury patterns of adult victims of domestic violence are similar to those of other causes of injury.
• The positive predictive value of a radiological examination alone for the possible presence of domestic violence is limited but can be better assessed and thus increased by considering the overall clinical context.
• This can include injury patterns that do not match the medical history, the presentation of multiple injuries of different ages and frequent radiological examinations in the past.
• The radiologist’s complementary view of the case and the often somewhat calmer situation when preparing and reporting the findings of the examinations (compared to the emergency room) can thus facilitate the detection of domestic violence.

• Slow weight gain (in infants)
• Noticeable examination findings or other indications of neglect
• Lack of or inadequate medical care for illnesses
• Poor care condition of the child
• Poor nutritional state of the child or extreme obesity
• Inappropriate clothing e.g. wearing long-sleeved clothing and trousers in hot weather
• Difficulty eating/sleeping
• Physical complaints
• Eating disorders (including problems of breast feeding)

• Aggressive behaviour and language, constant fighting with peers
• Passivity, submission
• Appearing nervous and withdrawn
• Difficulty adjusting to change
• Regressive behaviour in toddlers
• Speech development disorders
• Psychosomatic illness
• Restlessness and problems with concentration
• Dependent, sad, or secretive behaviour
• Bedwetting
• ‘Acting out’, for example animal abuse ⁴⁰
• Noticeable decline in school performance
• Unexplained absences from school
• Overprotective or afraid to leave mother or father
• Stealing and social isolation
• Exhibiting sexually abusive behaviour
• Feelings of worthlessness
• Transience
• Lack of personal boundaries
• Depression, anxiety, and/or suicide attempts

• Described history is not consistent with injuries.
• Unusual injuries, e.g.
  • Severe injuries of any kind
  • Frequent fractures
  • Unusual appearance (e.g., patterned injuries, such as bite marks)
  • Unusual (“protected”) localisation of injuries (including lips, teeth, oral cavity, eyelids, earlobes, buttocks, genitals, fingertips, etc.)
  • Untreated (old) injuries
  • Unexplained injuries in non-mobile children
  • Injury “unusual” for the child’s age; healthy /infants do not have bruises. Even small, medically irrelevant bruises indicate inappropriate handling of the child
• Injuries due to forced or careless feeding
  • Contusions (tissue bruising) of the lips or gingiva (due to extreme feeding)
  • Burns because the food was too hot
  • Forced feeding with bottle: upper incisors intruded lingually, gums show round tear from plastic ring on rubber teat

Caution: Severe internal injuries (e.g., fractures) may lack external injuries! Shaking an infant is life-threatening – and also not externally visible.

• Psychological abnormalities/illnesses in the parents/mother/father
• Signs of parental issues (e.g., aggression, potential for violence, delinquency, lack of education, marital conflicts)
• Families experiencing psychosocial stressors (e.g., poverty, unemployment, early and/or single parenthood, linguistic isolation, multiple births, child developmental delays)
• Substance use (regardless of the substance) and other addictions in parents (e.g., gambling, sexual, and shopping addiction)
• Inability of parents to correctly interpret and respond to signals from a /infant/child; inability to meet the needs of the new-born/infant/child; lack of attachment to the new-born /infant/child
• Lack of cooperation/therapy compliance on the part of parents e.g.:
  • Failure to follow recommendations of the medical personal, inadequate care of chronically ill children by parents
  • Failure to administer (regular) medication to the child, skipping the child’s check-up appointments
  • Failure to attend (follow-up) appointments after illness/injury, frequent unexcused absences from treatment appointments; conspicuously frequent cancellations of treatment appointments

This case is about Daniel, a 4-year-old boy, and his mother Ms. Luscak, aged 27 years who had four different partners. She misuses alcohol and depicts occasional violence towards her partners. She speaks little English. Daniel had 2 siblings, a 7-year-old sister Anna by mum’s first partner and a 1-year-old brother Adam by mum’s fourth partner, Mr. A. On 27 different occasions, the police were called to domestic violence incidents often complicated by both parents being drunk. On 2 occasions Daniel’s mum took sleeping pill overdoses with the intention of committing suicide. The family moved house on numerous occasions due to an inability to pay rent. When pregnant with Adam, Mr. A. urged Ms. Luscak to have a termination. She missed 4 antenatal appointments. At one stage she was hospitalised and Mr. A took the drip out of her arm and she self-discharged.

Daniel had a spiral fracture to the left arm reported as due to jumping off the settee with his sister the previous when being seen at the emergency room. Bruises on his shoulder and lower tummy were explained by his mother to be due to falling off his bike regularly. Meetings of health care professionals took place but the long history of domestic violence was not considered. When Daniel started school, there were frequent absences as for his sister Anna. Teachers became concerned as Daniel was getting markedly thinner and always seemed hungry, taking food from lunchboxes of other children. Daniel had poor English and was a shy and reserved boy and did not talk to the teachers.

Case adapted from The Medical Women’s International Association’s Interactive Violence Manual

(Maxillo)fascial trauma is damage to the soft tissues or bones of the face that can be caused by a traumatic injury such as a fall, collision or blow.

• Perform a head-and-neck examination.
• Evaluate the temporomandibular joint: if there was trauma it could be a sign of violence or abuse.
• Assess any injuries to lips, tongue, palate, frenules caused by repeated trauma from violence. If so, assess especially the different temporal location.
• Inspect skin for abrasions, bruises, healing burns, non-self-inflicted bite marks; Inspect eyes and nose (e.g., ecchymoses, hematomas, petechiae)
• Evaluate fractures that occur at the front of the skull. They are often the result of direct trauma to the forehead. Frontal bone fractures can manifest in a variety of ways: from initial pain and swelling to visible bruising, and in some cases, may even alter the shape of the forehead.
• Assess fractures of the nose, among the most common injuries when it comes to facial trauma.
• Assess fractures of the bony socket of the eye and prominent cheek bones, among are among the most delicate and complex to treat. They can affect the mobility of the eye and cause swelling and bruising.
• Evaluate a fracture of the upper jaw that can seriously affect daily function.
• Assess trauma to the rounded end of the mandible that connects to the temporal bone of the skull. Fractures of the mandible, or the lower jaw, represent one of the most challenging facial traumas to manage.  In addition to impairing normal mouth function, affecting the ability to open and close the mouth properly. These fractures can manifest a range of symptoms in addition to pain, such as anaesthesia, paraesthesia, and dysesthesia. Some patients may also report hypoesthesia or hyperesthesia.
• Assess fractures of the mandibular condyle, involving the rounded parts of the mandible, those that form a joint with the temporal bone of the skull, allowing us to open and close the mouth. In addition to pain, an injury in this area can seriously impair the mobility of the mouth.
• Evaluate fractures involving both the upper jaw and mandible, which are particularly complex since they affect both the upper and lower mouth. This type of trauma can have drastic effects on normal oral function, limiting the ability to chew, speak and even breathe.
• Assess facial smashing, which indicates multiple simultaneous fractures in different areas of the face and involving most, if not all, of the facial bones. Facial smashing can lead to combined fractures, making the facial bones particularly unstable. This instability can cause movement and deformation of bone fragments, compromising the structural integrity of the skull and face.

The English Society of Paediatric Dentistry:

“Dental neglect is defined as the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of the child’s oral or general health or development” ⁷¹

“Teat bottle caries” as a manifestation of child neglect: ⁷⁴

• Carious milk tooth disease, which occurs after the eruption of the first milk teeth until the beginning of the change of teeth at the latest (6th year of life).
• Cause: sugary drinks given via feeding bottles combined with inadequate dental care.

3 degrees of severity according to Wyne:

Type 1: Mild to moderate
– Isolated carious lesions on milk molars and milk incisors.

Type 2: Moderate to severe
– Carious lesions on the palatal surfaces of the deciduous incisors in the upper jaw, lower teeth are caries-free.
– Depending on age, the deciduous molars are also affected.

Type 3: Severe
– Carious lesions on almost all deciduous teeth, including the lower incisors.
– Areas are affected that only rarely show caries.

Initial caries or early forms of early childhood caries on the upper milk incisors:

3A) Inactivated initial caries on the upper incisors. The whitish bands are now shiny and smooth due to remineralisation. The localisation suggests that teeth were not brushed, especially in the first year of life, but that this has now been done well for some time, i.e. the recommendations have been followed.

3B) Maxillary anterior teeth with caries, which could only be recognised after removal of massive plaque, in a 12-month-old child represent an early marker for neglect of at least oral care. This is not only due to a temporary lack of dental care, but also to a high frequency of consumption of sugary drinks via the teat bottle. Fortunately, a change in cleaning and eating habits could inactivate caries and prevent toothache and subsequent treatment.

4A) Teeth brushing appears to have improved significantly following information/instruction provided by the parents during the preliminary visits for brushing at home. Clinically, there is no evidence of a dentogenic fistula or even an abscess. The degree of inactivation of the extensive lesions suggests a significant improvement, i.e. a longer-lasting change in behaviour with regard to oral hygiene at home and diet.

4B) Here too, the degree of inactivation of the large affected carious teeth indicates a significant change in behaviour with regard to oral hygiene at home and diet. However, mature dental plaque is still partially visible and an abscess in region 54 can be diagnosed, which is associated with a previous pulp necrosis with pain and the risk of a tendency to spread towards the eye. Acute dental treatment is therefore required here, which may be carried out under anaesthetic due to the large scope of treatment for this small child.

A little girl comes to your dental practice with her mother. She is about five years old. You notice that the girl, unlike most other girls her age, is very quiet and anxious. She is also much smaller and thinner. You also notice that the girl is wearing clothes that are clearly dirty. She also does poorly during your examination, and all of her existing milk teeth are severely damaged by decay. The girl tells you that some of her teeth hurt. The mother states that the teeth have actually been darkly discoloured for the whole time, i.e. for several years.

Task for reflection
(1) What could be possible causes or reasons for the child’s poor dental status?

A young boy is coming to your dental practice. He presents with this dental status.

Task for reflection
(1) Please look at this photo. Please describe what you see.
(2) What is your diagnosis? What may be the reason for this poor dental status?
(3) What would you do as dentist as next steps?