Introduction

Domestic Violence (DV) is a worldwide problem affecting adults and children alike. Despite the primary conflict being between two adults in a household, there are numerous deleterious secondary effects that can negatively shape the development of their children. It can lead to physical and/or emotional trauma that can last their lifetime. When the COVID-19 pandemic struck this year, families were forced to quarantine together, leaving many children increasingly vulnerable to violence and neglect. With this in mind, we present a case of a six year old medically complex male with concerns for medical neglect in the context of exposure to DV.

Keywords

Domestic violence; Intimate partner violence; Child neglect; Medical neglect; Pediatrics

Case

A six year old male with past medical history of a non-specific seizure disorder, presents to the emergency department for medication refill. The patient, his two sisters (four and two years old, respectively), and mother moved to a domestic violence shelter in a neighboring state approximately 1 month ago, before which time they used to live with the mother’s husband, father to only the two year old. Prior to moving to the United States two and a half years ago, the family had lived in the Caribbean, and the family is exclusively spanish-speaking. According to a filed report, the children had all witnessed significant DV, stating that the father was controlling, and threatened to kill the mother.

The patient was diagnosed with seizure disorder and hydrocephalus in the first year of life. He has had multiple daily episodes of upper extremity tonic seizures since the time of diagnosis, and had a ventriculoperitoneal shunt placed at one year of age. Despite this medical history, he did not have a primary neurologist in his home state, and had only received Divalproex from the emergency department. His mother was not able or allowed to go anywhere without approval from her husband. In addition, her husband took the child to the emergency department, and the mother was largely unaware of the severity of his underlying medical conditions. He was last seen in the emergency department in his hometown 1 month prior to presentation at the current hospital due to a prolonged seizure, at which time Levetiracetam was added to his daily medications. His mother states there has been improvement in seizure frequency since starting new medication, but they are still occurring daily.

Upon admission, the patient presented as nonverbal, with roving eye movements, baseline spasticity, and decreased truncal tone. He was placed on video EEG monitoring, which revealed mild generalized and intermittent left frontal slowing, with no epileptiform or electrographic seizures, no clinical seizures overall. It was also found that his valproic acid levels were subtherapeutic. Child protective services (CPS) was contacted, however, no police report could be made in the current jurisdiction because the crimes occurred in another state. He was eventually discharged with his mother to a domestic violence shelter with a plan to discontinue Divalproex and continue on Levetiracetam, with CPS follow up.

Discussion

There has been increasing evidence of the effects of DV on children, especially in the context of the ongoing pandemic. It is important to describe DV and intimate partner violence (IPV), as both terms are often used interchangeably, but contain some differences. Whereas IPV is defined as abuse occurring between romantic partners that do not necessarily live in the same household, DV can occur between any individuals living in a household together, may that be adults or children [1]. The exposure of children to DV does not have to be specifically limited to actually experiencing violence, it also includes the seeing, hearing, or witnessing the aftermath of DV in the household. It is estimated that 16-25% of children in America are exposed to DV at some point during their childhood [2]. Exposure to DV is not often defined as a type of child maltreatment in many states. In cases where there is exposure but lack of other threats to safety, there is not much information on how child protection agencies respond [2]. In addition, studies have shown that 30-60% of households that report either IPV or child maltreatment will have an overlap. If IPV is present shortly after the birth of a child, that child has a 3.4 times greater chance of suffering physical abuse, and is twice as likely to deal with psychological abuse or neglect in the first five years of life [3].

Cases of medical neglect in a household known to have occurrences of DV have not been described in the literature. In this case it is unclear if the patient’s mother understood that the patient required a higher level of care than emergency department visits. Her inability to understand the care that was needed or provide additional care to her child was secondary to threats of violence from her partner. He would not allow her to take the children for medical care, threatening her life. The only way that the mother was able to access healthcare was through the emergency department, when the patient would present with symptoms requiring either a refill of his current medications or a new medical treatment. In those cases, she was not allowed to go with him and instead the husband brought the patient. While healthcare can be a point of contact for patients in situations with DV, in this case healthcare was another tool for isolation. Despite such an extensive medical history, the patient had never seen a primary care doctor or specialist such as a neurologist. Further complicating the case was the inability to press charges for a crime that occurred in another state now that mother was safely residing elsewhere. The father was the only family member who was a documented citizen of the United States, likely pressuring the patient’s mother to continue to live with him in an abusive household. Being undocumented in the United States, she may have felt uncomfortable pressing charges even while she resided with him, for fear of prosecution from the authorities. In addition, coming from another country, there are cultural differences on how DV is defined [4]. Moreover, she may have been hesitant to contact authorities, because she was limited in her ability to communicate in English.

To define medical neglect, the American Academy of Pediatrics includes several components that must be present. To start, a child must be harmed or at risk of harm because of lack of health care, which is true in this case. In addition, the recommended health care must be significantly beneficial, and outweigh morbidity by a large degree so that most parents or guardians would choose treatment over nontreatment [5]. Our subject has a complex medical history that has not been controlled well, and would obviously benefit from medications with outpatient follow up, especially in regards to controlling his seizures. Though this case is rare due to the combination of DV solely involving the mother not the child, and mom’s desire to treat her child, this does define as a child medical neglect. Child protective services and child abuse specialists should all be involved, as well as law enforcement. It becomes important to look for warning signs of medical neglect due to DV. In this case, medical providers became concerned by the patient only receiving care through the emergency department. This should raise concerns for any provider, especially with a patient with such a complex medical history. This could also apply to a patient who names a primary care physician, but does not regularly make or keep appointments. It becomes useful to contact the physician and inquire about the patient’s visits.

Conclusion

This case shows why it is important to be cognizant of the various ways in which DV can hinder the safety of children in the household, even if it is not directly in the form of physical violence. There can be detrimental long-term effects via mental abuse, or for our patient, medical neglect. It is of utmost importance to ensure not just the well-being of the obvious victim in the household, may that be mother or father, but the children as well.

Acknowledgement

Dr. Pellegrini, Mr. Manzo and Dr. Kaplan have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Objectives

Define child medical neglect, as related to domestic violence.

Recognize the long-term effects that domestic violence has on children.

Describe some warning signs of childhood medical neglect.

References

1. Garcia-Moreno, Claudia, et al. (2012) “Understanding and Addressing Violence against Women.” World Health Organization.
2. Henry, Colleen. (2018) “Exposure to Domestic Violence as Abuse and Neglect: Constructions of Child Maltreatment in Daily Practice.” Child Abuse & Neglect, Pergamon, 86: 79-88.
3. Jenny, Carole. (2007) “Recognizing and Responding to Medical Neglect.” American Academy of Pediatrics, American Academy of Pediatrics, 120: 1385-1389.
4. Holtmann, Catherine, Tracey Rickards. (2018) “Domestic/Intimate Partner Violence in the Lives of Immigrant Women: a New Brunswick Response.” Canadian Journal of Public Health = Revue Canadienne De Sante Publique, Springer International Publishing, 109: 294-302.
5. Thackeray, Jonathan D, Roberta Hibbard, M. Denise Dowd. (2010) “Intimate Partner Violence: The Role of the Pediatrician.” American Academy of Pediatrics, American Academy of Pediatrics. 125: 1094-1100.