1-Introduction

2-Definition of Family
3-Function of family
4-Tyeps of family
5- Definition of family violence (Domestic violence)
6-Historitical back ground
7-Forms of family violence
8-Factors impacting on the likelihood and severity of
family violence
9- Vulnerability group violence
10-Family violence against children
11-school violence
12- Mistreatment of elders
13-Level of prevention: Crisis intervention and family
violence
14- Methods of crisis intervention and role of
Community Health Nursing in caring for families in
crises.

Objectives
*At the end of this lecture the participant
should be able to :
Define Family
Define the family violence.
Identify forms of family violence.
Determine signs of family violence.
Identify methods of crisis intervention.

Introduction
Family violencebehaviour that controls or dominates a family
member and causes them to fear for their own or another
persons safety or wellbeingis a fundamental violation of
human rights and is unacceptable in any form, any community,
or any culture.
Family violence can occur in all kinds of families, and in family
relationships extending beyond intimate partners, parents,
siblings, and blood relatives. It includes violence perpetrated
by older relatives, by younger family members, or against a
same-sex partner, or from a carer towards the person they are
looking after.
Family violence extends beyond physical and sexual violence
and often involves emotional or psychological abuse and
economic abuse. It can involve overt or subtle exploitation of
power imbalances and may consist of isolated incidents or
patterns of abuse over a period of time. There is family
violence in all areas of society, regardless of victims or
perpetrators location, socioeconomic and health status, age,
culture, gender, sexual identity, ability, ethnicity or religion.
However, while anyone can be a victim or perpetrator of family
violence, it is most likely to be committed by men against
women, children and other vulnerable people. The impacts of
violence on women and children can be profound. In some
cases family violence ends in death; in others, it can result in
physical harm, disability, mental illness or other serious health
problems. Family violence can affect many other aspects of
wellbeingincluding housing security, employment prospects
and educational achievement. Children are always affected by
family violence, even if they do not see or hear it. For example,

they may see the injuries or damage to property, or

experience an environment of fear.

Definition of family.

"A family includes a householder and one or more

people living in the same household who are
related to the householder by birth, marriage, or
adoption. All people in a household who are related
to the householder are regarded as members of his
or her family.

Function Of Family:
1- Socialization of child
2-Economic cooperation & division of labor
3-Care, supervision, monitoring, and interaction
4- Legitimizing sexual relations
5- Reproduction
6- Provision of status: Social - familial attributes
(SES, location)

Ascribed - birth order

Achieved - based on individual's effort
7-Affecction, emotional support & companionship

Tyeps of family:
1-Nuclear family:
Husband and wife and their biological children.

2- Extended family:
Three or more generations of biologically related
individuals.
3-Single-parent family:
Mother or father, never married or now divorced,
and his or her biological or adopted children.
4-Stepparent family:
One divorced or widowed adult with all or some of
his or her children and a new spouse with all or
some of his or her children, and also any children
born to this union so that parents, stepparents,
children, and stepchildren (or stepsiblings) live
together.

5-Blended family:
One parent with all or some of his or her children
and a new spouse with all or some of his or her
children, and any children the parents have
together.
6- Adoptive family:
One or more nonbiological children raised by a
single adult or couple.
7-Grandparent family:
Children living in their grandparents home, with
their parents (extended family) or without them
(grandparents alone).
8-Gay/lesbian family:
Gay or lesbian partners and the biological or
adopted children of one or both partners.

9-Single state:
Never married, separated, divorced, or widowed.
10-Patrifocal/patriarchal family:
Man has main authority and decision-making
power.
11-Matrifocal/matriarchal family:
Woman has main authority and decision-making
power.

Definition of Family violence (Domestic violence)

-Domestic Violence is a violent confrontation between family or
household members involving physical harm, sexual assault, or
fear of physical harm. Family or household members include
spouses / former spouses, those in (or formerly in) a dating
relationship, adults related by blood or marriage, and those
who have a biological or legal parent-child relationship.

Another definition:
An abuse of power perpetrated mainly (but not only) by men
against women both in relationships and after separation. It
occurs when one partner attempts physically or
psychologically to dominate and control the other. The most
commonly acknowledged forms are physical and sexual
violence, threats and intimidation, emotional and social abuse
and economic deprivation...For many indigenous people the
term family violence is preferred as it encompasses all forms of
violence in intimate, family and other relationships of mutual
obligation and support. (Australian Law Reform Commission and
New South Wales Law Reform Commission 2010, p.188).

History of family violence

-Family violence, once considered one of the most
underreported crimes, became more widely recognized during
the 1980s and 1990s
- It occurs in every racial, socioeconomic, ethnic, and religious
group, although conditions such as poverty, drug or alcohol
abuse, and mental illness increase its likelihood prior to the
mid-1800s, most legal systems accepted wife beating as a
valid exercise of a husband's authority over his wife.
- Political agitation during the nineteenth century led to
changes in both popular opinion and legislation regarding
domestic violence within the United Kingdom and the United
States
- Modern attention to domestic violence began in the women's
movement of the 1970s, particularly within the contexts of

feminism as concern about wives being beaten by their

husbands gained attention and women's rights
- In Egypt family violence is wide spread especially in rural
areas
- Many negative health consequences to the victims have been
associated with domestic violence against women. Data from
the 1995 Egyptian Demographic and Health Survey, a
nationally representative household survey, were analyzed for
6566 currently married women age 1549 who responded to
both the main questionnaire and a special module on women's
status16% were beaten in the past year and exposed to
domestic violence
- 25 November considered as the International Day for the
Elimination of Violence against Women from the United Nations
- A study built on a survey of experts in the field of gender
issues (gender) that Egypt is the worst place to live women
compared to other Arab countries.
- The study in Egypt to the spread of sexual harassment,
female genital mutilation, and the mounting influence of
militant groups, making the status of women become very
bad. Today, punishment of children by their parents remains
legal in most countries, but in Western countries that still allow
the practice there are strict limits on what is permitted.

Forms of family violence

Form

Intimidation

Verbal abuse

Example
-Smashing things.
-Destroying possessions.
-Putting a fist through the wall.
-Handling guns or other weapons in the
presence of the victim.
-Using intimidating body language such as
angry looks, raised voice.
-Questioning the victim in a hostile way.
-Harassing the victim by making persistent
phone calls, sending text messages or emails,
following her, or loitering near her home or
workplace.
-Screaming, shouting, making put-downs,

Physical abuse

name-calling.
-Using sarcasm.
-Ridiculing the victim in public or private.
-Showing lack of consideration for the victims
physical comfort or safety (such as dangerous
driving).
-Pushing, shoving, hitting, slapping, choking,
hair-pulling, punching or using weapons.
-Destroying possessions.
(Note: acts are physically abusive even if they do not
result in physical injury).

Emotional abuse

Social abuse

Economic abuse

-Any behaviour that deliberately undermines

the victims confidence
(for example, that leads her to believe she is
stupid, a bad mother, useless, or even crazy
or insane).
-Threatening to harm the victim, her friend or
family member; to take her children; or to
commit suicide
-Silence and withdrawal as a means to abuse.

-Isolating the victim from her social networks

and supports, either by preventing her from
having contact with her family or friends or by
verbally or physically abusing her in public or
in front of others.
-Continually putting friends and family down so
the victim is slowly disconnected from her
support network.
-Preventing the victim from having contact
with people who speak her language and/or
share her culture.
-Denying the victim access to money, including
her own.
-Demanding that the family live on inadequate
resources.
-Incurring debt in the victims name
-Making significant financial decisions without
consulting the victim.

-Selling the victims possessions

(Note: these can be contributing factors for women
becoming trapped in violent situations).

Sexual abuse

Controlling
behaviours

Spiritual abuse

Stalking

-Rape (which includes being forced to perform

unwanted sexual acts or to have sex with
others).
-Being pressured to agree to sex.
-Unwanted touching of sexual or private parts.
-Keeping the victim from making friends,
talking to her family, or having money of her
own.
-Preventing the victim from going to work.
-Not allowing the victim to express her own
feelings or thoughts.
-Not allowing the victim any privacy.
-Ridiculing or putting down the victims beliefs
and culture.
-Preventing the victim from belonging to or
taking part in a group. that is important to her
spiritual beliefs, or practicing her religion .
-Loitering around places the victim is known to
frequent, watching her, following her, making
persistent telephone calls and sending mail
including unwanted love letters, cards and gifts
(Note: stalking is a criminal offence. Under the stalking
legislation, more than one type of behaviour has to
occur, or the same type of behaviour has to occur on
more than one occasion. Stalking can occur before or
after separation).

Spousal homicide

-The death of the victim directly attributed to

family violence

Factors impacting on the likelihood and severity of -5

:family violence
Explanation

Risk factors
(for victims)

Family violence often commences or intensifies

during pregnancy and is associated with
increased rates of miscarriage, low birth
weight, premature birth, fetal injury and fetal

Pregnancy/new
birth

death. Family violence during pregnancy is

regarded as a significant indicator of future
harm to the woman and her child.
Victims with a mental illness may be more
vulnerable to family violence.

Depression/mental
health issue
Drug and/or alcohol
misuse/
Abuse

Victims may use alcohol or other drugs to cope

with the physical, emotional or psychological
effects of family violence; this can lead to
increased vulnerability.
Suicidal thoughts or attempts indicate that the Has ever verbalized
victim is extremely vulnerable and the situation or had
has become critical.

A victim is more vulnerable if she is isolated

from family, friends and other social networks.
Isolation also increases the likelihood of
violence and is not simply geographical. Other
examples of isolation
include systemic factors that limit social
interaction or support and/or the perpetrator
not allowing the victim to have social
interaction.

Risk factors
(for
perpetrators)

suicidal ideas or
tried to commit
suicide
Isolation

Explanation

Use of weapon in
most recent event

Use of a weapon indicates a high level of risk

because previous behaviour is a likely
predictor of future behaviour. A weapon is
defined as any tool used by the perpetrator,
that could injure, kill or
.destroy property

Access to weapons

Perpetrators who have access to weapons,

particularly guns, are much more likely to
seriously injure or kill a victim than
perpetrators without access to weapons.

Has ever harmed or

threatened to harm
victim
Has ever tried to
choke the victim
Has ever
threatened to kill
the victim
Has ever harmed or
threatened to harm
or kill
Children

Drug and/or alcohol

misuse/abuse
Obsession/jealous
Behavior towards
victim
Unemployment

Depression/mental
health issue

Psychological and emotional abuse has been

found to be a good predictor of continued
abuse, including physical abuse. Previous
physical assaults also predict future assaults.
Strangulation or choking is a common method
used by male perpetrators to kill female
victims.
Evidence suggests that a perpetrators threat
to kill a victim is often genuine.

Evidence suggests that where family violence

is occurring, there is a likelihood of increased
risk of direct abuse of children in the family.
Children are adversely affected through
experiencing violence directly and by the
effects of violence, including hearing and (or)
witnessing violence or through living in fear
due to a violent environment.
A serious problem with illicit drugs, alcohol,
prescription drugs or inhalants leads to
impairment in social functioning and creates a
risk of family violence.
Obsessive and/or excessive jealous behaviour
is often related to controlling behaviours and
has been linked with violent attacks.
Unemployment is associated with an increased
risk of lethal assault, and a sudden change in
employment statussuch as being terminated
and/or retrenchedmay be associated with
increased risk.
Murdersuicide outcomes in family violence
have been associated with perpetrators who
have mental health problems, particularly
depression.

Factors impacting on victims vulnerability to -6

:continued violence

Certain factors might make some victims more vulnerable to

continued family violence:
1- Perceived or actual dependence on the perpetrator (for
example, as an income earner, career, or sponsor for a visa).
2- Fears arising from the perpetrators threats against children
extended family members, friends, or pets.
3- Fears of their children being removed, or of losing access to
their children
4- The involvement of other family members who collude with
or co-perpetrate family violence (for example, resident inlaws).
5- Fears arising from the perpetrators threats to inform police
about illegal activities.
6-Fears arising from the perpetrators threats to report to
Centre link, Child Protection or immigration authorities (such
threats are potent even if there might be no grounds for action
by these authorities).
7-Geographic isolation, including having no safe place to flee
to
8-Social isolation, including lack of access to networks of social
support
9-Beliefs that taking steps to leave the violence would
necessitate a move away from home, schools, work and social
supports.
10- Lack of accommodation options and/or money to pay for
rental accommodation and relocation, if they do wish to leave.
11- The existence of court orders or visa conditions limiting
home location and/or travel movements.
12- Fears of not being believed, perhaps because of the
perpetrators high profile or valued status in a community or
because of previous experiences of poor system responses.
13- Lack of awareness of family violence support services and
protective mechanisms.
14- Concern about being stigmatized for being a victim of
family violence.
15- Normalization of their experience of family violence
(which might be attributed to both the perpetrator and
community attitudes).
16- Experiences or expectations of poor service responses.

:Family violence against children

Child abuse is the physical, psychological, social, emotional or
sexual maltreatment of a child. It harms or endangers the
survival, safety, self esteem, growth and/or development of
the child. It can involve a single act or a pattern of incidents.
-Physical abuse is the deliberate use of force against a child
which results, or may result, in bodily harm. It includes
behaviours such as shaking, choking, biting, kicking, burning,
poisoning, holding a child under water, or any harmful or
dangerous use of restraint.
-Emotional abuse refers to acts or omissions that harm a
childs sense of self in a way that causes, or could cause,
behavioural, cognitive and emotional disorders. This includes
making verbal threats, put-downs, forcing a child into social
isolation, intimidating, exploiting, terrorizing or routinely
making unreasonable demands of a child.
-Sexual abuse ranges from sexual harassment to sexual
activity. It includes attempted or completed sexual relations,
touching genitals, exposing adult genitals, sexual exploitation,
sexual harassment, and voyeurism.
-Neglect occurs when the childs basic needs are not being
met. Physical neglect may involve inadequate food, clothing,
shelter, cleanliness, medical care and protection from harm.
Emotional neglect occurs when a childs need to feel loved,
wanted, safe and worthy is not met.
Impacts of Family Violence on Children:
The following is only a guide as to some ways in which the
harm may affect them:
Infants

Poor brain development.

Poor health and development.
Poor sleeping patterns.
Cry and scream more than normal.

Toddlers

Become very distressed when witnessing violence.

Be severely shy, have low self esteem.

 Bite, hit, kick, pull other childrens hair.

Are argumentative.
Pre-schoolers

Blame themselves for the violence.

Become very distressed.
Become very withdrawn.
Show verbal and physical aggression.

Primary school children

Begin to learn that violence is a way of resolving conflict.

Have difficulty at school.
Have the highest levels of depression and aggression
(especially girls).
Have difficulty concentrating.
Become rebellious.
Become anxious and withdrawn.
Adolescents

Develop other social networks outside of the family.

Regard the victim of the violence as being responsible.
Development and future adult behaviour affected.
Strong possibility of depression (especially girls).
Become aggressive towards victim or other family members
(especially boys).
Continue cycle of violence.

:Mistreatment of elders
-Elders may experience additional vulnerabilities and
discrimination. For example, as they age, elders often
experience:
Shrinking social and friendship networks.
Reduced access to information.
Loss of economic power and access to resources.
Frailty or physical dependency, or the expectation or fear of
frailty.
Poor or limited housing options.
Signs of elders abuse:
-Bruises, pressure marks, broken bones, abrasions, and burns
may be an indication of physical abuse, neglect, or
mistreatment.

-Unexplained withdrawal from normal activities, a sudden

change in alertness, and unusual depression may be indicators
of emotional abuse.
-Bruises around the breasts or genital area can occur from
sexual abuse.
-Sudden changes in financial situations may be the result of
changes.
-Bedsores, unattended medical needs, poor hygiene, and
unusual weight loss are indicators of possible neglect
- Behavior such as belittling, threats, and other uses of power
and control by spouses are indicators of verbal or emotional
abuse.

:Level of prevention
Before the Problem Starts: Primary Prevention
The goal of primary prevention is to intervene before the
health or social problem occurs by removing the cause or
preventing the development of risk factors associated with the
problem.
- To date, the vast majority of primary prevention initiatives
for DV have involved some type of educational strategy which
is often school-based.
-Safe Dates, an adolescent dating violence prevention
program, is an example of an educational strategy that has
been evaluated. Eighth and ninth graders who participated in
Safe Dates reported less sexual and physical dating violence
perpetration and victimization and the reduction in violence
persisted four years after students had completed the program
compared to students who did not receive the intervention.
-The conceptual framework for Safe Dates is that changing
norms associated with partner violence, decreasing gender
stereotyping, and improving conflict management skills will
prevent the perpetration of dating violence.
-It is important to note that primary prevention does not have
to be limited to risk factors or problems that increase the risk
of victimization or perpetration. -Primary prevention
strategies can focus on protective factors.

Once a Problem has Begun: Secondary Prevention

The goal of secondary prevention is to identify a risk factor or
problem and take the necessary actions to eliminate the risk
factors and the potential problem.
-Screening programs in the health care setting are an example
of secondary prevention.
-By screening patients for DV, health care providers can offer
support and referrals to patients who disclose abuse to reduce
the likelihood of future victimization and prevent long-term
health consequences.
-To date, there is very limited evidence to support the
effectiveness of screening as a preventive measure.
-Home visitation services that are targeted to women with
identified risk factors for DV is another example of secondary
prevention. For example, the Nurse-Family Partnership home
visitation program offers services to low-income pregnant
women who are then screened for a wide range of risk factors,
including DV.
-Women who disclose abuse receive additional support and
referrals. Without this screening, home visitors may not
become aware of the DV until much later when there is overt
evidence of physical harm or the client chooses to self-disclose
due to escalating violence.
Responding Afterwards: Tertiary Prevention
Tertiary prevention occurs after the adverse event or illness
has occurred and interventions are designed to minimize the
impact and restore health, wellness, and/or safety as soon as
possible.
-However, a rapid, coordinated response and follow-up can
reduce the impact of victimization, and prevent predictable,
long-term consequences and re-victimization.
-Tertiary prevention for DV encompasses all of the services
directed to survivors and perpetrators once the violence has
occurred, and it is important for first responders and care-

givers to understand that they can have a role in prevention

when prompt, appropriate services and follow-up are provided.
-These services may address immediate needs such as medical
care for physical injuries, restraining orders, safety planning,
and shelter services, long-term needs such as trauma
counseling, support groups, employment assistance,
transitional housing, children's services, parenting after
domestic violence initiatives, and strategies to enhance the
quality, coordination, and access to victims' and batterers'
intervention programs.
-Legal advocacy programs to help victims navigate the legal
system are an example of tertiary prevention.

Methods of crisis intervention and role of community

:health nurse
Assessment
When assessing victim, nurses should be aware that some of the
following physical signs of injuries might be related to domestic
violence:

bruising in the chest and abdomen;

multiple injuries;
minor lacerations;
ruptured eardrums;
delay in seeking medical attention; and patterns of repeated injury.

However it is unlikely victim will present with a physical injury. They will
more likely present with issues such as:

a stress-related illness;
anxiety, panic attacks, stress and/or depression;
drug abuse including tranquilizers and alcohol;
chronic headaches, asthma, vague aches and pains;
abdominal pain, chronic diarrhea;
sexual dysfunction, vaginal discharge;
joint pain, muscle pain;
sleeping and eating disorders;
suicide attempts, psychiatric illness; or
gynecological problems, miscarriages, chronic pelvic pain.

The victim may also:

appear nervous, ashamed or evasive;

describe her partner as controlling or prone to anger;
seem uncomfortable or anxious in the presence of her partner;
be accompanied by her partner, who does most of the talking;
give an unconvincing explanation of the injuries;
be recently separated or divorced;
be reluctant to follow advice.

If nurses think a woman in their care may be experiencing domestic

violence, the detail of questioning will depend on how well they know
the woman and what indicators they have observed. Nurses should
begin with broad questions, such as:
'How are things at home?'
'How are you and your partner relating?'
'Is there anything else happening that may be affecting your health?'
Specific questions linked to clinical observations could include:
'You seem very anxious and nervous. Is everything all right at home?'
'When I see injuries like this, I wonder if someone could have hurt
you?'
'Is there anything else that we haven't talked about that might be
contributing to this condition?'
More direct questions could include:
Are there ever times when you are frightened of your partner?'
Are you concerned about your safety or the safety of your children?'

 Does the way your partner treats you ever make you feel unhappy or
depressed?'
I think there may be a link between your illness and the way your
partner treats you. What do you think?'
How to respond
The response of nurses to women in these circumstances can have a
profound effect on their willingness to open up or to seek help. Some
responses to assist successful communication in these circumstances
could include:
Listening

Being listened to can be an empowering experience for a woman who

has been abused.

Communicating belief
'That must have been very frightening for you.'

Validating the decision to disclose

'It must have been difficult for you to talk about this.'
'I am glad you were able to tell me about this today.'

Emphasising the unacceptability of violence

'You do not deserve to be treated this way.'
What not to say
Nurses should avoid responses that undermine the woman's actions,
such as:
'Why do you stay with a person like that?'
'What could you have done to avoid the situation?'
'Why did he hit you?'
Assisting safety
It is also imperative to assist the woman by assessing her safety and
the safety of her children. To do so, speak to the woman alone and ask
her:

Does she feel safe going home after the appointment?

Are her children safe?
Does she need an immediate place of safety?
Does she need to consider an alternative exit from your building?

 If immediate safety is not an issue, what about her future safety?

Does she have a plan of action if she is at risk?
Does she have emergency telephone numbers (i.e. police,
women's refuges)?
Help make an emergency plan: Where would she go if she had to
leave? How would she get there? What would she take with her?
Who are the people she could contact for support?
Document these plans for future reference.
Act now
Nurses can play an important role in working toward the creation of a
violence free community but they must first become informed. They
must then insist the organisations in which they work accept this
responsibility and work together to create environments that support
people experiencing domestic violence.
There is a growing awareness and commitment at health department
level to address the personal, social and economic costs of
abuse/violence, so the time is ripe for nurses to act and ensure serious
inroads are made in improving the health of all communities.