CARE OF A FAMILY IN CRISIS:

ABUSE AND VIOLENCE IN

THE FAMILY
 ABUSE
• DEFINITION: willful injury by one person of another.
• - different forms:CHILD ABUSE, which can be physical or emotional
and includes neglect and sexual abuse, INTIMATE PARTNER ABUSE
and MALTREATMENT FOR THE ELDERLY.
• - nurses need to be especially observant for signs of possible abse in
the family and prepared to handle this highly emotional and complex
problem objectively.
• the victims safety is paramount, but ensuring this safety must be
done with sensitivity to the importance of maintaining and
improving overall family functioning.
• it may also lead to a post traumatic stress disorder with long term
effects
 ASSESSING THE CHILD FOR SIGNS OF
ABUSE
• Head trauma
• Missing patches of hair
• Cigarette burns
• Burns on dorsal surface of the hand
• Nail biting,otehr mannerisms of stress
• Bruising
• Scalded feet and legs from being lowered into hot water.
• Multiple fractures in different stages of healing
 CHARACTERISTICS OF PARENTS AT HIGH
RISK TO CAUSE CHILD ABUSE OR NEGLECT
• 1. Frequent changes of address in the year before childs birth
• 2. Past or present psychiatric treatment
• 3. Emotional problems
• 4. Lack of intellectul ability
• 5. Unrealistic expectations of the new baby
• 6. Changed decision about adoption
• 7. Abuse or neglect of a previous child
• 8. History of parental violence or neglect in childhood.
• 9. Low self-estem
• 10. Unable to earn independent income
 CHILD ABUSE
• Abuse may be physical or it may be neglect - not fed, clothed,
supervised properly, or offered medical care or educational
opportunities.
• Abuse may also be psychological or emotional
• Physically abused children are found to be more angry, non
compliant and hyperactive than others, they may demonstrate poor
self control and low self esteem.
• Emotionally abused children are
apt to be more withdrawn and
to have flatter affect than others.
• Children often have undiagnosed
medical problems such as
anemia, otitis media, lead
poisoning, or sexually
transmitted intfections,
depression, guilt anddifficulty
enjoying sexual relations
 THEORIES OF CHILD ABUSE
• 1. SPECIAL PARENT: PARENT WHO ABUSE
• -many of tehse parents were abused as children.
• - less self control
• - unfamiliar with growth and development of children and so have
unrealistic expectations of a child
• - socially isolated, with no support people available
• abuse is strongly associated with excessive parental use of alcohol,
a substance that removes inhibitions and self control.
2. SPECIAL CHILD: CHILDREN WHO ARE ABUSED
• - more or less intelligent than other children in the family.
• - they may have been unplanned
• - may have a birth defect or attention span deficit
• - category of children at high risks includes those who are born
prematurely or who have illness at birth, because they are kept from
parents or separated from them
• - a good parent-child relationship is not developed
• - injured child- parents who are unable to deal with stress may not
show the usual degree of compassion for their child's pain or offer to
comfort.
• - a child may assume a role reversal with the parent or become the comforting,
solacing person.
• - they learn to comfort the parent and reduce teh parents stress and anxiety,
therefore avoiding the hurt.
• it is important to assess wh is comforting whom when a childhood injury
occurs.
• 3. SPECIAL CIRCUMSTANCE: STRESS
• - response to an event that would not necessarily be stressful for an average
parent.
• - might be something as blocked toilet, an illness in the fmaily, a lost job, a
landlord asking for the rent, or a rainstorm that cancels a picnic.
• - child abuse crosses all socioeconomic levels
• - stress generally has a greater impact on individuals who do not have strong
support people around them.
• families whose internal support system is faulty or who have not formed
outside support systems are apt to have a higher incidence of abuse.
 PHYSICAL ABUSE
• -the action of a caregiver that causes injury
to a child.
• commonly revealed by burns or by injuries
to head or hands.
• when children are examined, be certain
that they are fully undressed so that entire
body can be observed.
• plot the height and weight. Delays in
growth may suggest neglect.
• children who are beaten with electrical cords,
belts or clotheslines have peculiar circular and
linear lesions, additional curved lacerations
from the imprint of the buckle and contusions.
• abrasions or ecchymotic areas on the wrist and
ankles may be present if the child was tied to a
bed or against the wall.
• “doughnut hole” effect- ring of burns when a
child is placed in a hot tub.
• if a child is lowered into scalding water as
punishment, only the feet and the skin up to
the knees are scalded.
• cigarette burns causes blisters taht resembles teh scab of impetigo.
It heals with a definite circular scar.
• a broken bone at preschool age suggests that the child was thrown
or struck so hard.
• COMMON FINDINGS: a single fracture with multiple bruises, rib or
occipital fractures and metaphyseal-epiphyseal injuries.
 SHAKEN BABY SYNDROME
• caused by repetitive, violent
shaking of a small infant by the
arms or shoulders.
• causes a whiplash injury to the
neck, edema to the brainstem
and distinct retinal
hemorrhages.
• insidous form of child abuse
beacuse the damage on the
infant is not readily apparent.
• can be seen through CT scan and
MRI
 RITUAL ABUSE
• -cult based or religiously, spiritually or satanically motivated.
• can involve physical, sexual or psychological abuse with bizarre
ceremonial activities.
• multiple perpetrators may abuse multiple victims over and
extended period.
 PHYSICAL NEGLECT
• a neglected child may appear unwashed, thin and malnourished.
• infants are without mittens and coats
• failing to bring a child during immunizations and failing to seek early
medical care for an infection or other signs of neglect.
• not requiring a child to go to school or allowing a child to go
unsupervised after school
 PSYCHOLOGICAL ABUSE
• constant belittling or threatening, rejecting, isolating or exploiting a
child.
• absence of positive parenting
• likely to have difficulty becoming emotionally confident adults
• the parent only uses negative terms to describe a child
MUNCHAUSEN SYNDROME BY PROXY
• refers to a parent who repeatedly brings a child
to a health care facility and reports symptoms of
illness when, in fact, the child is well.
• the reporting of symptoms causes the child to
undergo needless diagnostic procedures or
therapeutic regimens.
• the parent deliberately inflict injury on the child
such as giving laxatives to induce diarrhea or
slowly poisoning the child with prescription drug.
 FAILURE TO THRIVE
(REACTIVE ATTACHMENT DISORDER)
• a unique syndrome in which an infant falls
below the 5th percentile for weight and
height on standard growth chart.
• the parent feels little emotional attachment
to the child.
• the parent may not be offering enough food.
• a child may be irritable, fussy, colicky or
“difficult” child,
 PHYSICAL EXAMINATIONS
• 1. Lethargy with poor muscle tone, a los of
subcutaneous fat, or skin breakdown
• 2. Possibly a greater reluctance to reach for toys
or initiate human contact than is demonstrated
by the average infant.
• 3. Staring hungrily at people who approach them
as if tehy are starved fro human contact.
• 4. Little cuddling or confroming to being held by
the second month of life.
• 5. Developmental milestones is poorly achieved.
• 6. Diminished or non existent crying.
 SEXUAL ABUSE
• - broadly defines as any sexual conatct
between a child and an adult.
• - involves the coercion of dependent,
developmentally immaature children or
adolescents in sexual activities that they do
not fully comprehend.
• - physically and emotionally destructive, leaves
children unable to trust others and may result
in a sense of ambivalence toward intimacy.
• -children should be taught at an early age that
their bodies are their own and to report
anyone who tries to touch them in a way they
do not like.
 MOLESTATION
• -””indicent liberties” such as oral-genital contact,
genital fondling and viewing and masturbation.
• - PEDOPHILE- an adult who seeks out children fro
sexual gratification. - may be very gentle and limit
the involvement of molestation.
• - takes photos or videos of their sexual activity
• -LISTEN carefully to a child who report that
someone enjoys photographing them, ask
children to describe “touching” them to detect
this type of abuse.
 INCEST
• -sexual activity between family
members. Often involves an older man
and a young girl, a brother and sister or
same sex partners.
• - results in destructive relationship
because it causes a great deal of guilt
and loss of self-esteem in both the
abusing and abused person.
 RAPE
• -sexual activity such as intercourse or penetration of a body orifice by
a penis or other object under ACTUAL THREATENED FORCE.
• STATUTORY RAPE- sexual activity with a person below 18
• SEXUAL ASSAULT- forced sexual acts, such as oral-genital or anal
genital acts
• DATE RAPE- an individual forces a date or casual friend into having
coitus despite a voiced unwillingness. FLUNITRAZEPAM- drugs easily
dissolved into a drink.
• - degrading and dehumanizing
• victims can be of any age or gender
• - rapist may be a relative or a family friend or a
stranger
• - based on arrest data- the average rapist is a young
adult man with a background of AGGRESSIVE
BEHAVIOR. His motivation usually relates to
expressions of power or anger- sexual satisfaction
does not appear to be a dominant motive.
• rape tends to be repititive, planned activity rather
than an isolated event.
• RAPE TRAUMA SYNDROME- a from of post traumatic stress sundrome
and usually occurs in 2 stages: DISORGANIZATION and
REORGaNIZATION.

• DISORGANIZATION PHASE- victim feel a combination of humiliation,

shame and guilt, embarassment, anger and vengefulness. They may
tremble from fear or be in great pain from perineal lacerations. They
need gentle symphathetic support people to allow them to feel safe.
• REORGANIZATION PHASE- may last fro months or
years.
• - victims report reccuring nightmares, sexual
dysfunction and continuing inability to relate to
men or to face new and surprising situations.
• - great deal of difficulty discussing the rape.
• - if not offered constructive counsel, victims may
feel guilt or shame as long as 20-30 years later.
 INTIMATE PARTNER ABUSE
• - absue by a family member against
anotehr adult living in the household
such as spouse or significant other.
• - common injuries suffered by abused
women include burns, laceraton,
bruises and head injuries.
• - occurs at higher rate during
preganancy than other times. This
probably happens because stressed is
often triggered to abuse, with all that
an expected new child entails.
GOALS OF CRISIS INTERVENTION FOR
FAMILIES OF RAPE VICTIMS
• 1. Help the family to express openly their immediate feelings in
response to a rape
• 2. Help the family work through immediate practical matters and
initiate problem solving techniques.'
• 3. Explain possibility of future psychological and somatic symptoms
taht characterize a rape trauma syndrome and what the family can do
to minimize the symptoms.
• 4. Educate the family about rape as a VIOLENT CRIME.
• 5. Allow time for thoughts and feelings in decision making later.
 KEY POINTS FOR REVIEW
• - Child abuse can exist in many forms.
• - A high suspicion for child abuse shoul be present if burns, head
injury or rib fractures are present
• - A triad of “special parent, special child, special circumstances” is
chcacteristic of the family in which child abuse occurs.
• - Child abuse is reportable by law.
• - Sexual abuse of children can be prevented by teaching children to
recognize abnormal advances and to know it is right to speak out
about wrongs against them.
• - Abuse is a family problem, not an individual problem. Therapy must
include family members to be effective.
 CRITICAL THINKING EXERCISES
(GROUP ACTIVITY)
• GROUP 1

• Sandra is a 4 years old child, brought by the mother for check up at

the clinic. Physical examination determines a purulent vulvovaginitis.
A culture reveals this infection is gonorrhea. What questions would
you want to ask her to determine how she contracted this infection?
Suppose her parents are influential people in your community. Would
this fact influence what question you asked?
• GROUP 2:

• Agnes is a 3 year old you see in a emergency department. Her mother tells
you Agnes fell of a swing in the backyard. Agnes has a broken forearm, a
broken rib, and multiple bruises on her chest and back. You notce in her chart
that Agnes was seen in the same emergency room a month ago for a burn on
palm of her hand. You suspect Agnes is a victim of child abuse. How would
you interview the mother and what nursing interventions are you going to
do?
• GROUP 3:

• Gail is a 14 years old and attends in the youth club where you aork as a
volunteer. She is quiet at the best of times, but this evening you notice that
she is more withdrawn than usual and has kept her jacket even though the
building is warm. Gail eventually takes her jacket off and you notice there are
superficial cuts on the outside of both her forearms, and some scans
elsewhere on her forearm taht are of the same apttern as the recent cuts.
• What type of abuse, harm or neglect could be taking place? What are the
signs and symptoms? What action should you take?