Family Intervention Services
Abuse / Neglect Self Study
Objectives: At the completion of this self study, the employee should be able to:
1.	Identify and define the purpose of the MCGHI program responsible for abuse/neglect issues.
2.	Identify at least 3 indicators of abuse/neglect.
3.	Describe ‘mandated reporting’ responsibilities.
4.	Describe MCGHI’s referral and reporting process.
5.	Describe JCAHO’s expectations regarding abuse and neglect.
Family Intervention Services is the MCGHI program responsible for providing crisis intervention, therapeutic follow-up, advocacy, and prevention services to victims and their families of Child Abuse/Neglect, Abuse of Disabled Adults/Elders, Abuse of Residents of a Long Term Care Facilities, and Intimate Partner Violence.
Policy: Hospital policy 14.50 is MCGHI’s primary policy addressing:
•	Child Abuse / Neglect
•	Abuse of Disabled Adults / Elders / Residents of Long term Care Facilities
•	Intimate Partner Violence
Section 1:	Child Abuse/Neglect
Definition: The non-accidental injuring of a child by a parent, caretaker or guardian, by an act of omission or commission.
•	Non-accidental Injury: injury that is otherwise avoidable
•	Child: Any person less than 18 years of age
•	Parent / Caretaker / Guardian: Can include anyone who stands “in loco parentis;” I.e., anyone with legitimate parental type authority or control over a child, if only temporarily. For example - baby sitters, teachers, health care professionals. etc.
•	Act of Omission: Something that is omitted. For example - food, clothing, shelter, medication, education, supervision.
•	Act of Commission: Something that is committed. For example - physical or sexual abuse of a child.
Statistics
•	Approximately 3 million children are reported each year to Child Protective Services.
•	Approximately 1 million cases are confirmed as actual abuse.
•	As many as 2000 children die each year in the USA from child abuse / neglect.
•	Parents are the identified perpetrators in approximately 78% of confirmed cases of child abuse.
•	MCGHI treats approximately 325 cases of child abuse / neglect each year.
Contributing Factors
Child Abuse / Neglect is not necessarily a random event. Rather, it can occur when certain “factors” are present. Factors are grouped in four subsets: Parent, Child, Family, and Environment. Examples are:
Parent Factors:
•	Parent(s) under stress.
•	The parent was abused as a child and they are now repeating a learned behavior, or expressing an unresolved anger, in being abusive.
•	The parent may expect too much from the child. For example, they may expect the child to care for himself, leaving the child unsupervised, when in fact the child is too young to be left alone.
•	The parent is unable to control their impulses, and thus lashes out at the child.
•	The parent is on drugs.
Child Factors
•	The child is very young, and thus has many needs, which causes the parent to feel stress.
•	The child has difficult behavior. For example, he is hyperactive, which causes the parent stress.
Family Factors
•	Marital conflict between parents may add to the possibility of abusive behavior towards the child. Physical violence between parents greatly increases this possibility.
•	Financial stressors in the home.
Environmental Factors
•	Economic Pressures: For example, an economic recession may cause greater financial stress in the family, which may increase the possibility of abusive behavior towards the child.
•	Isolation: A lack of emotional support of a parent or family, especially those with other problems, may increase the possibility of abusive behavior towards the child.
Indicators of Child Abuse / Neglect
Physicians, nurses, social workers, Child Protective Services staff, etc. look for certain physical and behavioral indicators of abuse. The presence of any of these suggests a further evaluation may be necessary. Examples include:
	Unexplained injuries or injuries that do not match accident account
	Injuries in various stages of healing.  Injury is not presenting illness
	Multiple, bi-lateral and/or patterned injuries
	Delay in seeking medical treatment
	Non-compliance with health care regimen (e.g., multiple broken appointments)
	Multiple falls;  Multiple explanations for injuries
	Injury inappropriate for developmental age (e.g., bruises on infants)
	Unattended physical and/or emotional problems; Substance abuse
	Venereal disease; pregnancy
	Sub-standard care, supervision, clothing, hygiene, nutrition;  Failure-to-Thrive
	Developmental delays (e.g., poor speech or motor skills)
	Behavioral problems and/or extremes (e.g., overly aggressive or compliant, depressed, rage, suicidal)
	Fear of physical contact; afraid of parents
	Unusual interest in or age inappropriate knowledge of sexual matters, seductive and/or promiscuous behavior; Inappropriate expressions of affection.
	Observable lack of parental support or concern
Section 2:	Abuse of Disabled Adults, Elders, Residents of a Long-Term Care Facility
Definition: Physical pain, physical injury, mental anguish, unreasonable confinement, exploitation, or the willful deprivation of essential services to a disabled adult / elder, or a resident of a long term care facility, inflicted by a caretaker by non-accidental means.
•	Non-accidental: injury that is otherwise avoidable
•	Disabled Adult: a person 18 years of age or older who is mentally or physically incapacitated, but who is not a resident of a long term care facility.
•	Elder: a person 65 years of age or older, who is not a resident of a long term care facility.
•	Resident: any person who is receiving or has received treatment or care in a long term care facility.
•	Long Term Care Facility: skilled nursing home, intermediate care home, or personal care home.
•	Caretaker: a person who has responsibility for the care of an adult patient as a result of a family relationship, contract, voluntary assumption of that responsibility, or by operation of law.
Statistics
•	There are approximately 281 million people in the USA (2000 census). Of these, approximately 35 million (12%) are over the age of 65.
•	It is estimated that as many as 2.1 million adults / elders are abused each year in the United States.
•	61% of reported cases involve abuse by a caretaker
•	38 % of reported cases involve self neglect
•	Family members are the perpetrators in 90% of elder abuse and neglect incidents.
•	Our oldest elders (80 years and over) are abused / neglected at two to three times their proportion of the elderly population.
Victims Characteristics
•	Gender: females are more at risk than males
•	Marital Status: widows / single women are more at risk than women whose spouses are still alive.
•	Health, Age & Behavior: As a person becomes older and increasingly more ill, they behavior may worsen in that they may become more demanding and less appreciative. These attributes results in more stress for the care giver, and may thus increase the possibility of abuse, neglect, or exploitation.
•	Dependent: Disabled Adults / Elders / Residents of Long Term Care Facilities are often totally dependent on the care giver for all of their needs. This may increase the possibility of abuse, neglect, or exploitation. Dependence of the care giver on the care recipient (e.g., financial) may also increase the possibility of abuse. neglect, or exploitation.
•	Isolation: Social isolation and a lack of family support have been suggested as reasons for why this type of abuse goes undetected. “Enforced isolation” can enable the victimization to continue.
Perpetrator Characteristics
•	Stress / Lack of Support: A lack of support, personal time, privacy, and decreased financial resources that can be associated with caring for a disabled adult / elder may result in increased stress in the care giver, and therein increase the possibility of abuse, neglect, or exploitation.
•	Lack of Experience / Training: Though a person may be willing to provide care, it cannot be assumed that they have the skill necessary to provide proper care. Motivation is not enough. Care giving requires the ability to provide care, and training is necessary. A lack of proper training may result in abuse or neglect, or even accidental injury.
•	Reluctant Care giver: A care giver may be reluctant to provide the care for any number of reasons. For example, an adult child and elderly parent may have a poor relationship. A reluctant caretaker, or one otherwise forced into providing care, may result in an increased possibility of abuse / neglect.
•	Mental / Emotional Illness: Care givers with emotional problems are often incapable of properly meeting the needs of an elderly person. However, the unavailability of a viable option may result in this arrangement. Role reversal may also occur. For example, an adult child with an emotional illness may live with an elderly parent who cares for them. As the parent ages, the roles may reverse so that the adult child now becomes the caretaker. None-the-less, the latter still suffers from the emotional illness, and therein may not be capable of providing proper care.
•	History of Abuse: Abuse is more prominent in families with established histories of abusive behavior. Violence behavior may be a learned response, or may be motivated by a conscious or unconscious desire for retribution. For example, a resentful adult child may abuse his father who had been abusive as a parent.
•	Substance Abuse: Abuse of substances by a care giver is felt by some researchers to be the single best indicator of abuse. It may result in the care giver making poor or inappropriate decisions. As well, the need to financially support the substance abuse may take precedence over caring for the elderly person. Misuse of the older person’s financial assets is likely.
Indicators of Abuse of Disabled Adults / Elders, or Abuse of a Residents of a Long Term Care Facility
Physicians, nurses, social workers, Adult Protective Services staff, etc. look for certain physical and behavioral indicators of abuse. The presence of any of these suggests that further evaluation may be necessary. Examples include:
	Unexplained injuries;  Injuries do not match accident account
	Injuries in various stages of healing; Injury is not presenting illness
	Multiple, bi-lateral and/or patterned injuries
	Delay in seeking medical treatment
	Multiple falls; Multiple explanations for injuries
	Decubiti; urine burns
	Sexually transmitted diseases
	Unattended physical / emotional problems; Substance abuse
	Signs of sub-standard care, supervision, clothing, hygiene,  nutrition
	Fear of physical contact
	Behavioral problems/extremes (e.g., overly aggressive or compliant, depressed, suicidal)
	Afraid of caretaker; Abandoned by caretaker; Caretaker unconcerned
	Non-compliance with health care regimen (e.g., multiple broken appointments)
	Financial exploitation
Section 3:	Intimate Partner Violence (formerly known as Spouse Abuse and Domestic Violence) 
Definition: Intimate Partner Violence involves a pattern of behavior used by one person to establish power and control over another person, through fear and intimidation, often including the threat or use of violence.
Statistics
•	25 - 50% of all women will experience Intimate Partner Violence at some point in their lives.
•	As many as 3 million women are victims each year.
•	Approximately 3,500 victims die from Intimate Partner Violence in the USA annually.
•	22% - 28 % of teens will experience abuse in a dating relationship.
•	Heterosexual and homosexual couples have approximately the same rates of abuse.
•	Separation Violence - The most dangerous time for a victim of Intimate Partner Violence is around the time when she is attempting to leave the relationship. Sixty Five percent of homicide victims killed by their intimate partner were leaving or had left when the murder occurred. 
Pregnancy and Intimate Partner
•	As many as 25% of pregnant women may be battered
•	Bleeding, miscarriage, delayed pre-natal care, pre-term labor, low birth weight, and injury and/or death to the mother and/or the fetus have been associated with Intimate Partner Violence in pregnancy.
Victim Characteristics
Victims:
•	are usually female, though it is recognized that male victims are less likely to disclose they have been abused.
•	come from all socio-economic, ethnic, racial, age & educational groups.
•	often have low self esteem, and may be unsure of their own emotional needs and boundaries. They may lack the emotional strength to set appropriate limits with the perpetrator regarding how they are treated and how they respond.
•	are often economically and emotionally dependent on the perpetrator.
•	often have unrealistic hope that the perpetrator may change the way he treats her. Because of this hope, she may remain with or return to the abusive environment.
Perpetrator Characteristics
Perpetrators:
•	come from all socio-economic, ethnic, racial, age & educational groups.
•	are very self centered, narcissistic.
•	as with the victim, may suffer from low self esteem.
•	can be very jealous and suspicious of their intimate partner. For example, they may often suspect infidelity when their suspicions are unjustified..
•	may abuse as a result of witnessing the abuse of their mother by their father,  or because they were abused as a child.
•	may have a belief system wherein they view women as submissive, subservient, or simply as objects to be owned and controlled.
Why Men Batter:	
•	because violence is an effective method for gaining and keeping control over another person
Why Women Stay:
Victims often stay because:
•	they have damaged or eroded self-esteem wherein they lack the emotional strength to undertake the difficult and often dangerous task of leaving.
•	they have been emotionally and/or physically isolated from their friends and family and thus have little or no support when attempting to leave.
•	the have limited economic resources.
•	their religious beliefs compel them to stay. For example, they may believe they should be submissive even if that involves enduring abuse.
•	the abuser promises to change (often unrealistic hope)
•	of fear of injury or death being inflicted by the perpetrator.
Indicators of Intimate Partner Violence
•	Physicians, nurses, social workers, Adult Protective Services staff, etc. look for certain physical and behavioral indicators of abuse. The presence of any of these suggests a further evaluation may be necessary. Examples include:
Physical and Behavioral Indicators: 
	Unexplained injuries; Injuries do not match accident account
	Multiple, bi-lateral and/or patterned injuries
	Delay in seeking medical treatment
	Injuries in various stages of healing; Injury is not presenting illness
	History of being "accident prone"; Evasiveness by patient when giving history; Self blame
	Observation of hyper-vigilance / hyper-sensitivity of patient towards present relationship
	Complaint of chronic / psychogenic pain; pain due to diffuse trauma, without visible evidence; frequent gynecologic problems
	Emotional problems and/or extremes (e.g., anxiety disorders, depressed, suicidal)
	Frequent use of prescribed minor tranquilizers or pain medications
	Frequent visits to health care provider with vague complaints or symptoms without evidence of physiologic abnormality
	Refusal by spouse or significant other to leave patient's room during exams, procedures and/or when requested by staff
	Manipulation, intimidation, jealousy, possessiveness or coercion of patient by spouse or significant other; 
	Patient discloses fear of their life being in danger
	Reluctance of patient to speak or disagree in front of the spouse or significant other
Section 4:	Mandated Reporting and Liability
•	Mandated Reporter/Reporting:   All Medical College of Georgia Hospital and Clinics personnel having reasonable cause to believe that a patient has been abused, neglected, or non-accidentally injured, are mandated to report those concerns. Accordingly, all MCGHI H&C staff are “mandated reporters.” Staff have fulfilled this mandate once they have communicated their concerns to MCGHI social work as outlined in Section 5.
•	Liability: An employee cannot be held liable for making a report, even if the investigation concludes that their concerns were unfounded, provided their participation was in good faith.
•	Failure to Report : Any employee who knowingly and willfully fails to report concerns or suspicions of abuse shall be guilty of a misdemeanor under Georgia law. This can result in a fine and/or incarceration for one year. An employee who knowingly and willfully fails to report concerns is also in violation of MCGHI policy. This can result in disciplinary action or dismissal.
Section 5:	Referral and Reporting
The presence of any of the physical and/or behavioral indicators listed above constitutes reasonable cause to suspect that abuse and/or neglect is occurring, has occurred, or may occur. In this instance, MCGHI staff shall immediately notify MCGHI Social Work (Utilization Management Department), who has the primary responsibility for conducting a psycho-social assessment and filing any reports with the authorities which may be required.  The social work provider will consult with appropriate staff and provide feedback as  necessary and/or when requested, on a need to know basis.
MCGHI social work may be contacted as follows:
1.	Normal business hours:	
•	721-8150 or, if unsuccessful or 
2.	After hours:	
•	721-7243; 1075 (on-call social work pager) or, if unsuccessful,
•	830-1823 (on-call social work cell phone) or, if unsuccessful,
•	721-3893 (paging operator) or, if unsuccessful,
•	721-7243; 6659 (MCGHI Family Intervention Services Coordinator - Lee Bultman or, if unsuccessful,
•	721-7243: 1889 (Director, Utilization Management  - Sandra McVicker or, if unsuccessful,
•	721-2911 (MCG Public Safety)
Section 6:	Joint Commission for the Accreditation of Hospital ORGANIZATIONS (JCAHO)
Abuse is an important issue for JCAHO for which they have several standards that hospitals have to meet. JCAHO expects employees to know:
1.	the hospital’s referral and reporting procedure (answer = MCGHI Social Work).
2.	several indicators of abuse / neglect that would prompt a referral to social work (See the  “Indicators” lists herein).

Family Intervention Services
Abuse / Neglect Self Study Post Test
Completion of this test is mandatory. Please complete immediately and return to 
Holly B. Walp, Graduate Medical Education Manager, Room AE 3042, Ext. 3052
Name (Print):      	 	Dept / Unit:      		Date:     	
1.	What is the name of the MCGHI program responsible for abuse/neglect issues?
	A.	Department of Family and Children Services
	B.	Department of Social Services
	C.	Family Intervention Services
	D.	Utilization Management
2.	MCGHI’s abuse program addresses which of the following:
	A.	Child Abuse / Neglect 
	B.	Abuse of Disabled Adults / Elders
	C.	Intimate Partner Violence
	D.	All of the Above
3.	Child Abuse is the accidental injuring of a child by a parent, caretaker or guardian?
	True		False
4.	Parents who were abused as children may repeat that behavior and abuse their children.
	True		False
5.	Of the following, which is considered an “indicator” of abuse?
	A.	Multiple injuries
	B.	Patterned injuries
	C.	Delay in seeking medical attention
	D.	All of the above.
6.	To be a Disabled Adult you must
	A.	Be 18 years of age or older, and be mentally or physically incapacitated
	B.	Live on your own and receive government assistance.
	C.	Have a broken leg
	D.	None of the above
7.	Most victims of Intimate Partner Violence are men.
	True		False
8.	All MCGHI employees are mandated reporters.
	True		False
9.	In abuse cases, which MCGHI staff have the primary responsibility for conducting a psycho-social assessment and filing required reports with the authorities?
	A.	Nurses
	B.	Physicians
	C.	Social Workers
	D.	All of the Above
10.	Which of the following does JCAHO expect a hospital employees to know (Check all correct answers)?
	A.	The hospital’s referral and reporting procedures
	B.	Statistics on abuse.
	C.	The National Abuse Hotline phone number
	D.	Several indicators of abuse