Module 2: Indicators of domestic violence

• Chronic conditions including headaches, pain and aches in muscles, joints and back
• 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 hostility
• Self-harm or suicide attempts
• Psychosomatic complaints
• Sleeping and eating disorders (e.g. anorexia, bulimia, binge eating)
• Depression/pre-natal depression
• Social isolation/no access to transport or money
• Submissive behaviour/low self-esteem
• Fear of physical contact
• Alcohol or drug abuse

• Frequent use of medical treatment in various facilities
• The constant change of doctors
• 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

• 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• Appearing nervous and withdrawn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⁽³⁾
• 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

• Observation of behavioural problems of a child or an adolescent
• Documentation
• Reflection on the observation
• Assumptions about possible causes for the child’s or adolescent’s behaviour (forming hypotheses)
• Involvement of a colleague
• Team meeting (collegial consultation)
• Involvement of the management
• Decision on how to proceed and agree on further steps of action

The last step, “decision on how to proceed and agree on further steps of action”, must be organised individually depending on the case. One possibility would be to talk to the respective child’s or adolescent’s mother and/or father. In the first place, the observed and documented behavioural problems of the child or the adolescent should be discussed. If it becomes clear that the mother or father could be affected by domestic violence, then it is important to have another conversation with him or her in private. Confidentiality should always be assured and information about help options such as counselling centres, anonymous telephone counselling, etc. should be given.

The cooperation with the mother and father as educational partners should be very sensitive and thus be secured in the long term. If mothers and/or fathers are not willing to work on the problems and make use of help offers, then cooperation with other institutions without the parents’ consent is only possible if the child’s or adolescent’s well-being seems to be at risk. Otherwise the school must guarantee data protection. However, it is possible to get advice from different help organisations by phone or in person without revealing the data of the family concerned. If the child’s or adolescent’s well-being is at risk, the youth welfare office must be informed. The child’s or adolescent’s well-being takes precedence over data protection. Also, for the clarification of a possible endangerment of the child’s or adolescent’s well-being, the youth welfare office can first be consulted while preserving the anonymity of the family concerned, to then be able to decide on further steps, e.g., to officially involve the youth welfare office.

You can discuss your own feelings, uncertainties and fears with colleagues, counselling centres or the district youth welfare office. Be careful and cautious with your suspicions to avoid uncontrolled actions by other people. Everything you do must be in the best interest of the child or young person.

Conspicuous behaviour can also have very different reasons: a child or adolescent may be in a difficult life situation, perhaps parents are getting divorced, or important caregivers such as grandparents have died. However, a possible cause for conspicuous behaviour can also be witnessing domestic violence or being a victim of domestic violence. It is always important to ask yourself the following: what is the basis for the suspicion? Are abuse, neglect, sexual abuse, or domestic violence the only explanation for the child’s or adolescent’s behaviour? Are there are other possible causes?

Example: physical violence

Alice always has some kind of injury – mostly bruises. The other children have also noticed this. Anyone who asks the five-year-old girl about it always gets new explanations and stories that all have one thing in common: apparently, it is always she herself who has sustained the injuries in her clumsiness. Sometimes she fell down the stairs, sometimes she fell off her bicycle.

But anyone who knows Alice knows that she is anything but clumsy. The teacher also becomes suspicious, because the explanations do not really “fit” the injuries. The other children tell her that Alice’s parents are strict. They punish their daughter for little things like being late. She is not allowed to make any appointments.

When Alice does not come to the day care centre one day, the teacher dares to visit her at home. The parents refuse to let her into their home and say that the child is not there. She then calls the police, who find Alice locked in her nursery, covered in bruises and welts, her mouth taped shut with parcel tape. When the police ask how the massive head injury came about, the parents explain that their daughter had run into the cupboard with her head out of anger.

Source: Handout to promote the recognition of child abuse and the adequate handling of suspected cases (only in German)

Example: psychological violence

Tom is actually quite fat for his eleven years. He has less and less contact with his classmates and no longer takes part in any group activities. It is not the others who tease him, but Tom, who withdraws more and more. He is frighteningly passive.

He also participates less and less in class and seems somehow insecure and afraid. When his transfer is threatened, the parents are invited to a meeting at school. Only the mother shows up for the meeting.

During the conversation with the teacher, it quickly becomes clear that she has a very distant attitude towards her son. She disparagingly calls him stupid and ugly. With regard to his transfer, she indifferently says, “If he doesn’t change, he will have to bear the consequences.”

After the conversation with the teacher, Tom meets his mother and the teacher as he is leaving the classroom with his class. His mother speaks to him in front of the teacher and his classmates, “You’re useless, I’m only in trouble because of you. “

Source: Handout to promote the recognition of child abuse and the adequate handling of suspected cases (only in German)

Example: neglect

Late again! Leo sneaks into the classroom and hopes that the teacher doesn’t notice that he hasn’t managed to arrive on time again. It’s not the first time that the twelve-year-old has been late for school, and he nods off several times during the first lesson. Books and exercise books: missing! Most of the time, he doesn’t have a packed lunch either. He has long since outgrown his trousers, his jumpers are worn out, and no one wants to sit next to him. “You stink!”, the others say.

The teacher is worried about the boy, who seems somehow neglected, but the mother does not respond to her letters. She also ignores the parents’ evenings. But when the teacher asks Leo himself, he always has conclusive explanations ready as to why the mother can’t come.

When Leo’s little sister, who attends the same school, is supposed to take part in a school trip, but the referral of the payment is not made, an appointment is made with the mother, the teacher, and the youth welfare office at the school. The mother does not show up, whereupon Leo is asked about her whereabouts. Then the boy breaks down crying and reports that the mother has been living with her boyfriend for three quarters of a year and only shows up at the flat now and then to leave five euros for groceries. During this entire period, Leo has had to bear the responsibility for the entire household, the totally neglected flat and his three younger siblings.

Source: Handout to promote the recognition of child abuse and the adequate handling of suspected cases (only in German)

Inform yourself through further training on this topic to reduce your own uncertainties and fears.

Here you can find further education and training offers in the field of domestic violence in the social sector.

Gabby married her husband Nick after a long relationship and shortly thereafter moved to her husband’s family farm. The couple was happy at the farm and soon had their first child. During the pregnancy Nick’s behaviour began to change and by the time their daughter was born the relationship did not ‘feel’ as it had before. Nick seemed withdrawn and spent long periods of time by himself. He began to remind Gabby of Nick’s father who had always been a stern presence in his life.

Nick’s behaviour became threatening and controlling, especially in relation to money and social contact. He was increasingly aggressive in arguments and would often shout and throw objects around the room. Gabby thought that, because he wasn’t physically hurting her, his behaviour did not qualify as abuse. Nick did not show much interest in their daughter, Jane, except when in public, where he would appear to be a doting and loving father.

Jane was generally a well-behaved child, however, Gabby found that she was unable to leave her with anyone else. Jane would cry and become visibly distressed when Gabby handed her to someone else to be nursed. This was stressful for Gabby, and also meant that her social activities were limited further.

Jane took a long time to crawl, walk and begin talking. Her sleeping patterns were interrupted, and Gabby often did not sleep through the night, even when Jane was over 12 months of age. When Jane did begin to talk, she developed a stutter, and this further impeded her speech development. Gabby worried about Jane a lot. Their family doctor told her that this was normal for some children and that, if the speech problems persisted, she could always send Jane to a specialist at a later date.

After a number of years, Nick’s behaviour became unacceptable to Gabby. During arguments he would now hold on to the rifle that he had for farming purposes, and Gabby found this very threatening. On a number of occasions, items that Nick threw hit Gabby and she was increasingly afraid for their daughter. Gabby decided to leave and consulted the local women’s service, who assisted her to get an intervention order against Nick.

Once Gabby had taken Jane away from Nick, her behaviour changed. Jane’s development seemed to speed up and Gabby couldn’t understand why. As part of her counselling at a local women’s service, she discussed this issue, and her counsellor recognised the developmental delay, stutter, irritation, and separation anxiety as effects of Jane’s previously abusive situation.

This can be seen as a missed opportunity for identifying family violence. If the family doctor would have asked Gabby or Nick (who had presented with chronic back pain) about their relationship, about what was happening to the family, and specifically to Jane, the situation could have been identified much earlier.

The wide range of professionals, provider services and specialist agencies who may be involved in supporting victim-survivors of domestic violence can include—but are not limited to—primary and secondary health care services, mental health services, sexual violence services, social care, criminal justice agencies, the police, probation, youth justice, substance misuse, specialist domestic violence agencies, children’s services, housing services and education.

Adapted from a case study from RACGP (2014): Abuse and Violence: Working with our patients in general practice

https://www.abuseisnotlove.com/de-de/signs

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https://eige.europa.eu/gender-based-violence/eiges-work-gender-based-violence/intimate-partner-violence-and-witness-intervention?lang=sl

Mota-Rojas D, Monsalve S, Lezama-García K, Mora-Medina P, Domínguez-Oliva A, Ramírez-Necoechea R, Garcia RdCM (2022). Animal Abuse as an Indicator of Domestic Violence: One Health, One Welfare Approach. Animals. 12(8):977. https://doi.org/10.3390/ani12080977

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Women’s Legal Service NSW (2019): When she talks to you about the violence – A toolkit for GPs in NSW: https://www.wlsnsw.org.au/wp-content/uploads/GP-toolkit-updated-Oct2019.pdf

Western Australian Family and Domestic Violence Common Risk Assessment and Risk Management Framework (2023), Factsheet: https://www.wa.gov.au/system/files/2021-10/CRARMF-Fact-Sheet-2-Indicators-of-FDV.pdf

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Violence against children and adolescent – What to do? A guide for Berlin educators and teachers (only in German)

Handout to promote the recognition of child abuse and the adequate handling of suspected cases (only in German)