What is a neurologist's role when it comes to dealing with an abused patient? That is an important question considering the fact that neurological patients who may have cognitive and physical disabilities are at a higher risk for maltreatment, according to the authors of a new AAN position statement on abuse and violence. A 2006 study published in the International Journal of Geriatric Psychiatry, for example, found that 52 percent of caregivers admitted to having carried out some form of abuse.
The AAN position statement, which is available in the Jan. 25 online edition of Neurology, was developed by two neurologists who have been working steadily with their institutions and outside organizations to increase the visibility of abuse. Elliott A. Schulman, MD, adjunct clinical professor of neurology at Jefferson School of Medicine and professor at Lankenau Institute for Medical Research in Philadelphia, and Anna DePold Hohler, MD, assistant professor of neurology at the Boston University Medical Center, had attended the Palatucci Advocacy Leadership Forum together three years ago; the statement is a direct result of the action plan that had been developed at the forum.
Neurology Today spoke with Dr. Schulman about how neurologists should use this statement in practice, as well as why it is particularly important to pay attention to abuse in their patients. He provides tips on discussing the difficult subject with patients, as well as strategies for recognition, treatment, and prevention of the problem.
DO YOU THINK THAT THERE HAS BEEN AN INCREASE IN ABUSE CASES OR HAVE THEY BEEN JUST PUBLICIZED MORE RECENTLY?
Those cases highlighted in the media happen to be the high profile examples. The abuse that has been publicized is the tip of the iceberg. Unfortunately, maltreatment is prevalent. Twenty to 30 percent of women and 7-10 percent of men suffer physical or sexual abuse during their lifetime. This doesn't include emotional abuse, such as bullying and cyber-bullying, neglect, elder abuse, or child abuse. The position statement increases the focus on the issue.
IDEALLY, HOW WOULD NEUROLOGISTS USE THIS POSITION STATEMENT?
The statement sets a standard of care for neurologists, and this position statement will encourage physicians to ask about abuse on a routine basis in all patients. It communicates that abuse is common, particularly among neurology patients. If you don't ask about abuse, you may be missing a big piece of the puzzle.
WHAT ARE THE MOST IMPORTANT TAKE-AWAY POINTS OF THE PAPER?
Neurologists need to understand that some neurological complaints may be either directly or indirectly associated with maltreatment. Some of our patients are at higher risk for maltreatment because they may have cognitive or physical disabilities, making them especially vulnerable to neglect, elder abuse, and physical abuse.
One of the things that we want the statement to emphasize is that neurologists are not expected to fix this problem. Sometimes patients are currently being abused. Your job then is to make sure that the patient is safe and provide resources. When there's a history of past abuse, it's important to know about it. The patient may never have told anyone — and that's happened to me with some of my patients on a number of occasions. This is a terrible secret that they have never shared. It is a very humbling experience when they disclose it.
IN YOUR OWN EXPERIENCE, HAVE PATIENTS BEEN RESPONSIVE TO QUESTIONS ABOUT ABUSE?
It really varies with the patient. Most patients are generally receptive to being asked about abuse. They understand that if they are having [other neurological] issues that may be related to the abuse, it's important for the physician or the neurologist to know. They are generally appreciative because it communicates that the physician is concerned about the whole patient. It usually serves to enhance the doctor-patient relationship.
Sometimes patients are emotional and you have to be sensitive as to how much to ask. There are also several ways to ask. The more frequently you ask, the more comfortable you become.
HOW DO YOU BROACH THE SUBJECT OF ABUSE WITH YOUR PATIENTS?
I start by mailing out a questionnaire to patients to be filled out prior to the visit. I routinely ask, along with family history, “Have you ever been abused? Yes/No. If you have, have you ever been sexually, physically or emotionally abused?” As I review the questionnaire with them, they anticipate that question, and are not surprised when it is asked.
When I get to that question, I ask them to tell me a little bit about it. I don't really get into specifics. I clarify the type of abuse, and whether it is ongoing. I want to make sure that they are safe. I want to have some idea of what happened. Was it a family member? Was it when they were young or more recently? I saw a patient the other day, and when I asked her if she'd ever been abused, she told me that she was raped and stabbed at 17. That is important for me to know.
WHAT OTHER WAYS CAN PHYSICIANS DISCUSS ABUSE?
Some physicians like to ask directly. For this method, I suggest using a brief introductory statement like, “I'm going to ask you some questions that are important. I ask these in a routine fashion. I ask these to all my patients.” Screening tools for abuse are also available.
Additional approaches, which may not be as effective, include wearing buttons that say, “I am interested in knowing if you are currently being abused,” or having posters on the office or bathroom walls that read, “If you're currently being abused…” with a tear-off sheet that provides information.
It's important to show your patients compassion, respect, and make clear that you are going to be their advocate. You are not there to fix the problem, but you can direct them to the resources they need.
WHAT ABOUT PATIENTS WHO CANNOT TALK ABOUT THEIR ABUSE?
Some patients will not be able to share their experiences because they are cognitively impaired or cannot speak. What should neurologists look for? Tell-tale signs include a failure to provide adequate food, clothing, shelter, medical care, or hygiene. In some cases, unexplained bruises, lacerations, or dehydration are present. If one suspects a caregiver is involved, ask a social worker to assist in clarifying the situation. Make certain the abuse is reported.
ONE OF THE INTERVENTION PRINCIPLES LISTED IN THE DOCUMENT STATES THAT “NEUROLOGISTS SHOULD SUPPORT MULTIDISCIPLINARY EFFORTS TO RECOGNIZE, TREAT AND PREVENT ABUSE AND IPV [INTIMATE PARTNER VIOLENCE].” WHAT ARE SOME OF THE WAYS THEY MIGHT DO THIS?
Recognition begins with asking in a routine fashion. If you only question patients who you think are at high risk, you're going to overlook a lot of people. No demographic, ethnic, or age group is immune to abuse. When I ask about it, I tell patients that it's important for optimal treatment, and I show empathy when they're relating the abuse. I typically will say, “I'm truly sorry that happened to you, and we're going to see how that relates to your current problem — if it does.” The major job of the neurologist is to provide resources, including a list of domestic violence service agencies, hot lines, and educational materials.
Often times, I'll put individuals in touch with a victim advocate, who will ensure their safety, and provide information on how they can help themselves. Report it to the authorities where appropriate. For some patients I recommend counseling. Journaling is another good option. I typically also call the referring physician, who is often times unaware of the abuse. Prevention is challenging. It is best addressed by raising the visibility of abuse and educating the public.
WHAT OTHER STEPS COULD NEUROLOGISTS TAKE TO PREVENT AND RECOGNIZE ABUSE IN THEIR PATIENTS?
This is a really good opportunity for physicians — not only neurologists — to become patient advocates. One of the things that I did was present grand rounds at our hospital on abuse. We want to make sure that our colleagues, including those in the hospital setting and the emergency room — are keyed into abuse and are able to address it. Physician resources are listed in the appendix of the position statement.
Another important step will be evaluating the connection between neurological disease and how it is impacted by abuse.
HOW CAN NEUROLOGISTS LEARN MORE ABOUT HOW TO HELP?
At the AAN annual meeting in New Orleans in April, Dr. DePold Hohler, and I, along with Amy Wallace of the AAN, will be off`ering a training session called the Ambassadors' Training Program. The session, which will be held on April 23 from 10 AM-12 PM, will provide the step-by-step basic tools for anyone who wants to learn to become an educator on abuse.
It will be a good opportunity for [neurologists] to learn about maltreatment, and afterwards, they will be able to address their state or local society on the subject.
NEW RESEARCH LINKS CHILDHOOD ABUSE WITH NEUROLOGICAL EFFECTS
It has long been speculated that childhood abuse can have lingering effects on the brain. Two recent studies have demonstrated just that. In the Dec. 6 issue of Current Biology, Eamon J. McCrory, PhD, of the Division of Psychology and Language Sciences at the University College London, led a study that examined the neural reactivity in children who had experienced family violence.
Using fMRI, Dr. McCrory and colleagues observed brain responses to threatening (angry) and non-threatening (sad) facial expressions relative to neutral faces in 20 children who had been exposed to documented violence in their homes. Although we know that childhood maltreatment is a strong environmental risk factor for poor outcome in adulthood, there is still a lot we don't know about how it might shape brain development into adulthood, Dr. McCrory wrote in an e-mail to Neurology Today. Children may adapt to early stress at the neural level, he said; adding that the goal in completing this study was to try to define these potential markers of neural vulnerability.
The investigators found that those children who had been exposed to family violence, with normative anxiety levels, “show increased [anterior insula] AI and amygdala reactivity in response to angry but not sad faces,” the authors wrote. The degree of activation to angry faces in the left AI was positively correlated with the severity of violence exposure (r(20) = 0.54, p = 0.007).
Dr. McCrory said that these are important findings because even the “healthy and well functioning” children studied showed brain changes, which may reflect adaptation to a dangerous environment. The impact of physical and domestic abuse on children should not simply be overlooked in the absence of concurrent psychological problems — such experiences may still have a “measurable effect at the neural level,” he said, “that could increase vulnerability for later mental health problems.”
Another study examining the long-lasting neurological impressions of abuse completed at Yale University, authored by Erin E. Edmiston (now at Vanderbilt University in Nashville, TN) and colleagues, was published in the December 2011 issue of the Archives of Pediatric Adolescent Medicine. The authors looked at childhood maltreatment and cerebral gray matter (GM) morphology in adolescents without psychiatric diagnoses. Results were obtained using a self-reported questionnaire.
The childhood trauma questionnaire total scores correlated negatively (p<.005) with GM volume in the prefrontal cortex, striatum, amygdala, sensory association cortices, and cerebellum. “We found that the more the exposure to maltreatment in childhood the more volumes were reduced in areas of the brain that regulate emotions and impulses in the adolescents. We saw effects whether the adolescents had been exposed to neglect, in addition to abuse, and if the maltreatment was emotional as well as if it was physical,” senior study author Hilary P. Blumberg, MD, associate professor of psychiatry, diagnostic radiology and in the Child Study Center, and director of the Mood Disorders Research Program at Yale University Medical Center, told Neurology Today.
“We saw different patterns in adolescents who were exposed to these different types of maltreatment. For example, emotional neglect was associated with differences in the parts of the brain that regulate emotions.”
More research is critically needed, she said, to understand how these brain changes occur — the developmental neurobiology behind them. The next step will be to follow the youths to try to understand which individuals go on to have difficulties such as depression, Dr. Blumberg said, in order to develop more effective intervention strategies for individuals with a history of childhood abuse.
For an extended discussion with Elliott A. Schulman about what neurologists can do to detect and respond to abuse in their patients, tune in to this podcast: http://bit.ly/ripSoq/