1. Chapter 33 Abuse in the Family and Community

2. Child Abuse
Every family faces many types of stress at one time or another
Dysfunctional family
One that cannot resolve these stresses and work through them in a positive, socially acceptable manner
Abuse in the family can take various forms
Abuse in the family can have a significant negative impact on the child’s growth and development, physical and emotional health

3. Child Abuse (cont.) Events that create stress for a family include
Illness
Job loss
Economic crisis or poverty
Relocation
Birth
Death
Trauma

4. Child Abuse (cont.)
Evolution of cultural practices in the United States during the last few decades of the 20th century emphasized the rights of children
Child abuse has come to mean any intentional act of physical, emotional, or sexual abuse, including acts of negligence, committed by a person responsible for the care of the child
Estimates of the number of children treated in emergency departments after an episode of abuse range from 500,000 to 1 million annually

5. Child Abuse (cont.)
Child abuse: Not limited to one age group, can be detected at any age
Children from birth to 3 years old has the highest number of victims of child abuse
Girls are abused more frequently than boys
Abusive parents can be found at all socioeconomic levels
Families with greater financial means may be able to evade detection more easily
According to some studies, low-income families show greater evidence of violence, neglect, sexual abuse

6. Child Abuse (cont.) Commonly, abusive parents
Have inadequate parenting skills
Have unrealistic expectations of the child
May not respond appropriately to the child’s behavior
State laws require health care personnel to report suspected child abuse

7. Child Abuse (cont.) If abuse is suspected
Health care facility can hold the child for specified amount of time
Usually 72 hours
Then a court holds a hearing
To determine if charges are true
To decide where child should be placed

8. Child Abuse (cont.) Types of child abuse Physical abuse
If inexperience is coupled with dysfunctional coping, the caregiver may physically abuse
Some young women become pregnant to have a child to love, and they expect that love to be returned in full measure
Some cultures support physical punishment for children, citing the principle “spare the rod, spoil the child”

9. Child Abuse (cont.) Types of child abuse (cont.)
Physical abuse (cont.)
Physical punishment that leaves marks, causes injury, or threatens the child’s physical or emotional well-being is considered abusive
A child’s physical injury requires medical attention
Family caregivers may attribute the injury to some action of the child’s
May be inconsistent with the child’s age or level of development

10. Child Abuse (cont.) Types of child abuse (cont.)
Physical abuse (cont.)
Pay attention to what you see
Young, active children often have a number of bruises that occur from their usual activities
Bruises that occur in areas of soft tissue may be suspect
Bruises: Distinctive in outline
Injuries may be in varying stages of healing

11. Child Abuse (cont.) Types of child abuse (cont.)
Physical abuse (cont.)
Signs or possible evidence of child abuse can be further evaluated by the use of technology
Bone fractures in various stages of healing
Spiral fractures of the long bones
Computed tomography may demonstrate cerebral edema or cerebral hemorrhage

12. Child Abuse (cont.) Types of child abuse (cont.)
Physical abuse (cont.)
Burns are another common type of injury
Cigarette burns
Burns from immersion
Hot register (as evidenced by the grid pattern)
Steam iron
Curling iron

13. Question Tell whether the following statement is true or false.
Child abuse has come to mean any act of physical, emotional, or sexual abuse, including acts of negligence, committed by a person responsible for the care of the child.

14. Answer
False
Rationale: The act of abuse must be intentional. Child abuse has come to mean any intentional act of physical, emotional, or sexual abuse, including acts of negligence, committed by a person responsible for the care of the child.

15. Child Abuse (cont.)
Shaken baby syndrome: Occurs when a small child is shaken by the arms or shoulders in a repetitive, violent manner
Causes a whiplash-type injury to the child’s neck
Child may have edema to the brainstem and retinal or brain hemorrhages
Loss of vision, mental retardation, or even death may occur in these children

16. Child Abuse (cont.) Shaken baby syndrome (cont.)
Clinical manifestations may include
Lethargy; irritability
Vomiting; seizures
Often the signs of this form of child abuse are not easily observed and may be missed during physical examination
Internal symptoms are detected by the use of computed tomography (CT) and magnetic resonance imaging (MRI)

17. Child Abuse (cont.)
Munchausen syndrome by proxy: Child is brought to a health care facility with reported symptoms of illness when the child is actually well
Child’s mother is most often the person who has the syndrome
Mother appears very attentive to the child
Often is familiar with medical terminology
Situation is frustrating for health care personnel
Close observation of caregiver’s interactions with child is necessary

18. Child Abuse (cont.) Emotional abuse Types of emotional abuse
Verbal abuse: Humiliation, scapegoating, unrealistic expectations with belittling, erratic discipline
Emotional unavailability when caregivers are absorbed in their own problems
Insufficient or poor nurturing, or threatening to leave the child or otherwise end the relationship
Role reversal in which the child must take on the role of parenting the parent and is blamed for the parent’s problems

19. Child Abuse (cont.) Emotional abuse (cont.)
Evidence of emotional abuse
Appearing worried or fearful
Vague complaints of illness or nightmares
Young children: Failure to thrive
Potential clues in older children
Poor school performance and attendance
Poor self-esteem; poor peer relationships

20. Child Abuse (cont.) Neglect
Failure to provide the following supports needed for growth and development
Adequate hygiene; health care
Education; nutrition
Love; nurturing; supervision
Often a child who fails to thrive as a result of being underfed, deprived of love, or constantly criticized can be classified as neglected

21. Child Abuse (cont.) Sexual abuse
“The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or interfamilial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children” (Child Abuse Prevention and Treatment Act as Amended by the CAPTA Reauthorization Act of 2014).

22. Child Abuse (cont.) Sexual abuse (cont.) Incest
Knows no socioeconomic, racial, religious, or ethnic boundaries
Contributing factors
Substance abuse
Job loss
Poverty

23. Child Abuse (cont.) Sexual abuse (cont.) Commonly used terms
Sexual contact
Sexual assault
Sexual abuse by a person the child trusts seems to be the most damaging type

24. Question
A 4-year-old boy is brought to the clinic with a vague history of stomach aches and vomiting. While in the clinic the nurse overhears the mother telling the child that if he doesn’t behave she will just leave him in the clinic and not come back for him. The nurse knows this is what kind of abuse?
a. Physical
b. Emotional
c. Neglect
d. Verbal

25. Answer
b. Emotional
Rationale: Emotional abuse includes insufficient or poor nurturing, or threatening to leave the child or otherwise end the relationship.

26. Child Abuse (cont.) Effects on the child and family
Long-term and immediate effects
Hyperactivity
Exhibit angry, antisocial behavior
Especially withdrawn
Child may be removed from family
Abusive parents often were abused themselves as children

27. Nursing Process for the Child Who is Abused
Assessment
It is important to observe and document thoroughly and completely
Complete physical examination
Most difficult part: Maintain a nonjudgmental attitude throughout interview, examination

28. Nursing Process for the Child Who is Abused (cont.)
Selected nursing diagnoses
Anxiety, fear by child related to history of abuse and fear of abuse from others
Impaired parenting related to situational stressors or poor coping skills
Disabled family coping related to unrealistic expectations of the child by the parent
Ineffective coping by the nonabusive parent related to fear of violence from abusive partner or feelings of powerlessness

29. Nursing Process for the Child Who is Abused (cont.)
Outcome identification and planning
Major goals for the abused child include
Caring for any injuries the child has sustained
Relieving anxiety and fear
Important family goal
Improve parenting and coping skills of the caregiver or family

30. Nursing Process for the Child Who is Abused (cont.)
Implementation
Relieving child’s anxiety and fear
Observing interaction between caregiver and child
Promoting parenting skills and coping
Supporting nonabusive caregiver
Evaluation: Goals and expected outcomes

31. Question What is one of the major goals for the abused child?
a. Subduing the abusive caregiver
b. Removing the nonabusive caregiver from the family
c. Relieving the child's anxiety and fear
d. Reporting the child’s injuries

32. c. Relieving the child's anxiety and fear
Answer
c. Relieving the child's anxiety and fear
Rationale: Major goals for the abused child include
Caring for any injuries the child has sustained
Relieving anxiety and fear

33. Domestic Violence in the Family
Effects on the child and family
Even if all family members are not victims of the violence, each family member is affected
Child may
Witness domestic violence
Overhear it from another room
See physical evidence such as bruises or broken bones on the victimized parent

34. Domestic Violence in the Family (cont.)
Effects on the child and family (cont.)
In most cases, domestic violence victim is the mother
Older children, especially adolescent males, may feel a need to intervene to protect their mother
A person who is violent toward a spouse will often abuse his or her children as well

35. Domestic Violence in the Family (cont.)
Clinical manifestations in the child
Symptoms may be referred to as symptoms of post- traumatic stress disorder, may include
Inability to sleep; bedwetting
Temper tantrums; withdrawal
Feelings of guilt for not being able to protect the victim
School-aged child may have academic problems, frequent absences, behavior issues, or self-isolation

36. Domestic Violence in the Family (cont.)
Clinical manifestations in the child (cont.)
Older children will often use drugs or alcohol; get into legal trouble, many times by committing a crime against another person; attempt/commit suicide
As a nurse, be aware of the signs/symptoms exhibited by families affected by domestic violence
Ask direct and specific questions
Provide support to the child
If child is a victim, may be removed from home

37. Bullying
Peer abuse: Deliberate and repeated aggressive behavior, usually against a weaker peer
Physical: Hitting, kicking, taking belongings
Verbal: Teasing, name-calling, insulting
Psychological: Spreading rumors, exclusion
Cyber: Text messaging, , social networking

38. Bullying (cont.) Effects on the child
Potential long-lasting psychological effects
Clinical manifestations
Physical signs
Subtler signs
Avoidance of behaviors

39. Parental Substance Abuse
>10% of children come from a home affected by parental alcoholism
Children of alcoholics have increased risk of becoming alcoholics themselves
When other substances are included, number of affected homes increases substantially

40. Parental Substance Abuse (cont.)
Effects on the child and family
Substance abuse is a family problem
Developmental delays occur in young children
Parent is not dependable, cannot provide stability
Children of substance-abusing parents often become loners, avoid relationships
Codependency adds to the dilemma of children living with an addicted parent

41. Parental Substance Abuse (cont.)
Clinical manifestations in the child
Children rarely talk about the parent’s problem even to the other parent
Children often experience guilt, anxiety, confusion, anger, depression, and addictive behavior
Older child, often a girl, may take on parental role and tasks toward younger siblings
May become overachievers in school, remain emotionally isolated

42. Parental Substance Abuse (cont.)
Clinical manifestations in the child (cont.)
Another child may try to deflect embarrassment and anger of other siblings by trying to make everyone feel good
As these children become adolescents or young adults, they may have problems such as substance abuse or eating disorders
Child in the family who “acts out” and engages in delinquent behavior is most likely to come to the attention of social services
May be identified as a child who needs help

43. Behaviors that may Alert to an Addiction Problem in the Family
Loner child who avoids classmate interaction
Child who is failing in school or has frequent unexcused absences or truancy
Child with frequent minor physical complaints, such as headaches or stomachaches
Child who steals or commits acts of violence
Aggressive child
Child who abuses drugs or alcohol

44. Behaviors that may Alert to an Addiction Problem in the Family (cont.)
Support strategies
Children can benefit from programs that support them and help them understand what is happening in the home
May include group therapy
Professional help is necessary to prevent the child from developing more serious problems