Types of Abuse Overview

Victims of Abuse

• Types of abuse include child abuse, elder abuse, and intimate partner violence.
• Physical abuse involves intentional acts causing injury.
• Sexual abuse is non-consensual or exploitative sexual behavior.
• Emotional/psychological abuse uses words and actions to control.
• Neglect is failing to meet a dependent's basic needs.
• Financial abuse uses someone's finances to exploit or control them.

Types of Abuse

• Physical abuse, defined as any intentional act that causes trauma or bodily injury.
• Sexual abuse, defined as any non-consensual or exploitative sexual behavior imposed without consent.
• Emotional/psychological abuse, defined as regular and deliberate use of words and non-physical actions to hurt, manipulate, demean, confuse, frighten or otherwise control another individual.
• Neglect, defined as failure to provide for or meet a dependent's basic physical, emotional, educational and/or medical needs.
• Financial abuse, defined as using an individual's finances to exploit or control that individual.

Physical Abuse of Children

• Sometimes referred to as Non-Accidental Injury
• May include hitting, slapping, kicking, shaking, throwing, burning, biting, scratching, breaking bones, drowning, poisoning, or causing illness.

Accidental vs Non-Accidental Injuries in Children

• Consider age and ability.
• Any physical injury for non-mobile children is cause for concern.
• Toddlers/pre-schoolers/early school age are often covered in bruises and injuries.
• Accidental injuries become less frequent in older children (with exception to sport injury).

Typical Accidental and Abusive Injuries in Children

• Accidental injuries typically involve bony prominences, match the history, and align with the child's development.
• Abusive injuries often affect both sides of the body, target soft tissue, have unusual patterns, delay in presentation, or no clear explanation.
• Common injury locations include the head, forehead, nose, chin, palm of hand, ears, inner aspects of arms, back and side of trunk, knees, shins, and soles of feet.
• Black eyes (especially if bilateral). Soft tissues of the cheeks. Forearms when raised to protect themselves. Chest and abdomen. Any injury to the groin or genitals.

Physical Abuse: Non-Physical Signs and Symptoms in Children

• Fearfulness (unusual for age/stage of development).

• Odd behavior for age/stage.

• Bedwetting.

• Hypervigilance (jumpy, anxious, always "on guard").

• Overly compliant, unusually calm during examination.

• Especially pained by painful procedures.

• Dissociated or a “thousand-yard stare.”

Physical Abuse: Adults/Elders

• Consider age and ability. Disabled/bed-bound adults should sustain minimal injuries.
• Elderly people and those on blood thinners bruise easily; elderly skin is thinner and more susceptible to tearing.
• Consider the accompanying stoy in comparison to the presenting injuries.

Physical Abuse: Cultural/Religious Practices

• Female Genital Mutilation (FGM) is predominantly in African and some Middle Eastern countries.
• Types of FGM include clitoridectomy (partial or total removal of clitoris), excision (partial or total removal of clitoral glans and labia minora), and infibulation (narrowing of the vaginal orifice).
• Other harmful procedures to the female genitalia include pricking, piercing, incising, scraping, or cauterization.

Sexual Abuse: Children

• Any form of sexual penetration.
• Inappropriate sexual touching of a child (clothed or unclothed).
• Forcing a child to touch an adult sexually/forcing a child to strip or masturbate.
• Taking, downloading, viewing, or distributing sexual images of children.
• Not taking measures to protect a child from witnessing sexual activity or images.
• Engaging in any kind of sexual activity in front of a child, including watching pornography.

Sexual Abuse: Children - Indications

• Genital or anal pain, irritation, and/or bleeding.
• Injuries to external genitals or inner thighs.
• Difficulty walking or sitting.
• Torn, stained, or bloody underclothing.
• Sexually transmitted diseases.
• Distress exhibited when a particular caregiver approaches.
• "Mimicking" behavior or re-enacting the abuse during play.
• Bizarre, sophisticated, or unusual sexual knowledge.

Sexual Abuse of Adults

• Any contact (or non-contact) sexual activity without consent.
• May include rape/date rape, attempted rape, sexual assault, groping/forced kissing, exposing genitals, or other forms of sexualized activity.
• Exploitation concerning adults with physical or psychological disabilities in long-term care facilities, group homes, and home care services.

Human Trafficking

• Recruitment, transportation, or harboring of a person with the goal of exploitation.
• Victims are often young girls held hostage, forced into the sex trade, often with a traumatic past.
• Common types of traffickers include "Romeo" or "boyfriend" types, who lure victims online or in person.
• Indicators include inappropriate clothing for weather in a specific location, unusual places/circumstances, and any apparent form of controlling behavior.
• Tattoos/brands (crown, roses, barcodes, dollar signs), often located at the neck, wrist and collarbone areas.

Psychological Abuse in Children/Adults

• Humiliating or constantly criticizing.
• Threatening, shouting at, or calling demeaning names.
• Subjecting to jokes or sarcasm.
• Blaming and scapegoating.
• Making perform degrading acts/acts that should not be imposed on others.
• Not allowing to have friends.
• Ignoring them constantly.
• Never showing kind or positive reinforcement.
• Manipulation.
• Gaslighting (pushing for perfection, or ignorant of limits/ignorant of their limits).

Neglect

• Unmet basic needs including food/water, clothing, warmth, shelter, hygiene.
• Inadequate access to health care services.
• Inadequate education.
• Inadequate supervision
• Inadequate protection from hazards.
• Can include self-neglect in adults

Financial Abuse

• Pressuring/forcing/tricking someone into theft of money/possessions, lending/giving possessions, moving from home, or changing of will/power of attorney/document signing.
• Including those who sign legal or financial documents that they don’t understand.
• Includes working for little to no money and using bank cards/cheques for items that aren’t needed, without consent.
• Providing food, but without compensation for work.
• No/limited access to financial accounts.

Paramedic Roles and Responsibilities

• Function as patient advocates.
• Employ power to speak up for those vulnerable.
• "Mandated reporters" for duty to report any and all suspected cases or known cases of child maltreatment.
• This overrides normal professional confidentiality laws.

Assessment

• Employ a nonjudgmental and noninterrogative approach.
• Carefully listen to patient and caregivers.
• Probe gently when necessary.
• Observe inconsistencies.
• Look for subtle signs of abuse (quiet children who seem abnormally compliant).
• Be sensitive to patient/caregiver issues (especially elderly).

History Taking

• Assume nothing. Don't immediately jump to conclusions about a situation
• Active listening without being interrogative.
• Gently probe for inconsistencies in stories.
• Avoid accusations or judgmental remarks.
• Guarantee patient privacy, especially when speaking to family/caregivers privately.
• Nonjudgmental approach.
• Avoid immediately reacting with emotion of disgust, shock, etc.

Therapeutic Approach

• Be aware of personal bias.
• Conduct thorough assessment and history taking.
• Secure a safe and private space.
• Employ least invasive approach when first speaking to a patient.
• Build rapport by active listening, sensitivity, dignity, respect.

Patient Advocacy & Duty to Report (Children)

• Function as patient advocates.
• Duty to report child abuse.
• This overrides normal professional confidentiality laws
• Report to appropriate authorities and make all relevant disclosures.
• Even if someone else states they will report, you are also required to make a report.
• Pass concerns to hospital staff.

Patient Advocacy & Duty to Report (Adults)

• Function as patient advocates.
• Report if needed to appropriate authorities.
• This overrides normal professional confidentiality laws.
• If a person has capacity, ensure you don't act on their behalf without consent.
• Be aware of capacity and allow them to make their own decisions.

External Assistance

• List of services available to provide assistance.
• This includes; police, Children's Aid Societies, Victim Service Agencies, Crisis Centres, temporary shelters, and the National Human Trafficking Helpline.

Child in Imminent Danger?

• If a child is in immediate danger, and/or significant danger; have the police attend to the scene.
• Provide specific details; be thorough and concise.

General & Specific Standards

• General geriatric standards.
• Sexual Assault (reported) standards.