The American Academy of Neurology position statement on abuse and violence

PURPOSE OF THE POSITION STATEMENT

The consequences of not asking about IPV might include further physical and emotional harm, treatment failure, and when children are exposed, perpetuation of the intergenerational cycle of abuse.^13,–,15 Providing resources to those being abused can result in improved outcomes.¹⁶ Further, identification of an abuse history may influence the assessment and treatment of presenting health concerns.^17,18 By identifying this issue, and providing an appropriate referral, neurologists may improve quality of life and potentially ameliorate neurologic disability. The AAN is endorsing the assessment of abuse and neglect in our patients and supports the education of the neurologic community to achieve this end. Additional research on the physiologic and psychological consequences of abuse may lead to better treatment strategies to prevent related adverse health outcomes.

DEFINITIONS OF ABUSE

Abuse may be defined in a variety of ways. The following definitions are from Kruger and Moon.¹⁹

• Physical abuse: A willful act carried out with the intent of causing pain or injury.

• Emotional abuse (including bullying and financial abuse): Willful act executed to cause emotional pain, injury, or mental anguish.

• Sexual abuse: Nonconsensual sexual activity.

• Child abuse: Any type of cruelty inflicted upon a child.

• Elder abuse: Abuse or neglect of an individual 65 years of age or older, and those who are physically or mentally disabled.

ABUSE AND ITS RELATIONSHIP TO NEUROLOGIC DISEASES

Abuse can effect the development of neurologic disease. More than 90% of all injuries from IPV occur to the head, face, or neck region^20,21 and may be associated with traumatic brain injury (TBI). The consequences of lifetime exposure to violence and abuse commonly include neurologic problems.²⁰ The short- and long-term consequences of adverse childhood experiences, including abuse and neglect, can result in a multitude of physical and social problems.²² Headaches,^23,–,28 fibromyalgia, chronic pain syndromes, syncope, and psychogenic nonepileptic seizure have been linked to abuse.^29,–,32 In addition, adults who were exposed to parental verbal abuse experienced higher rates of depression, irritability, and somatization.³³ Finally, patients with physical (e.g., Parkinson disease or stroke) and mental disabilities (e.g., Alzheimer disease) are at higher risk for being abused or neglected than their counterparts.^34,–,36

PRINCIPLES OF INTERVENTION IN ABUSE AND NEGLECT

1. The physician should routinely screen all patients for past and ongoing violence, fully integrating the questions into the medical history.

2. Patients should be treated with respect and dignity.

3. Optimally, patients should be questioned when alone. This is essential when questioning children about abuse.

4. If spousal abuse is present, ask if child abuse is also occurring.

5. Do not blame patients or force them to prove their “victimhood.”

6. Document the abuse as reported (who, what, where, when, and what type).

7. Use established protocols once abuse is identified. Most guidelines for managing IPV are based on the emergency medicine literature. Specific treatment interventions for women exposed to violence have not been adequately evaluated.³⁷ The AMA³⁸ suggests assessing immediate risk, providing police and legal options, safety planning, and providing intervention to assess depression.

8. Child abuse, elder abuse, and abuse of those who are disabled must be reported in all states. Spousal abuse must be reported in California, Colorado, Kentucky, New Hampshire, New York, and Rhode Island.

9. Provide resources. The aim of the neurologist should be to identify abuse and support the patient through referral.³⁹ Social workers, victim advocates, hospital staff, support group leaders, hotlines, and Web site resources are all reasonable options.

10. Neurologists should support multidisciplinary efforts to recognize, treat, and prevent abuse and IPV.

SUGGESTED ASSESSMENT QUESTIONS AND STRATEGIES

Patients often need to be asked multiple times before acknowledging abuse.

Information gathering can occur by having new patients fill out a questionnaire in the office or at home. Questions on abuse can be listed in the social history section. If answered in the affirmative, clarify whether the abuse is sexual, emotional/financial, or physical. When self-administered questionnaires are followed by a brief discussion of the subject, the most reliable responses are obtained.⁴⁰

Patients may also be asked about abuse directly. These questions may include the following:

• Have you ever witnessed violence?

• Have you ever been hit, kicked, punched, or otherwise physically abused?

• Has anyone ever tried to control you by threat or intimidation?

• Have you ever felt controlled or isolated by your partner?

• Have you ever been forced to perform sexual acts?

• Have you ever been taken advantage of financially?

• Have you ever been concerned for your safety?

Regardless of whether patients are currently being abused or have been abused in the past, offer a referral to a support group or domestic violence advocate.

For patients currently being abused, enlist in-depth safety planning by a trained health care provider, social worker, or abuse prevention advocate, and encourage patients to utilize advocacy services in conjunction with mental health services, if indicated.⁴¹

For patients with a past history of abuse, help the patient to understand how a history of victimization may be related to current or past health problems and risk behaviors, and explain to the patient that survivors can benefit from advocacy and counseling services even if the abuse was many years or decades earlier.

PATIENT RESOURCES

• National Domestic Violence Hotline, 1-800-799-SAFE (7233) or TTY 1-800-787-3224; www.thehotline.org

• National Sexual Assault Hotline, 1-800-656-4673; www.rainn.org

• Futures Without Violence (formerly Family Violence Prevention Fund/Health Resource Center), 1-800-799-7233; www.futureswithoutviolence.org

• National Clearinghouse on Abuse in Later Life; www.ncal.us

• National Organization for Victim Assistance (NOVA), 1-800-879-6682; www.trynova.org

• National Resource Center on Domestic Violence

• Manweb: A Web site with information for battered men; www.batteredmen.com

• Child Welfare Information Gateway; www.childwelfare.gov/responding/reporting.cfm

• National Center on Elder Abuse, 302-831-3525; www.ncea.aoa.gov

PHYSICIAN RESOURCES

• Futures Without Violence (www.futureswithoutviolence.org)

• Centers for Disease Control and Prevention

• Academy on Violence and Abuse

• ACOG: Violence against Women

• ACE_Score_1 pg Calculator²²

AUTHOR CONTRIBUTIONS

Dr. Schulman: drafting/revising the manuscript, study concept or design, acquisition of data. Dr. Hohler: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data, statistical analysis, study supervision.