Welfare and Safety

Intimate Partner Violence (IPV)

COVID-related concerns:

  1. Unemployment, economic instability, food insecurity, and housing stressors may continue long after the improvement in viral spread and the lifting of isolation measures, meaning that the stressors contributing to IPV and the episodes of abuse may persist

  2. Worsening of anxiety, depression, and PTSD, as well as new-onset illness in previously well individuals may be expected

  3. Individuals not already connected with mental health care may require referrals, and frontline providers such as internists, family medicine practitioners, and OBGYNs may need to provide screening measures for mental illness and/or initial mental health care

General principles about screening for/asking about IPV:

  1. Different patients may respond better to different approaches.

  2. Make sure to ask in a private environment

  3. Do not use family or friends as interpreters. 

  4. Showing compassion and a non-judgmental attitude are essential

  5. Be aware of issues potentially contributing to the perpetuation of IPV and/or affecting the patient’s ability to acknowledge the issue. For example: Immigration issues and/or language barrier. Lack of economic options or economic abuse with lack of access to funds, accounts, credit cards, etc.  Realistic fear that leaving will aggravate the violence. Lack of trust in others e.g. police to keep them safe.

Scripts for Providers:  (Adapted from Ashur M. SAFE Questions JAMA 269:18)

  1. Stress/safety:

    1. What stresses do you experience in your relationships?

    2. Do you feel safe in your relationship?

  2. Afraid/abused:

    1. People in relationships sometimes fight.  What happens when you and your partner disagree?

    2. Have there been situations in your relationship where you have felt afraid?

    3. Have you been physically hurt or threatened by your partner?

    4. Has your partner forced you to engage in sexual activities that you didn’t want?

  3. Friends/family:

    1. Are your friends and family aware of what is going on?

  4. Emergency:

    1. Do you have a safe place to go in an emergency?

Disposition:

  1. Once you have established that there is an abusive situation, whether it is a reportable situation or not, refer the patient to appropriately trained support services.

    1. If you are at U of M, contact the Social Worker serving your clinic and/or Department.

    2. It is the responsibility of the medical care provider or the social worker to make sure that that someone has assessed suicidality and safety and made a safety plan as needed before the patient leaves your office or is discharged from the hospital.

Other Suggestions and Resources:

  1. Screening questions and measures should be implemented in all patient encounters/appointments in order to identify possible victims

  2. Michigan Department of Health and Human Services, Domestic and Sexual Violence: https://www.michigan.gov/mdhhs/0,5885,7-339-71548_7261---,00.html

  3. CDC section on Intimate Partner Violence: https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html

  4. Safe House Center:   http://www.mhweb.org/washtenaw/safehouse.html

  5. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu

Child Abuse and Neglect (CAN)

COVID-related concerns:

  1. If rates of child abuse and neglect increase, or if supports for already identified abused and neglected children are inadequate during the height of the pandemic, we can anticipate an increase in mental health problems in the immediate aftermath.

  2. In particular, we may anticipate increases in anxiety, depression, PTSD, and suicidal thinking/attempts.

  3. Children who were not previously connected with mental health providers are likely to need referrals, increasing the wait-list burden and necessitating that more frontline care be provided by pediatricians and family practitioners.

  4. Courts are likely to be backlogged with cases that were postponed, potentially delaying the reunification of families of origin (which is the preferred dispositional goal of child protection proceedings, if possible), or causing children to wait for long-term placement in institutional settings designed for short-term stays.

  5. Layoffs, furloughs, and disabilities (or even deaths) due to the virus may decrease the already inadequately staffed child welfare workforce

General principles about screening for child abuse/neglect:

  1. Be non-judgmental and supportive.

  2. Make sure that there is privacy during the discussion, including privacy from children age three or older.

  3. Do not use family or friends as interpreters. 

  4. Familiarize yourself with Signs and Symptoms of abuse and neglect: https://www.mottchildren.org/health-library/tm4865#tm4882

  5. Risk factors for child abuse and neglect:  Domestic violence. Alcohol abuse and neglect. Untreated mental illness. Lack of parenting skills. Stress and lack of support.

Scripts for Providers:

  1. Asking verbal children:

    1. Avoid asking leading questions.  If sexual abuse is suspected, leave detailed questions for professional interviewers.

    2. To assess neglect, ask the child to describe what they eat, who makes the food, where do they play, who comes to or leaves the house and when, do they have electricity, etc.

    3. What happens when you do something your parents don’t like? What happens at your house (or daycare) when people get angry?

    4. Do people ever hit?  Who do they hit?  What do they hit with? How often does it happen? Is it scary? Are you afraid of anyone?

    5. What happens when you take a bath? Where do you sleep?  What happens when you go to sleep?

  2. Asking Teens:

    1. How are your parents getting along? How would you describe your parents’ relationship? How are disagreements handled in your family?

    2. “Sometimes when I see an injury like yours, it’s because somebody got hit.  How did you get this injury/bruise?  Many teens I see are dealing with violence or bullying issues, so I’ve started asking questions about this routinely.”

    3. Have you seen anyone get hurt in your home? Have you ever been hurt or threatened by anyone? Do you ever feel afraid of your boy/girl friend?

Disposition:

  1. If you suspect child abuse/neglect, or if you have any questions or concerns, contact the University of Michigan Child Protection Team:

    1. https://www.mottchildren.org/conditions-treatments/ped-cpt

Other Suggestions and Resources:

  1. Make every effort to speak to children without a parent nearby (especially over video visits) to check in about safety.

  2. Take advantage of video visits to observe the home environment as much as possible and be vigilant for items of concern

  3. Michigan Department of Health and Human Services (MDHHS), Children’s Protective Services (855) 444-3911: https://www.michigan.gov/mdhhs/0,5885,7-339-73971_7119_50648---,00.html

  4. MDHHS Family Well-Being Guide: https://www.michigan.gov/documents/coronavirus/Family_Wellness_Guide_FINAL_web_688650_7.pdf

  5. CDC Section on Child Abuse and Neglect: https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html

  6. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu

Elder and Vulnerable Adult Abuse

COVID-related concerns:

  1. Unemployment, economic instability, food insecurity, and housing stressors may continue long after the improvement in viral spread and the lifting of isolation measures, meaning that the stressors contributing to IPV and the episodes of abuse may persist

  2. Worsening of anxiety, depression, and PTSD, as well as new-onset illness in previously well individuals may be expected

  3. Individuals not already connected with mental health care may require referrals, and frontline providers such as internists, family medicine practitioners, geriatricians, and OBGYNs may need to provide screening measures for mental illness and/or initial mental health care

  4. With the elderly population taking a greater hit from the illness and requiring high-level interventions like intubation and prolonged ICU stays, we are likely to see more lingering cases of delirium, with longer lasting cognitive effects in this population

General principles about screening for elder abuse:

  1. Primary care visits may be the only time the patient can have safe, confidential contact with someone other than the abuser.

  2. Make sure that there is privacy during the discussion.

  3. If the patient can understand questions and respond to them, interview in a quiet, private location. Use a professional interpreter if needed.

  4. If the patient is mentally challenged, or if you suspect the caregiver is the abuser, interviewing can be difficult. It may be better to refer a patient to someone with expertise in geriatrics and/or disabilities.

Scripts for Providers

  1. Do you feel safe where you live? Does someone help you with your medication? Who takes care of your money/checkbook/finances?

  2. Does anyone at home hurt you? Do they scold or threaten you?

  3. Does anyone take anything that’s yours without asking? Had you sign documents that you did not understand?

  4. Are you afraid of anyone at home? Are you alone a lot? Has anyone ever failed to help you take care of yourself when you needed help?

Disposition:

Other Suggestions and Resources:

If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu