Family violence is abuse or neglect by a family member, intimate partner, or caregiver. It includes intimate partner violence (IPV), child maltreatment, and abuse of older or dependent adults. Forms of abuse:
| Form | Examples |
|---|
| Physical | Hitting, choking/strangulation, burning, restraining |
| Sexual | Forced or coerced sexual acts; reproductive coercion |
| Emotional / psychological | Threats, humiliation, isolation from family and friends, intimidation |
| Economic | Controlling money, preventing work, stealing benefits |
| Neglect | Failure to provide food, shelter, hygiene, medical care, supervision |
| Stalking and technology abuse | Tracking phones, monitoring messages |
The core issue is power and control. Abuse is a pattern of behavior used to dominate a partner or dependent person, not an isolated loss of temper.
Cycle of violence (Walker)
- Tension-building — minor incidents, criticism; victim tries to calm the abuser
- Acute battering (explosion) — serious violence
- Reconciliation ("honeymoon") — apology, gifts, promises to change, minimizing
The cycle usually repeats and escalates; the honeymoon phase may shorten or disappear over time.
Why people stay: fear of retaliation (risk of homicide is highest when leaving), financial dependence, children, housing, immigration status, cultural and religious pressure, isolation, love and hope for change, and self-blame. Chronic abuse can produce learned helplessness, low self-esteem, depression, and PTSD. A victim's statement such as "It's my fault — I made him angry" reflects self-blame, often reinforced by the abuser.
Risk factors for perpetration: witnessing or experiencing abuse as a child, substance misuse, controlling or jealous personality traits, and social stressors (these explain but never excuse violence). Risk factors for victimization: pregnancy, disability, social isolation, dependence, young or old age.
Screen privately. Ask when the client is alone (no partner, family member, or older child present); use a professional interpreter, never a family member. Ask directly and nonjudgmentally: "Has anyone at home hurt you, threatened you, or made you feel afraid?"
Signs suggesting IPV
- Injuries inconsistent with the explanation, injuries in various stages of healing, delay in seeking care
- Injuries to the face, head, neck, breasts, abdomen (especially in pregnancy); defensive injuries on forearms
- Strangulation: neck bruising, petechiae, voice change, difficulty swallowing — a strong predictor of later homicide
- Partner who answers for the client, refuses to leave, or controls the visit
- Frequent visits for vague complaints, chronic pain, depression, anxiety, substance use, missed appointments
Signs of child maltreatment
- Bruises on padded or protected areas (torso, ears, neck), any bruising in a non-mobile infant, patterned injuries (hand, belt, cord), immersion burns ("stocking" or "glove" pattern), cigarette burns
- Fractures inconsistent with development (posterior rib fractures, metaphyseal "corner" fractures), abusive head trauma (irritability, vomiting, seizures, retinal hemorrhages)
- Behavioral: withdrawal or aggression, age-inappropriate sexual knowledge or behavior, regression (bedwetting), fearfulness, reluctance to go home, school problems, or over-mature behavior ("parentified" child)
- Children who witness IPV show similar emotional and behavioral effects
Signs of elder or dependent-adult abuse: unexplained injuries, pressure injuries, poor hygiene, dehydration, over- or under-medication, fearfulness around the caregiver, sudden financial changes.
Lethality (danger) assessment: escalating frequency or severity, access to a firearm, prior strangulation, threats to kill, recent or planned separation, forced sex, abuse during pregnancy, perpetrator unemployment, extreme jealousy, and threats of suicide by the abuser.
| Tool / test | Use |
|---|
| IPV screening tools (e.g., HITS, HARK, STaT, WAST) | Brief screening of women of reproductive age, including in pregnancy and postpartum |
| Danger Assessment (Campbell) | Estimates risk of lethal violence; guides safety planning |
| Skeletal survey (children under 2), head CT/MRI, eye examination | Suspected child physical abuse |
| Labs (CBC, coagulation studies, liver enzymes, lipase, urinalysis) | Rule out bleeding disorders; detect occult abdominal injury |
| Forensic examination (sexual assault nurse examiner) | Evidence collection, STI and pregnancy prevention |
| Depression, PTSD, and substance use screening | Co-occurring conditions |
- Treat injuries; manage strangulation with imaging and observation when indicated (delayed airway swelling, vascular injury)
- Forensic evidence collection with consent
- Trauma-focused psychotherapy (cognitive processing therapy, prolonged exposure) for PTSD; medication for depression or PTSD as indicated (see Topic 9 for safety)
- Interprofessional response: social work, advocates, shelters, legal aid, child protective services, adult protective services
- Protective orders issued by courts
- Batterer intervention programs for perpetrators; couples counseling is not recommended while violence is ongoing
Listed in priority order.
- Immediate safety and medical needs — treat life-threatening injuries; assess current danger (Is it safe to go home? Is the abuser here now? Are there weapons?)
- Provide privacy and confidentiality — separate the client from the suspected abuser; do not confront the abuser
- Respond therapeutically
- Believe and validate: "This is not your fault. No one deserves to be hurt. You are safe to talk here."
- Validate fear and ambivalence: "It makes sense to feel afraid. What worries you most about leaving?"
- Avoid blaming ("Why didn't you leave?"), pressuring, or excusing the abuser
- Respect autonomy for competent adults — the client decides when and whether to leave; the nurse provides information, options, and support. Pressuring the client to leave can increase danger and break trust
- Safety plan (developed with the client)
- A safe place to go and how to get there; emergency numbers; a code word with trusted people
- An escape bag hidden or kept with a friend: identification, birth certificates, money, bank cards, keys, medications, important documents, children's essentials
- Plans for children and pets; how to call emergency services; safer rooms in the home (avoid kitchens and rooms with weapons)
- Technology safety (location sharing, passwords)
- Document accurately — the client's own words in quotation marks; objective description of injuries (location, size, color, shape) on a body map; photographs with the client's consent; avoid opinions ("alleged," "claims")
- Report as required by law — suspected child abuse must be reported; elder and dependent-adult abuse reporting is required in most jurisdictions; reporting IPV of a competent adult is usually based on the adult's consent unless local law mandates reporting certain injuries. Inform the client about reporting requirements
- Refer with consent to advocates, shelters, legal services, counseling, and support groups; ensure follow-up
- For children — ensure immediate safety, involve child protective services, use developmentally appropriate communication (play, drawing), avoid leading questions
- Violence tends to repeat and escalate; it is not caused by the victim
- Know emergency numbers and local shelters; keep them hidden if the abuser checks the phone
- Protective orders are available through the courts
- Children exposed to violence need support even if not physically harmed
- Caregivers of older or dependent adults: seek respite and support before stress becomes neglect or abuse
| Red flag | Why it matters |
|---|
| Strangulation history | Markedly higher risk of homicide |
| Abuser has access to a gun or has threatened to kill | High lethality |
| Client is leaving or has just left | Period of greatest danger |
| Pregnancy | Abuse often begins or escalates; fetal injury |
| Suicidal thoughts in the victim | Assess suicide risk |
| Child with unexplained injuries or sentinel bruising in an infant | Risk of severe or fatal abuse — report |
| PTSD, depression, substance use | Long-term consequences; early goal is restoring safety and a sense of control, not forcing trauma disclosure |
- Assess current safety and danger first; interview the client alone
- Cycle of violence: tension-building → acute battering → honeymoon/reconciliation, repeating and escalating
- Abuse is about power and control
- Self-blame and learned helplessness are common in victims
- Therapeutic response: "It's not your fault"; validate fear; respect the client's decisions
- Safety plan: escape route, safe place, emergency contacts, escape bag with documents, money, keys, medications
- Document verbatim quotes, body map, photographs with consent
- Child abuse reporting is mandatory; competent adult IPV is generally consent-based unless law requires otherwise
- Child signs: withdrawal, aggression, age-inappropriate sexual knowledge, regression, parentification
- Leaving is the most dangerous time; strangulation and gun access predict homicide
- PTSD care begins with safety and normalization of reactions
Country Notes
United States
- The USPSTF (2025) recommends screening women of reproductive age (adolescents and adults), including during pregnancy and postpartum, for IPV and referring those who screen positive to support services (grade B); evidence is insufficient for routine screening of older or vulnerable adults for caregiver abuse.
- National Domestic Violence Hotline: 1-800-799-7233 (24/7), text START to 88788, or online chat. All states mandate reporting of suspected child abuse; adult protective services handle elder and dependent-adult abuse.
Philippines
- The Anti-Violence Against Women and Their Children Act (RA 9262) provides protection orders: a Barangay Protection Order issued by the Punong Barangay (effective 15 days), a court-issued Temporary Protection Order (effective 30 days), and a Permanent Protection Order.
- Health care provider duties under RA 9262 (Section 31 and IRR Section 49). Any health care provider (physician, nurse, clinician, barangay health worker, therapist, or counselor) who suspects abuse or is told of it by the victim must:
- properly document the victim's physical, emotional, or psychological injuries
- properly record the victim's suspicions, the provider's observations, and the circumstances of the examination or visit
- safeguard the records and release them to the victim on request at actual cost
- give immediate notice of the victim's rights, remedies, and available services
- provide emergency care (added by the IRR)
- The Act also lists a free medical certificate of the examination or visit; the IRR assigns this to physicians of public hospitals, clinics, and rural health units, so it is not a nurse's task.
- For an adult woman victim, RA 9262 does not require health care providers to report to the police. The duty to respond and to immediately report to the DSWD, the LGU social welfare office, or accredited NGOs falls on barangay officials and law enforcers (Section 30). The nurse's duties are documentation, safe records, information on rights and services, and emergency care. If the victim is a child, the RA 7610 reporting rules below also apply.
- Child abuse is addressed by the Special Protection of Children Against Abuse, Exploitation and Discrimination Act (RA 7610). It defines a child as a person below 18 years of age, or older but unable to fully take care of or protect themselves from abuse, neglect, cruelty, exploitation, or discrimination because of a physical or mental disability or condition (Section 3(a)). Under the DOJ Rules on the Reporting and Investigation of Child Abuse Cases (1993), the head of the hospital or clinic and the attending physician and nurse who examine or treat a child who appears to have been abused must report to the DSWD, orally or in writing, within 48 hours from knowledge (Section 4). Any person may also report to the DSWD, the police, or the Barangay Council for the Protection of Children (Section 3). Good-faith reporters are free from civil or administrative liability (Section 7).