Abuse and Neglect

Abuse is defined as the cruel or violent treatment of a person. It comes in many forms, including physical, sexual, and emotional abuse.

Physical abuse is often the most easily recognized form of abuse. It occurs when there is physical suffering or injury. For example, slapping, pinching, hair pulling, shaking, burning, and punching are all forms of physical abuse. Physical abuse also includes things like physically restraining another person, confining a person to a space without allowing them leave, or intentionally starving them.

Sexual abuse occurs when a person is used for or forced into any sexual activity. For example, any sexual contact by an adult to a child is considered sexual abuse. The term "sexual assault" is typically reserved for sexual abuse that occurs between two or more adults.

Emotional abuse occurs when a person is repeatedly put down or made to feel worthless or less than a person. For example, name-calling, criticizing, shaming, humiliating, threatening, bullying, ridiculing, and dismissing are all forms of emotional abuse.

Neglect involves not taking care of the basic needs of a dependent or vulnerable person. For example, withholding love, food, clothing, medical care, shelter, or emotional support is considered neglect.

Abuse can occur across the lifespan, with differing impacts on development and differing requirements for mandated reporting. This chapter will specifically discuss child abuse and neglect, domestic violence, sexual assault and rape, and elder abuse.

Child Abuse and Neglect

Child abuse is when an adult physically, sexually, or emotionally harms someone under the age of 18; child neglect is when parents or caregivers do not take care of a child’s basic needs. Any suspected incident of child abuse or neglect must be reported to the authorities. See Chapter B-5: Mandatory Reporting and Duty to Warn for details.

Child Physical Abuse

Physical abuse involves “non-accidental” physical injury of a child by a person who has responsibility for the child. Physical injury can range from minor bruises to broken bones to death. In Alaska, physical discipline, such as spanking or paddling, is not considered abuse as long as no bodily injury results from the discipline. However, when physical discipline results in marks or bruises, it may be considered physical abuse.

Parents and caregivers who commit physical abuse may also:

• Talk negatively about the child.
• Perceive the child as “bad” or “difficult.”
• Report using harsh discipline.
• Encourage teachers or caregivers to use harsh discipline for misbehavior.
• Have a history of being physical abused themselves.
• Provide inconsistent or strange explanations for the child’s injuries.
• Have abused animals or pets.

Child Sexual Abuse

According to the Alaska Office of Children’s Services, “sexual abuse includes acts by any adult which include fondling a child’s genitals, penetration by objects, oral sex, incest, sexual assault, indecent exposure, exploitation through prostitution, or the production of pornographic materials.”

Examples of child sexual abuse include:

• Asking or pressuring a child to engage in sexual activities.
• Role-playing or engaging in sexual behaviors.
• Using a child in pornographic pictures or materials.
• Showing genitals (private parts) to a child.
• Looking at or touching a child’s genitals (private parts) except for the purpose of medical exams or helping with issues related to hygiene when the child is small (e.g., diaper changing, washing, wiping, or checking for a rash).
• Sexual penetration or intercourse with a child.

Incest occurs when there is any sexual activity between close relatives that is illegal, socially taboo, or against religious norms, regardless of the child’s age or consent.

Child Emotional Abuse

Child emotional abuse is a pattern of behavior that impairs a child’s emotional development of sense of self-worth. Emotional abuse can be harder to recognize because there may not be any physical signs of the abuse. However, emotional abuse is most often present when other forms of abuse are present. Childhood trauma and abuse can lead to overproduction of stress hormones, which may result in changes to the structure and functionality of the developing brain.

Child Neglect

Neglect is when parents or caregivers do not take care of a child’s basic needs. Neglect occurs when a child is not given things needed for healthy physical and mental growth. Neglect can include physical, medical, educational, or emotional neglect, or, most often, a combination of these types of neglect. A neglected child may appear dirty, hungry, or inappropriately dressed for weather.

Remember: do not confuse poverty for neglect. A family that lacks access to housing, food, and other basic necessities may need supportive services to help meet their children’s basic needs. In Alaska, it is important to consider community standards. In some Alaskan communities, running water and electricity are either unavailable or beyond the means of community members. Homes may appear in disrepair due to the high cost of living in some communities. These factors alone do not necessarily point to child neglect.

Domestic Violence

Domestic violence is a form of abuse that occurs in the context of intimate partner relationships. All genders are susceptible to domestic violence, though most common is abuse of a woman by a man. Domestic violence can include physical violence, sexual violence, psychological violence, and emotional abuse. The frequency and intensity of abuse can vary from one situation to another. However, a constant element of domestic violence is one partner’s effort to gain and maintain power and control over the other.

The Domestic Abuse Intervention Project (1984) created the Power and Control Wheel to present the most common tactics used to gain power and control in abusive relationships. Providers can use the wheel to assess for domestic violence. See for more information.

It is not always easy to identify or intervene with domestic violence. Many violent relationships follow a common cycle, termed the “cycle of domestic violence.” The entire cycle can occur within one day or over weeks or even months. Not all violent relationships follow this cycle. Some victims report constant, non-relenting abuse. However, the cycle of domestic violence can help providers understand and work with victims of domestic violence more effectively.

The Cycle of Domestic Violence

1. Tension-building phase: During this phase, tension builds over common issues. For example, money, cleaning, children, and employment are common tension builders. Verbal abuse may begin during this phase, while the victim tries to please the abuser in order to avoid abuse. These efforts to avoid abuse are often not successful as the tension continues to build. Eventually, the tension hits a “boiling point” and physical abuse begins.
2. Acute battering episode: Once the tension hits the boiling point, then the physical violence begins. The physical violence is typically not triggered by the victim's behavior; rather, the violence is triggered by an external event or the abuser's mental state. In other words, battering episodes are rather unpredictable and beyond the victim's control or responsibility.
3. Honeymoon phase: During this phase, the abuser becomes ashamed of his or her behavior. He or she expresses remorse, minimizes the abusive behavior, and, at times, even blames the victim for the abuse. He or she then exhibits excessively loving, kind behavior, apologizing for the abusive behavior and promising it will never happen again. The honeymoon phase often results in a perceived strengthening of the relationships, leaving the victim unwilling to leave the relationship.

Domestic violence is not a reportable event unless children are witnessing the violence (see Chapter B-5: Mandatory Reporting and Duty to Warn ).

Sexual Assault

Sexual assault is a form of abuse that has an unfortunately high rate of occurrence in Alaska. Sexual assault is defined as “any involuntary sexual act in which a person is coerced or physically forced to engage against their will, or any non-consensual sexual touching of a person.” Rape would fall under the category of sexual assault, as would domestic violence that involved any sort of non-consensual sexual acts. Sexual assault can occur by force (e.g., pushed, pinned down), by threat (e.g., at gunpoint), by trickery (e.g., drugged), by manipulation (e.g., pressured, guilted), or by coercion (e.g., bribed, blackmailed). Women and men can be sexual assaulted. Consent is necessary for any sexual contact.

For more information on healthy and unhealthy sexual interaction, see Chapter D-23: Sexual Health and Wellness and Chapter D-24: Sexual Aggression.

Elder Abuse and Neglect

As elders age, they may become more susceptible to different types of abuse, including physical abuse, emotional abuse, sexual abuse, neglect and abandonment, financial exploitation, and health care fraud and abuse. Due to elder vulnerability, elder abuse is a reportable event. See Chapter B-5: Mandatory Reporting and Duty to Warn.

Remember to see Chapter B-5: Mandatory Reporting and Duty to Warn to determine whether or not a report of abuse or neglect is reportable.

The manner in which you intervene with a patient who reports some form of abuse or neglect will vary based on the patient’s age and vulnerability. Any report of child or elder abuse or neglect is reportable.

Sexual assault and domestic violence involving typically functioning adults do not fall under mandatory reporting laws. You may encourage your client to report the abuse to the appropriate authorities. You can also help your client navigate the necessary resources to help her find safety and heal from the abuse.

Create a safety plan with an adult patient who reports abuse but is not ready to leave the relationship. The safety plan should include how to protect oneself at home, how to contact emergency services, and how to protect oneself after leaving the abusive context.

In any case, listen empathetically to your patient. Validate his experience. Realize you may be the first person he has told about the abuse.

Safety is the primary goal; the patient needs to be safe and feel safe.

Early intervention can prevent the development of more severe problems.

A sexual offender is usually older and has conscious knowledge of what he is doing. A sexual offender will consciously cover up what he has done.

Abuse can take place between adults and children, as well as between children.

The sexual aggressor may plan the offense, “groom” the victim, or appear overly friendly so that the victim is tricked, conned, or manipulated into the act. For example, an aggressor may give small gifts or candy to lure a child.

A person might not report abuse because:

• He is dependent on the offender for basic needs.
• He fears being shunned by family members or members of the community.
• He fears it will hurt other family members or community members who are close.
• She is afraid others will not believe her.
• She feels shame or as though it is her fault.

Individuals may use substances as a result of being sexually victimized.

Children with a history of sexually transmitted infections may have been sexually abused.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to sensory functioning, development, and psychological history.

Treatment Plan, including a history of the presenting problem and recommended course of treatment.

Child Physical Abuse (from the Alaska Office of Children’s Services)

A child may:

• Have unexplained bruises, welts, fractures, dislocated limbs, skeletal injuries, and/or burns
• Display self-destructive behavior, aggression, or withdrawal
• Run away from home
• Provide inconsistent or strange explanations of injuries
• Fear adults, including parents, guardians, or caregivers
• Intentionally harm animals
• Report the abuse

Parents or caregivers may:

• Talk negatively about the child
• Perceive the child as “bad” or “difficult”
• Report using harsh discipline
• Encourage teachers or caregivers to use harsh discipline for misbehavior
• Have a history of physical abuse themselves
• Report inconsistent or strange explanations of the child’s injuries
• Have abused animals or pets

Child Sexual Abuse (from the Alaska Office of Children’s Services)

• Bleeding, cuts, burning, bruises, rash, or swelling in genital area
• Frequent urinary or yeast infections
• Painful urination or bowel movements
• Sore throats or trouble swallowing
• Difficulty walking or sitting
• Feeding and bowel problems
• Excessive crying
• Fear
• Failure to thrive
• Sleeping problems (including nightmares)
• Violent behavior toward siblings or other children
• Regressive behavior, such as thumb-sucking or bedwetting
• Exhibiting adult-like sexual knowledge, behavior, or language
• Engaging in inappropriate sex play
• Feeling shameful or guilty
• Excessive or public masturbation
• Reenacting sexual abuse or trying to imitate behavior with siblings or other children
• Writing, drawing, playing, or dreaming of sexual or frightening images
• Developing phobias
• Self-harm
• Weight gain or loss
• Becoming pregnant or contracting a venereal disease
• Depression
• Suicidal thoughts or gestures
• Sudden changes in school performance
• Drug or alcohol abuse
• Promiscuous activities
• Run away from home
• Secretive or isolated
• Trouble making friends
• Complaints of physical ailments such as headaches, stomachaches, or pain

Child Emotional Abuse (from Alaska Office of Children’s Services)

• Emotional or behavioral problems
• Habits like thumb-sucking, rocking, head-banging, or biting
• Avoidance of people
• Extremely passive or aggressive behavior
• Suicidal thoughts and behavior
• Interpersonally cold or distant
• Discomfort when someone shows them care or concern

Child Neglect (from Alaska Office of Children’s Services)

• Lack of food or shelter
• Lack of supervision
• Needed medical or mental health treatment not sought
• Not educating for or addressing special educational needs
• Children’s emotional or psychological needs not met
• Permitting drug and alcohol use by underage children

Elder Abuse and Neglect

• Unexplained injuries including bruises, welts, or scars
• Broken bones, sprains, or dislocated limbs
• Broken eyeglasses or frames
• Failure to take medication as prescribed; overdosing on medication
• Physical signs of being restrained (e.g., rope marks on wrists)
• Caregiver refusing to allow elder to be seen alone
• Threatening, belittling, or controlling caregiver behavior
• Elder rocking, sucking, or mumbling to self
• Unexplained vaginal or anal bleeding
• Torn, stained, or bloody clothing
• Unusual weight loss, malnutrition, or dehydration
• Untreated bed sores
• Unsanitary living conditions (e.g., bugs, soiled clothing or bedding, dirt)
• Unsafe living conditions
• Desertion of elder in public
• Significant withdrawals from elder’s bank accounts or sudden changes in financial conditions
• Items or cash missing from elder’s home
• Duplicate billings for the same medical service
• Evidence of over-medication or under-medication

Screening for different forms of abuse and neglect can be made a routine part of clinic visits, or screening may come up if the provider becomes concerned about the client. You may choose to ask questions indirectly or directly, in writing or orally. Below are some sample questions you might ask to screen for the different forms of abuse described in this chapter.

You might begin with a statement like the following: “I would like to ask you some questions. It may be hard to answer some of these questions, and some of them might be personal, but if you can do your best to answer them, I will do my best to help you.”

Child Abuse and Neglect

Questions to ask the minor:

• Tell me about your home and your family.
• Have there been any accidents in your home?
• Do you wish you could live in a different home?
• Do your parents or caregivers often leave you alone?
• Is there anything or anyone in your life that makes you feel unsafe?
• Do you often feel ignored, or wish you had someone to keep you company?
• Do your parents or caregivers or their friends drink, use drugs, or party a lot in your home?
• Have any of your brothers or sisters been hit or hurt by anyone?
• Have you ever been hit or touched in a way that made you feel uncomfortable?
• Do a lot of different people take care of you? Tell me about them.
• Has anyone ever hurt you before? How did they hurt you?
• Has anyone ever hurt you because they touched your private parts?
• Are you ever afraid that someone might hurt you? Who and what are you afraid of?

Questions to ask the caregiver:

• What is your child like?
• Who does he spend time with?
• Are there certain things that make him happy? Sad? Upset?
• Does this child have special needs that make it difficult to care for him? Are you getting the help you need?
• How does your child get your attention?
• Do you think the child is mischievous?
• What do you do when you feel disappointed by your child’s behavior?
• What do you do when you feel irritated or upset by your child’s behavior?
• How do you discipline the child when you are upset?
• Are you able to care for your child the way you would like?
• How do people get along in your home?
• Does anyone in your household drink alcohol or abuse drugs? What, when, and how often?
• Does the child spend much time with another caregiver? Tell me about this person.
• Does the child ever complain about his caregivers?
• Does the caregiver express concerns about the child? What kinds of concerns?
• What issues or concerns would you like addressed in your child’s treatment?

Domestic Violence

The SAFE Questionnaire is an effective way of assessing for domestic violence. The questions are asked sequentially; add each question only if the previous one was answered "yes."

Stress/safety (“S”)

• What stresses do you experience in your relationships?
• Do you feel safe in your relationship?

Afraid/abused (“A”)

• People in relationships sometimes fight. What happens when you and your partner disagree?
• Have there been situations in your relationship where you have felt afraid?
• Have you been physically hurt or threatened by your partner?
• Has your partner forced you to engage in sexual activities that you didn’t want?

Friends/family (“F”)

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

Emergency (“E”)

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

Sexual Assault

• Have you ever been touched sexually against your will or without your consent?
• Have you ever been forced or pressured to have sex?
• Do you or your partner ever disagree about sexual things? Like what? How do you resolve these conflicts?
• Do you feel that you have control over your sexual relationships and will be listened to if you say “no” to having sex or engaging in sexual touching?

Elder Abuse and Neglect

• Do you feel safe where you live?
• Who prepares your food?
• Does someone help you with medication?
• Who takes care of your checkbook?
• Does anyone at home hurt you? Do they:
  • Scold or threaten you?
  • Touch you without consent?
  • Make you do things you don’t want to do?
  • Take anything that’s yours without asking?
  • Have you sign documents you did not understand?
• Are you afraid of anyone at home?
• Are you alone a lot?
• Has anyone ever failed to help take care of yourself when you needed help?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Specifically, you may consider focusing case management efforts and individual counseling on helping the abuse survivor understand that the abuse is not her fault, learn to identify safe people in her life, develop coping skills, and increase her ability to set boundaries and communicate in healthy ways.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.