Partner Physical Maltreatment

For this item, you’re going to indicating whether or not there was any physical injury or any physical impact. So, you would indicate yes, if there were things as severe as say loss of consciousness down through a minor superficial scratch. You’re considering any and all physical injuries or physical impacts based on maltreatment for this item.

If you’ve indicated that there was a sustained physical injury or physical impact, the next question is going to answer whether or not it was a severe injury or impact. The list is very straightforward. It is within the item itself: Loss of consciousness, loss of functioning (which include several things like those that are listed), heatstroke or heat exhaustion, damage to internal organs (again with some language there in the item itself to help you), disfigurement and death. So, it is very straightforward and if any of these occurred, then you indicate yes. This brings you to a severe rating for the incident.

So, if the victim did not sustain any of these severe physical injuries or physical impacts as listed in the previous item, you are brought to this item which contains a fairly extensive list of other possible physical injuries or physical impacts. Three key things to remember here, first wording of the question itself. You are rating the most serious physical injury or physical impact. Often in cases victims report multiple types of physical injuries or physical impacts. If they do, take the most serious from what they are reporting and click it from the list in this item.

The second thing to remember is that you will almost always be asked a pain question as a follow-up. So, let’s say your victim is reporting significant bruising, minor scratches, and pain. You indicate that bruising is the most serious, and you’d answer the type of bruise that the victim sustained, and assuming the bruising is not severe in nature, you will be asked to rate pain as a follow-up question. You will get to do that pain follow-up based on any of these that are selected as long as it’s not a severe injury from that list. The third thing to keep in mind is there is a nice catchall category at the bottom called physical impacts not listed here. You are probably not going to use this often, but there were a few cases in the pilot that used the catchall category.

For this item, you are going to be rating how long direct pressure was required to stop the bleeding. This information is not always found in reports unless medical or police attention was required to stop the bleeding. If you’re directly interviewing someone, there are some techniques you can use to get this information. You can ask: Were you bleeding? What did you stop the bleeding? How long did you do that to stop the bleeding? And if needed you can ask some follow-up questions. Okay so you said you used gauze, how many gauze pads did you use? At any point the blood soaked through a gauze pads requiring a new one? Or instead of gauze pads fill in what they’re telling you, paper towels, bandages, and try to get at that information through your interviewing techniques. If you’re unable to ask these questions directly, use your clinical judgment and try to piece together based on the reports that you do have at hand to determine the best possible option.

If welts were the most serious physical injury or physical impact, you’re going to need to know the condition of the victim’s skin to accurately be able to answer the follow-up item. Specifically, you need to know whether or not there was broken skin, blistering, and in the case of older injuries scarring.

If swelling was the most serious physical injury or physical impact, you are going to answer how much the swelling impacted the person’s functioning. So did the swelling significantly limit functioning, did it impact but not significantly limit functioning, or was it just noticeable swelling. If you do get into the item itself, you’ll notice there’s some helpful language and some examples to help you determine whether significantly limits functioning such as a swollen ankles requires crutches, or impacts but does not significantly limit functioning. In this swollen ankle example, one does not require crutches but results in a limp for the victim.

If bruising was the most serious injury or impact, you’re going to be using two markers to answer the follow-up item. The first marker is the total area of the bruising as is measured by the size of the victim’s hand. So, what you need to do is keep in mind how old the victim is and what size they are roughly. If they are in person it’s easier to do it. If you’re not able to interview in-person, age and other descriptors for physical characteristics, you will be using those to make determination. The other thing to keep in mind is the tenderness or pain caused by the bruising. Using those two in combination, you’ll be able to answer the bruising item. Again, as is in the case with all of the other physical injuries and physical impacts, you can use some good interviewing techniques if you are able to speak with the affiliated parties for the child case. If you’re not, what you want to be doing is using clinical judgment and piecing together the reports you do have in order to try and answer this question.

So, to answer the pain item, you’re going to need to know two things:

• First, how long did the pain last. Was it less than 24 hours or was it longer than 24 hours?
• Second, you also need to know how much the pain impacted the victim. So, did significantly limit their functioning in normal activities? Were they in so much pain that it was hard to walk, hard to sit, hard to lie down? If it wasn’t, maybe it impacted but not significantly limit their functioning. So perhaps their arm or hand hurt and was difficult to engage in self-care such as person their teeth or brushing their hair. They were able to do it, but it didn’t impact. Maybe they reported that they were uncomfortable or it took them a long time due to the pain.

To answer the damage to eye item, you are going to need to know how the damage impacted the victim’s vision. So, was it damage that significantly limited vision? Was it damage to the eye that impacted but did not significantly limit vision? Was it just noticeable damage to the eye? Within the item itself, there are some examples for you to follow to help determine whether the physical impact to the eye significantly limited the vision, or just impacted vision.

For burn being most serious physical injury or physical impact, you need to know one of two things. You either need to know if the rating of the burn was first, second, or third degree, or you need to match the description found in the item that corresponds with first, second, or third degree burn based on the interview data you collected or based on the reports that you have from medical personnel, police, or other third parties. If you look at the item itself, for each rating of first, second, and third there is a description that you can use to determine the final rating for the burn. You need to know the color of the skin, the pain being reported, and whether blistering happened or not.

If the most serious physical injury or physical impact was a bloody nose you’re going to need to have the information that follows: whether there was an actual broken nose, whether there was swelling involved. Based on that you will be able to answer the item. If the nose itself is broken, that is a severe rating for the case. If there was swelling involved, you’re going to be branched to the swelling item and you will be answering some specific questions based on swelling. If neither was involved, you’ll be directed to the pain follow-up.

During the pilot of Severity, this item did not come up very frequently, but it came up often enough that it required its own separate spot in the list of possible physical injuries and physical impacts. The good news is that for this item, all you need to know is whether medical attention was required to stop the bleeding for the cut inside the mouth or if medical attention was not required to stop the bleeding inside the mouth.

Physical functioning can take many forms. In this item, you’re being asked to rate a physical impact resulting from maltreatment that wasn’t covered in the earlier list of items (like bruising, damage to skin, etc.). So, instead of giving an example, here’s what to look for:

• How did this physical impact or physical injury limit the person’s physical functioning?
• Was the person able to engage in normal activities?
• Was the person limited in what he or she was able to do?

So, this is a very straightforward item asking you to indicate whether there was pain or not. For this, you’re thinking of any sort of pain from really debilitating pain and severe tenderness, through slight discomfort maybe not lasting long or if it is not lasting long, it is low-level and not really impacting the victim.

So, to answer the pain item, you’re going to need to know two things. First, how long did the pain last. Was it less than 24 hours or was it longer than 24 hours? Second, you also need to know how much the pain impacted the victim. So, did significantly limit their functioning in normal activities? Were they in so much pain that it was hard to walk, hard to sit, hard to lie down? If it wasn’t, maybe it impacted but not significantly limit their functioning. So perhaps their arm or hand hurt and was difficult to engage in self-care such as person their teeth or brushing their hair. They were able to do it, but it didn’t impact. Maybe they reported that they were uncomfortable or it took them a long time due to the pain.

Overview:

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. Then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife. Let’s change the actual incident. Let’s say that the husband threw the knife but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No. 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has an actual injury. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations let’s say she doesn’t catch her fall, and she falls down more stairs. That could have perhaps caused a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident, if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder trying to get into the pool, but the neighbor was able to run over to the backyard to move the child away from the pool before the child fell in, and the child is not able to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high for a loss of consciousness and loss of functioning.

In the recreations would it be reasonable to say that the neighbor did not witness this and intervene? Certainly. You can add that to recreations. Would it be possible to change the scenario in ways that there was not potential for serious injury? No, because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” You can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Example:

Reasonable potential is perhaps the most challenging concept in severity. And is often further complicated when there is an act that brings up a strong reaction such as placing a hand or two on a partner’s neck (often called choking or strangulation).

We know many clinicians have gone to wonderful in-service trainings that talk about how dangerous strangulation is. That is true, it is a dangerous act. The question with severity is: how dangerous is it? Is it dangerous, very dangerous, or incredibly dangerous? And we ask you to consider different factors when it comes to placing hands on the partner’s neck: use of force, symptoms reported, what made the perpetrator stop (was it a self-regulation thing or an external force). And then, evaluating all of those things together and making a rating.

It sounds harsh on the surface to say that a person being choked is not a severe act, understandably. But you need to go beyond that information in making a determination. An example that we often give to clinicians is one that looks at a physicality piece. If a 6’5″ service member, muscular and fit, goes to place his hands around his wife’s neck, who is 5’2″ a civilian, and 100lbs, does that look different than if she (the 5’2″ 100lb civilian) goes to put her hands around her husband’s neck? On the surface those are different events, and we would probably assign different levels of dangerousness to them.

So, we’re not asking you to minimize the event of course, but we’re also asking you to not elevate it to severe without evaluating all of those pieces together.

Overview:

Reasonable potential is perhaps the hardest concept in the Severity Scales. You’re being asked to re-create the actual incident 100 times with reasonable variation. Then evaluate whether or not a serious physical injury or physical impact could have occurred as a result of those slight reasonable variations.

So, what is a reasonable variation? I’m going to run through some case examples just to give you a flavor of reasonable variations being asked of you. So, let’s say a husband threw a knife and he missed his wife’s shoulder by 2 inches. Could the knife have reasonably hit her shoulder in a reasonable variation recreation? Yes. Follow-up: would that cause loss of functioning? Perhaps, it could’ve caused significant bleeding and significant pain to the wife. Let’s change the actual incident. Let’s say that the husband threw the knife, but he missed his wife shoulder by 20 feet. Was there reason potential for the knife to have hit the wife? No. 20 feet is just too great a distance.

Let’s run through another different example. Let’s say a mother and her teenage daughter are having a fight at the top of a staircase. Mom pushes daughter, the daughter catches herself from falling down the entire flight of stairs, but in the process of catching her fall she twists her ankle, and she has some pain. So, she has an actual injury. Is there reasonable potential though to have a more serious injury or physical impact? Yes. In your recreations, let’s say she doesn’t catch her fall, and she falls down more stairs. That could have perhaps caused a loss of functioning.

Let’s change the actual incident. Let’s say the actual fight happened in the living room rather than the top of the stairs. Is there is no potential for severe injury? Probably not. Let’s say you’re running your recreations, a lot of times when clinicians are running recreations, questions come up regarding the environment itself. So, in your recreations, are you in reasonable variation allowed to move it from the living room to the top of the staircase? No. If that didn’t actually happen during the incident if they didn’t move from us in the living room and are fighting and they walked upstairs and then continue to fight upstairs, you can’t move the environment in such a drastic measure in your recreations.

Let’s do a younger child example for child neglect. So, let’s say a two-year-old left unsupervised in the backyard when dad fell sleep in a hammock because he had a couple of beers. The neighbor saw the child at the top of the pool ladder trying to get into the pool, but the neighbor was able to run over to the backyard to move the child away from the pool before the child fell in, and the child is not able to swim. Is the reason potential for injury in this incident? Yes certainly. The potential is certainly very high for a loss of consciousness and loss of functioning.

In the recreations would it be reasonable to say that the neighbor did not witness this and intervene? Certainly. You can add that to recreations. Would it be possible to change the scenario in ways that there was not potential for serious injury? No, because that is just too many changes. You can’t say “well what if the child could swim?” because it is too unreasonable of a variation. “What if dad was not sleeping?” You can’t add that because dad was actually sleeping. So, these are some guidelines to consider in your reason potential recreations as you answer this item in the Severity Scales.

Example:

Reasonable potential is perhaps the most challenging concept in severity. And is often further complicated when there is an act that brings up a strong reaction such as placing a hand or two on a partner’s neck (often called choking or strangulation).

We know many clinicians have gone to wonderful in-service trainings that talk about how dangerous strangulation is. That is true, it is a dangerous act. The question with severity is: how dangerous is it? Is it dangerous, very dangerous, or incredibly dangerous? And we ask you to consider different factors when it comes to placing hands on the partner’s neck: use of force, symptoms reported, what made the perpetrator stop (was it a self-regulation thing or an external force). And then, evaluating all of those things together and making a rating.

It sounds harsh on the surface to say that a person being choked is not a severe act, understandably. But you need to go beyond that information in making a determination. An example that we often give to clinicians is one that looks at a physicality piece. If a 6’5″ service member, muscular and fit, goes to place his hands around his wife’s neck, who is 5’2″ a civilian, and 100lbs, does that look different than if she (the 5’2″ 100lb civilian) goes to put her hands around her husband’s neck? On the surface those are different events, and we would probably assign different levels of dangerousness to them.

So, we’re not asking you to minimize the event of course, but we’re also asking you to not elevate it to severe without evaluating all of those pieces together.

Overview:

For this item, you are evaluating the fear or anxiety caused or exacerbated by the incident and how it relates to the overall level of functioning. So, look at fear and anxiety, first. Often adults can simply report: “geez, I’m feeling really scared, really afraid, really fearful.” Or “geez, I’m just so anxious and jittery it’s hard for me to cope with that.”

Other times you need to keep an eye out for behaviors. Is the adult reporting difficulty let’s say going to sleep at night, staying asleep? Are they changing their normal routine because they are fearful of perhaps certain locations or certain activities? Then you need to evaluate the impact and the overall level of functioning. So, how are they doing at work, with friends and family, if they engage in religious observance is that impacted by fear anxiety is related to the maltreatment, are they not connecting with necessary medical or mental health services?

And you want to be thinking again about that related back to this very anxiety caused or exacerbated by the incident. So what did things like before the incident happened, and after the incident did things get worse?

Example:

Let’s say following an incident where wife attacks service member husband in the middle of the night while he slept. She jumped on the bed, hit him on the face with a closed fist, and put her hands around his throat after she saw another woman had texted him. Wife was removed from the home and given a no contact order, but service member husband says he is fearful wife will find a way to get back at him. Service member husband finds it hard to get things done at work, significantly limits his activities in town, and he mostly stays on the installation. This sounds like he is highly impacted.

If the service member husband said something like: “I get nervous she’ll do something stupid, so I don’t hang out in town the way that I used to. But I feel fine when I get through the gate.” This would be somewhat impacted.