Violence among family members is a complex issue intertwined with many factors such as, poverty, alcohol/substance abuse, stress and an ongoing cycle of violence. These factors are not necessarily the cause of violence but may influence the development of family violence.

Child Abuse:

Child abuse - Parents anonymous recognize six forms of child abuse.

1. Physical abuse: Acts of commission such as burning or beating
2. Physical neglect: acts of omission or inadequate parenting abilities like improper food or clothing.
3. Emotional abuse: attitudes directed to the child that may be harmful to emotional development.
4. Emotional neglect: lack of parent-child interaction
5. Sexual abuse: involvement of the child with a parent or adult family member in activities ranging from sex play to actual intercourse.
6. Verbal abuse: assaults on the child that are verbally degrading like constant ridicule.

We must be aware of behavioral clues that indicate potential or suspected abuse.

Physical abuse behavioral indicators include the following:

Wary of adult contacts

Apprehensive when other children cry

Extremes such as aggressiveness or withdrawal

Frightened of parents/ afraid to go home

Reports injury by parents

Physical neglect behavioral indicators:

Begging or stealing food

Extended stays at school

Constant fatigue/ sleeping in class/ listlessness

Alcohol or drug abuse

Delinquency

States there is no caregiver at home

Sexual abuse behavior indicators:

Unwilling to change for gym class or participate in gym

Withdrawal, fantasy, or infantile behavior

Bizarre, sophisticated or unusual sexual knowledge or behavior

Poor peer relationships

Delinquent or runaway behavior

Reports sexual assault by caretaker

Emotional maltreatment behavioral indicators:

Habit disorders (rocking, biting, sucking)

Conduct disorders

Sleep disorders or inhibition of play

Obsession/ compulsion/ phobias/ hypochondria

Behavior extremes- passive, compliant or aggressive and demanding

Inappropriately adult or inappropriately infantile

Developmental lags

Attempted suicide

For physical indicators see page 824

Physical Abuse:

Physical abuse is also emotional abuse. Abusive parenting behaviors are a consequence of many factors. The most potent factors are stress, family resources, social isolation, or a combination of them all. Having experienced a particular form of punishment as a child is a significant risk factor for parents who approve of that style of punishment for their children. For example, the parent was whipped with a leather belt as a child and now as a parent, he/she thinks that whipping their child with a leather belt is appropriate.

Munchausen syndrome by proxy- is a form of physical abuse. The parent (typically the mother) fabricates an illness in her child. The parent lies about the Childs illness to get praise or attention.

Sexual Abuse:

Sexual abuse- forced, tricked, or coerced sexual behavior between a young person and an older person. Older definitions include an age difference of at least 5 years between the victim and the perpetrator. Sexual abuse is not limited to intercourse. The sexual abused child may be unable to cope physically, emotionally, or intellectually. They often suffer shame, guilt, and anxiety. As many as 80% of the victims are abused by people known to them.

Characteristics of the sexually abusive adult:

1. Lack of impulse control
2. Confusion of roles (child is regarded as an object of the adult’s need)
3. Both of the above may be seen in all types of child abuse
4. Passive, introverted, sociopath, alcoholic, socially isolated, or inadequate.
5. Low self- esteem, emotional immaturity, and difficulty relating to age appropriate peers.
6. Chaotic or dysfunctional family of origin- increases the risk for molestation.
7. Both parents may be distant or inaccessible, stimulate a sexual climate in the home, or keep family secrets such as an affair.

Characteristics of the sexually abused child:

1. Girls are victimized more often than boys are.
2. It is unclear what factors increase a Childs risk.

Children expect adults to perceive what is happening and protect them. When this does not occur the childs trust diminishes. If a female victim enters therapy typically, she is 20-25 years old, married, and complains of marital problems.

Short-term consequences of sexual abuse:

1. Nightmares, anger, hostility, withdrawal from activities, academic problems, daydreaming, aggressive behavior, and over compliance or anxious to please. Other behavioral problems seen in older abused children include: Prostitution, suicide attempts, drug or alcohol abuse, and entrance into cults. DID and PTSD. They also may have confusion about their sexual identity and sexual norms or equate sex with love and caring.
2. Health care concerns: STD’s, pregnancy, and/or eating disorders.

Long- term victim consequences:

1. Rageful behaviors, disrupted marriages, dissatisfaction with marital relationships, and a tendency to be religious non- practitioners.
2. Increased risk of adult alcohol abuse, marriage to an alcohol abuser, being the victim of date or marital rape.
3. DID, PTSD

Emotional Abuse

Emotional Abuse, verbal abuse and neglect fall under the category of emotional maltreatment. Keep in mind that the emotional maltreated child may also be sexually or physically abused. Physically abused children are always emotionally maltreated.

Parents of an emotionally disturbed child WILL recognize that there is a problems and seek help. Where as parents of an emotionally maltreated child will not. They may blame the child for the problem and refuse or delay seeking help. The parents at times may appear to be unconcerned for the childs welfare.

Behavioral indicators of abusive parents:

1. Lack of concern about the child
2. Attempt to conceal the injury to protect the abuser
3. Routine use of harsh, unreasonable or age inappropriate punishment
4. High demands from the abusers own parents
5. Inability to provide emotionally for self as an adult
6. Expectations that the child will fill an emotional void
7. Views the child as a small adult
8. Use displacement

Effects of violence on the child:

• Medical damage and health complications- early developmental delays, STD’s, Neurological soft signs, Scars, physical injuries, intracranial bleeding and intraocular bleeding to name a few.

• Wary of physical contact with adults, seems frightened by parents, stares in a vacant or frozen manner, seeks affection from everyone, may not cry or react in a frightened way during a painful procedure.

• Loss of school days, deficit in reading, poor grades and academic performance, low self –esteem, aggression, social and peer difficulties.

• Denial, repression, dissociation, identification with aggressor, absence of feelings, rage, depression, sadness.

NURSING PROCESS

• ASSESSMENT:

1. Screening families for possible child abuse.
1. Generational abuse- do the parents have a history of childhood or partner abuse? What are their attitudes towards abuse?
2. Prenatal characteristics- denial of pregnancy or lack of prenatal care?
3. Intrapartum characteristics- labor and delivery concerns, separation of mother and baby immediately after delivery?
4. Postpartum characteristics- no interest in the infant, no name given, poor eye contact
5. Infant and child characteristics- multiple births, physically challenged, low birth weight, premature.
6. Parental characteristics- drug/alcohol use or history
7. Family characteristics- unemployed/ financial concerns
8. Stress and life crisis
9. Social isolation

• Any of these predictors alone or in combination may not indicate abuse but they are signals of needed interventions for optimal parenting.

1. Investigating child abuse- complete a social assessment of the family to determine if the child is safe in his/her present surroundings. Find out the following:
1. Are weapons available to the abuser?
2. Have weapons been used or may have a weapon been used in the present abusive situation?
3. Is there use of alcohol or a history of abuse of alcohol?
4. Is there talk of murder or suicide?
2. Evaluate the childs physical health:

• The Multidisciplinary approach (nurse, social worker, psychologist, physician, chaplain and lawyer) is widely advocated. The nurse is responsible for getting a health history on the child, finding out the parents’ explanation of the childs injury and if it correlates with the childs injury. The accident-prone child should be further assessed.

• Physical assessment should focus on the condition of the skin (bruises in various stages of healing, lacerations, burns, etc). Determine preventative health practices by asking the parents if the childs immunizations are up to date and if the child is seen on a regular basis. Nutritional status is assessed by a history of the childs diet, the age appropriateness, and adequacy of the diet.

• When collecting evidence for a sexual assault examination the following types of evidence is useful to prove an assault occurred:

1. Evidence of force or coercion against the victim’s will

1. Evidence indicating the identity of the assailant
2. Evidence indicating that sexual assault occurred in a specific time frame.

Evaluating the childs psychosocial status:

Pay particular attention to the quality of parent-child interaction, the degree of parental cooperation or resistance to medical treatment, the degree of parental concern of the situation and the parents coping abilities.

A CHILD BROUGHT TO THE E.R AS A SUSPECTED VICTIM OF ABUSE SHOULD BE ADMITTED TO THE HOSPITAL. This allows time to perform a thorough examination and protects the child from a potentially abusive situation. If the parents do not comply, the hospital can obtain a court order. It is mandatory for nurses who suspect abuse to report it.

NURSING DIAGNOSIS:

1. Risk for family violence R/T lack of family support and medical care during pregnancy, identification of unliked traits in the child that are seen in one or both parents.
2. Risk for family violence R/T increased daily use of alcohol and drugs, inability to communicate effectively among all family members, lack of social involvement with family and friends, history of child abuse to one or both parents, increased stress (perceived or actual) currently or continuing for long periods of time.

INTERVENTION:

1. Know your feelings
2. Establish trust and rapport with the victim and family
3. Do not forget the childs emotional needs
4. Explain all tests and procedures in words a child can understand before the procedures begin.
5. Talk, sing, read, and play with the child to establish rapport
6. Remember that the child may not permit touching
7. Communicate feelings verbally or though some other medium
8. Bibliotherapy
9. Accept the child and provide activities in which the child excels

• Intervening with the parents:

1. Establish trust and rapport- be nonjudgmental
2. Communicate honestly regarding the report filed and the possible outcomes
3. A feeling of faith that the parents can learn to parent is important to express.
4. Confidentiality
5. Establish realistic goals
6. Community resources such as Parents Anonymous
7. The courts may require the parents to undergo a psychiatric consultation
8. Nursing interventions must be directed at the entire family don’t single out the abuser. The entire family will gain from the interventions regardless if they are the abuser or not.

ABUSIVE SPOUSES AND PARTNERS

• They are often characterized as having a need to control, an inability to recognize anger, have low self-esteem, dependency conflicts, a fear of intimacy, and have violent family backgrounds. The abuse often begins or becomes worse during pregnancy especially during the third trimester.

• There is a cycle of abuse the three stages are as follows:

1. Reconciliation- the couple temporarily resolves the state of increased tension but it is short lived.

Effects on the woman:

• Physical - injuries to the head, neck, and shoulders. Black eyes are most common.

• Behaviors - fearfulness, jumpiness and distance seeking. Emotional and financial dependency, a rigid adherence to patriarchal sex roles, low self-esteem and a socially learned pattern of violence.

• Psychological symptoms - anxiety, fear, recurrent nightmares, sleep and eating disorders, numbed affect, hypervigilance, and increased startle responses.

• The battered woman often feels powerless, defeated, and fearful in a battered relationship. They often turn to alcohol and drugs to help them cope (which we know is maladaptive). More severe consequences include suicide, attempted suicide and homicide.

ASSESSING THE BATTERED WIFE / PARTNER:

1. May be tied in with child abuse- some women who are abused by their partner abuse their children and some men abuse their spouse and their children.
2. She is likely to come to the E.R without her spouse, has no private doctor, and complains of a fall. There may be a delay between the time of the injury and seeking treatment. She may be hesitant in providing information about the injury or minimize the injury.
3. A history of repeated injuries or an injury that is not adequately explained should alert suspicion and encourage a closer investigation of the woman’s situation.
4. Between battering incidences the woman may see her doctor and C/O insomnia, nervousness, abdominal pain and / or H/A. These manifestations are precipitated by the woman’s knowledge that the battering is cyclical and the next episode is approaching.
5. If abuse is suspected but the clues are indecisive, the woman MUST be asked direct questions. Ask, " How often does your partner hit (push, punch, slap, etc.) You? Instead of asking,"does your partner hit you?"
6. Keep in mind cultural and religious practices.

Nursing Diagnosis:

Risk for family violence R/T increased daily use of alcohol and drugs, inability to communicate effectively with all family members, lack of social involvement with friends and family, increased perceived or actual stress currently or continuing for a long period of time, history of child abuse to one or both parents. (Sound familiar?)

Planning:

Establish trust and rapport with client and family. Be nonjudgmental. Acceptance and willingness to be open and work with the family will promote the attainment of long-term goals to prevent further abuse.

Interventions:

1. Treat the injuries; if they are not severe enough to admit the patient to the hospital consider where the patient will go. Many women choose to go home and this is a choice that the nurse must accept. Walk through safety issues with the woman and follow up. If the woman chooses to go to a shelter she will have increased social support, increased quality of life, less depression, less emotional attachment to the assailant, and an increased sense of power.
2. A thorough assessment and record keeping is crucial in cases of suspected abuse.
3. Effective interventions of marital and courtship violence works on the following three levels.
1. Primary intervention- emphasis on education and development of problem solving skills.
2. Secondary intervention- provides education and problem solving techniques to partners who were previously in violent relationships. Learning to negotiate and compromise is essential
3. Tertiary intervention- emphasizes the identification of the group needing services.

Treating the batterer (abuser)

1. Be nonjudgmental and open without condoning the situation
2. Group therapy is # 1.
3. Honest communication and building rapport is important
4. Use the following strategies:
1. Be familiar with research on sexual offenders
2. Remain in control during the interview
3. Allow the offender to assume that you know a great deal of his history
4. Interview the family members separately
5. Use multiple data sources
6. Emphasize what happened and not why it happened
7. Use behavioral descriptions
8. Ask direct questions
9. Develop a "yes" set of questions it helps with agreement and cooperation with the offender
10. Ignore answers that you believe are untruthful
11. Repeat questions
12. Avoid multiple questions
13. Ask questions quickly
14. Alternate support and confrontation
15. Frame disclosure as positive action

ELDER ABUSE

It does not always involve physical abuse.

Definitions of abuse:

1. Physical abuse- willful and direct infliction of pain and injury
2. Neglect- lack of attention, abandonment, or confinement by family or society.
3. Psychosocial abuse- withholding decision making power and affection or social isolation
4. Exploitation- dishonest or inappropriate use of the elder’s money, property, or other resources.

• The majority of elder’s are abused by their partners. Elderly men are at greater risk than elderly women are because they are most likely to be married.

ELDER ABUSERS Profile:

Middle aged or older

Often a spouse but may be a daughter or a son

Experiencing stress (financial, medical, marital, unemployment)

Increased demands on caretaker role depleting family resources

Resentful of role reversal with parent

Low self-esteem

Impaired impulse control

Possible abuse as a child

Substance abuse

Possible behavioral clues during contact with the elderly victim:

Acts excessively concerned or unconcerned

Treats the elder like a child or nonperson

Shows minimal eye contact or verbal contact with the elder and you

Refusal to permit hospitalization of the elder

Failure to visit the elder if admitted to the hospital

Refusal to allow the elder to be interviewed alone

Effect on the elder:

Physical consequences

Embarrassment may prevent the elder to report abuse

Assessing the abused elder:

1. Client brought to the hospital by a person other than the caregiver
2. Frequent repeat visits for various injuries
3. History of going from Dr. to Dr.
4. Delay between time of injury and seeking help
5. Inconsistency between the explanation of the injury and the clinical findings

1. Care needs exceed or soon will exceed the care takers abilities
2. Care giver is feeling frustrated in giving care
3. Care giver is demonstrating signs of stress
4. The living situation includes substance abuse by the caregiver
5. Family history of abuse

Nursing diagnosis:

Risk for elder abuse R/T adult caregivers history of abuse as a child by the elder; increased caregiver stress due to increased dependency of the elder.

Planning:

Establish trust and rapport with the elder and the family- see planning for spouse abuse

Intervention:

• Be aware of community resources for the elderly victim and caregiver.
• There is more information on page 850

• The nurse should educate other professionals about family violence

Theories:

• Psychobiological theory- (Restak) there is an association between poor mother-infant interaction and potential child abuse

Human Ecological Theory- 4 levels

1. Ontogenic development- considers the history of abuse in abusing parents and parental expectations of the child
2. Microsystem- Infant and child characteristics and marital stress or conflict
3. Exosystem- work world and neighborhood- is there social isolation?
4. Macrosystem- the attitude of society about violence in general

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