Chapter 25: Abuse and Neglect PDF

**Chapter 25: Abuse and Neglect** - Abuse statistics by gender: CDC 2018 report on intimate partner & sexual violence - **Women** - 1 in 5 experienced attempted or completed rape - 1 in 6 stalked - 1 in 4 experienced contact sexual or physical violence...

**Chapter 25: Abuse and Neglect** - Abuse statistics by gender: CDC 2018 report on intimate partner & sexual violence - **Women** - 1 in 5 experienced attempted or completed rape - 1 in 6 stalked - 1 in 4 experienced contact sexual or physical violence and/or stalking by intimate partner or some form of intimate partner violence-related impact - **Men** - 1 in 14 forced to sexually penetrate someone else - 1 in 17 stalked - 1 in 10 experienced contact sexual or physical violence and/or stalking by intimate partner or some form of intimate partner violence-related impact - **Most incidents often occur before the age of 25 (men & women)** - **Abuse statistics by age (all abuse cases)** - **Children (below age 18)** - Adverse Childhood Experiences (ACEs) - 61% neglected, 10.3% physical abuse, 7.2% sexual abuse (2021, US DHHS) - In 2019, 1840 children died due to abuse or neglect - Human trafficking - Many abusers experienced abuse as children - **Mandatory reporting of child abuse federal law in 1968** - **Elder (over age 60)** - 1 in 10 living with family are victims of physical/sexual abuse, neglect, abandonment, and/or financial exploitation (CDC, 2020) - Neglect is most common - Institutional Abuse - Only 1 in 24 case of institutional abuse are reported - **Predisposing factors: biological theories** - **Neurophysiological** - Lower volume of amygdala \[responsible for fear; immediate processor of every sensory received\] - People are more prone to react quickly & impulsively if it's smaller vs if it was bigger - Decreased connectivity between amygdala & prefrontal cortex - Limbic prefrontal cortex gray matter volume & connection to amygdala - Lower left-side & greater right-side volumes - Striatum dysfunction (striatum is involved in motivation and reward) - **Biochemical** - Role of serotonin - Low striatal serotonin is implicated in violence - Elevated plasma concentrations of serotonin in CSF - GABA and glutamate modulate serotonin-influenced violence - Increased dopamine release - Testosterone & cortisol levels - Complex interaction with serotonin - **Reactive aggression:** an impulsive response to a received threat or provocation - Associated with impulsivity and is more common among people who have a history of being abused - **Proactive aggression:** aggression is a deliberate and planned action to achieve a specific goal - Is initiated rather than provoked and is more common in psychopathy - **Genetic** - At least 40 genes associated - Trauma can alter genetic expression - 50% heritability - ADHD & depression share common DNA variants - Possible X-chromosome linked mutations of MAO-A gene \[breaks down neurotransmitters\] - Serotonin transporter gene - **Brain structure/function** - **Organic brain syndromes associated with various cerebral disorders and traumatic brain injury have been implicated in the predisposition to aggressive and violent behavior.** - Tumors: Limbic system & temporal lobe - Brain trauma: Cerebral changes - Disease process - Epilepsy especially temporal lobe - Encephalopathy and medications that impact this - **Predisposing factors: Psychological, pg. 702** - **Psychodynamic Theory** - Expresses how our childhood experiences shape our development - Unmet needs of satisfaction & security results in underdeveloped ego and weak superego - When frustration occurs, aggression and violence follows - Feeling of power & prestige will boost self-image and validates a lacking significance - The immature ego cannot prevent dominant id behaviors from occurring, and the weak superego is unable to produce feelings of guilt - **Learning Theory** - Imitation of role models perceived as prestigious, powerful, influential, OR when the behavior is followed by positive reinforcement - Children may have an idealistic perception of their parents during the very early developmental stages but as they mature may begin to imitate the behavior patterns of their teachers, friends, and others. - Individuals who were abused as children or who witnessed domestic violence as children are more likely to manifest reactive aggression as adults - Individuals who have a biological predisposition toward aggressive behavior may be more susceptible to negative role modeling - **Predisposing factors: Sociocultural** - Aggressive behavior is primarily a product of one's culture and social structure - Accepted as primary influence for aggressive behavior - American society has accepted some forms of aggression and violence as the means to solve problems - War, physical discipline of children, law enforcement - Other society influences - Relative deprivation, marginalization, subcultures - Poverty, prolonged unemployment, lack of access to resources, emotional stress - Family breakdown, exposure to violence in family and/or community - **Nursing process: Intimate Partner Violence (IPV), pg. 704** - Aka Domestic violence, spousal abuse, battering - 9% of all homicides are committed by an intimate partner - **IPV**: A pattern of abusive behavior that is used by an intimate partner to gain or maintain power and control over the other partner - Physical, sexual, emotional, economic (controlling partners financial resources), or psychological actions or threats - Physical or sexual violence, stalking, psychological aggression - Intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound - **Battering**: a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner - **IPV Victim profile:** - No distinction in age, race, religion, culture, education or socioeconomic level - Low self-esteem - Women adhere to feminine sex-role stereotypes & accept relationships as male dominant - Accept blame for abuse - **Grew up in abusive homes & left at a young age through marriage** - **Learned Helplessness** - Progressive inability to act on their own behalf - Occurs when an individual comes to understand that regardless of their behavior, the outcome is unpredictable and usually undesirable - **IPV Perpetrator (Victimizer) profile** - Low self-esteem - Pathologically jealous & possessive - Views partner as personal possession - Threatened by partner independence or attempts to share self w/ others \[including children\] - **"Dual personality": one to the partner and one to the rest of the world** - May be charming to the world but yet is abusive to the intimate partner - Limited ability to cope with stress - Often ignore young children but may become targets of aggression as they grow & especially if they attempt to protect abused parent - May threaten to taking children away - Frequent degradation, insulting, and humiliating behavior toward partner - Achieves power and control through intimidation tactics - Goal to keep partner dependent **Cycles of Battering:** - **Phase 1: Tension-Building phase** - Senses declining tolerance for frustrations - Abuser becomes increasingly irritable, angry, and verbally abusive - Becomes angry with little provocation but apologizes quickly - Victim becomes increasingly nurturing & compliant in effort to prevent escalation of anger - Minor battering incidents - Victim rationalizes partner's abuse - Assumes guilt & accept "deserving it" - Abuser fears partner will leave; jealousy & possessiveness increases - Increased threats & brutality - Battering incidents become more frequent & intense - Victim unable to restore psychological equilibrium & withdrawals from partner - Example: The victim denies her anger and rationalizes his behavior (e.g., "I need to do better," "He's under so much stress at work," "It's the alcohol---if only he didn't drink"). She assumes the guilt for the abuse, even reasoning that perhaps she did deserve the abuse, just as her aggressor suggests. - **Phase 2: Acute Battering Incident** - **Most violent and shortest duration (up to 24 hours)** - Abuser releases built-up tension through severe verbal, emotional, or physical abuse - Begins with abuser justifying their behavior to self but ends with a feeling of loss of control - Desire to "teach them a lesson" - Victim may intentionally provoke behavior in effort to release unbearable tension - In long-term abuse, victim realizes once tension is released general interactions will improve - Victim may feel only option is to find safe place to hide - Potential dissociation from body; many victims can describe incidents in great detail - Abuser minimizes severity of abuse - Help is sought only if injury is severe or if in fear for life of self or children - **Phase 3: Calm, Loving, Respite ("Honeymoon") Phase** - Abuser becomes extremely loving, kind, & contrite \[feeling remorse\]; promises "never again" and begs forgiveness - Fear of partner leaving so uses "charm" - Believes he can control own behavior not that "lesson has been taught" & victim will not "act up" again - Abuser plays on victim's feelings of guilt & victim wants to believe cycle will end - Victim relives original dream of ideal love & chooses this vision of abusive partner - She bases her reason for remaining in the relationship on this "magical" ideal phase and hopes against hope that the previous phases will not be repeated - Victim holds this phase as view of the relationship - Basis for remaining in the relationship - Victim & abuser become locked in an intense, symbiotic relationship - In an effort to "steal" a few precious moments of the phase III kind of loving, the battered woman becomes a collaborator in her own abusive lifestyle. - **IPV: Why they stay** - Fear of retaliation (most common reason), Fear of losing custody of children - Physical or financial dependence, Lack of support network - Cultural/religious reasons, Hopefulness (that the abuser will change) - Lack of attention to danger - Abuse often doesn't stop once they leave - Risk of being killed increases by 75% after leaving an abusive relationship - **Child abuse:** - Erik Erikson (1963) "the worst sin is the mutilation of a child's spirit" - **Child Abuse Prevention & Treatment Act (CAPTA): identifies a minimum set of acts or behaviors that characterize child abuse or neglect.** - **Physical abuse**: any non-accidental physical injury as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting, burning or otherwise harming a child that is inflicted by a parent, caregiver, or other person who has responsibility for the child - **Sexual abuse**: 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 any visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other forms of sexual exploitation of children, or incest with children - **Emotional abuse**: Emotional injury resulting from belittling, rejecting, ignoring, blaming, isolating, use of harsh or inconsistent discipline - **Childhood physical abuse:** - Physical child abuse includes any nonaccidental physical injury as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, chocking, hittings, burning, etc. - **Signs in children** - Unexplained burns, bites, bruises, broken bones, or black eyes - Fading bruises or other marks noticeable after an absence from school - Seems frightened of parents; protests or cries when time to go home - Shrinks at approach of adults - Reports injury by parent or another adult caretaker - Abuses animals or pets - Sudden change in behavior - **Signs in parents/caretakers** - Offers conflicting, unconvincing, or no explanation of child's injury - Describes child as "evil" or in other negative ways - Uses harsh, physical discipline, History of being abused as a child - History of abusing animals or pets - **Childhood emotional abuse:** - **Signs in the child** - Extremes in behavior: overly compliant or demanding, extreme passivity or aggression - Behavior is either inappropriately adult or infantile - Parenting other children vs frequently rocking or head-banging - Delay in physical or emotional development - Attempted suicide - Reports lack of attachment to a parent/caregiver - **Signs in parent/caregiver** - Constantly blames, belittles, or berates the child - Unconcerned about the child & refuses to consider offers of help for child's problems - Overtly rejects the child - **Neglect** - **Physical neglect:** includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision. - **Emotional neglect:** refers to a chronic failure by the parent or caretaker to provide the child with the hope, love, and support necessary for the development of a sound, healthy personality. - **Childhood physical and emotional neglect:** - **Signs in children** - Frequently absent from school - Begs for or steals food or money - Lacks needed medical, dental, or other healthcare \[immunizations or glasses\] - Consistently dirty/severe body odor - Lacks appropriate clothing for weather - Abuses alcohol or drugs - Reports no one at home to provide care - **Signs in parents/caregivers** - Appears indifferent to child - Behaves irrationally or bizarre - Seems apathetic or depressed - Abuses drugs or alcohol - **Characteristics of parent/caregiver who abuse** - Often victims of childhood abuse - Active substance use - Currently experiencing a stressful life situation - Few support systems; commonly isolated from others - Lacks adaptive coping strategies, angers easily, difficulty trusting others - **Expecting child to be perfect: may exaggerate any mild difference the child manifests as "normal"** - **Childhood sexual abuse, pg. 708:** - **Child sexual abuse:** Child being used for the sexual pleasure of an adult or other person - **Signs in the child** - Difficulty walking or sitting - Suddenly refuses to change for gym or participate in physical activities - Nightmares and/or bedwetting (nocturnal enuresis) - Sudden changes in appetite - Bizarre, sophisticated, or unusual sexual knowledge or behavior - Becomes pregnant or contracts STI under age 14 - Runs away - Reports sexual abuse by parent or another adult - Attaches very quickly to strangers or new adults in their environment - **Signs in parent/caregiver** - Unduly \[unwarranted degree\] protective of child or severely limits contact with other children, esp opposite sex - Secretive & isolated - Does not respect boundaries or listen when someone tells them "no" - Gives a child gifts without occasion or reason - Jealous & controlling with family members - **Sexual exploitation of a child** - Child is induced or coerced into engaging in sexually explicit conduct for the purpose of promoting any performance - **Incestuous Relationships** - Most research has been in father-daughter incest - Often starts b/t 8-10 years old - Oldest daughter is most valuable - If reported in one child in a household, suspect all children - As adults: - Lack of trusting relationships, low self-esteem, poor sense of identify, alterations in consenting sexual activity - Increased findings in inflammatory markers - **Sexual violence, pg. 710:** - Includes any act of sexual coercion including penetration, unwanted sexual experiences, noncontact unwanted sexual experiences, and rape per definitions of rape - Includes sexual assault, acquaintance rape \[date rape\], marital rape, & statutory rape - **Rape**: The expression of power and dominance by means of sexual violence, most commonly by men over women, although men may also be rape victims. - Rape is a traumatic experience, and many victims experience flashbacks, nightmares, rage, physical symptoms, depression, and thoughts of suicide for many years after the occurrence. - **Acquaintance rape/date rape**: term applied to situations in which the rapist is acquainted with the victim. - **Statutory rape:** unlawful intercourse between a person who is over the age of consent with a person who is under the age of consent - **Sexual assault** is any type of sexual act in which an individual is threatened or coerced to submit against their will. - Sexual assault is identified as an act of aggression, not passion (book) - **Profile of Perpetrator** - Not distinguishable by physical traits or intelligence - Increased likelihood if experienced childhood abuse - Rapes are often premeditated - Ignore or violate rights of others - Underlying motives: Inflicting pain, exploitive predator, inadequacy, displacement of anger or rage - 1 in 10 rapes involved the use of a weapon - **Profile of Victims** - **Highest risks:** females younger than 34 years old, lower income levels, and have never married - **Sexual violence: psychological responses rape trauma syndrome** - **Rape-trauma syndrome:** identified two emotional patterns of response that may occur within hours after a rape and with which health-care workers may be confronted in the emergency department or rape crisis center. - **Expressed Response Pattern:** expresses feeling of fear, anger, & anxiety through crying, sobbing, restlessness, & tension - **Controlled Response Pattern**: feelings are masked or hidden with calm, composed, or subdued affect - Feelings of guilt - **In following days to weeks:** - Contusions/abrasions on body - Headaches, fatigue, sleep pattern disturbances - Stomach pains, nausea/vomiting - Vaginal discharge/itching, burning upon urination, rectal bleeding and pain - Rage, humiliation, embarrassment, desire for revenge, and self-blame - Fear of physical violence and death - At risk for PTSD symptoms to develop - Long term effects: restlessness, dreams, nightmares, phobias - **Sexual violence: other psychological responses** - **Compound Rape Reaction** - Rape trauma syndrome symptoms with added depression, suicidal ideation, substance use, psychotic behaviors - **Silent Rape Reaction** - Tells no one about the assault - Anxiety is suppressed and the emotional burden may become overwhelming - The unresolved sexual trauma may not be revealed until forced to face another sexual crisis in her life - **Sexual violence: Nursing dx, pg. 713** - Rape trauma syndrome r/t sexual assault - Evidenced by verbalization of attack; bruises/lacerations over areas of body, severe anxiety - Powerlessness r/t cycle of battering - Evidenced by verbalization of abuse; bruises/lacerations over areas of body; fear for her safety and that her children's safety; verbalizations of no way to get out of the relationship - Risk for delayed development related to abusive family situations - **Sexual violence: Outcomes, pg. 713** - **Patient who has been sexually assaulted:** - No longer experiencing panic anxiety - Demonstrates a degree of trust in the primary nurse - Received immediate attention to physical injuries - Initiated behaviors consistent with grief response - **Patient who has been physically battered:** - Received immediate attention to physical injuries - Verbalizes assurance of immediate safety - Discusses life situation with primary nurse - Verbalizes choices from which they can receive assistance - **The child who has been abused:** - Received immediate attention to physical injuries - Demonstrates trust in primary nurse by disclosing abuse through play therapy - Decrease in regressive behaviors - **Sexual violence: Interventions** - Communicate: - "You are safe" - "I'm sorry that it happened" - "I'm glad you survived" - "It's not your fault. No one deserves to be treated this way" - "You did the best you could" - Explain every assessment procedure and why it is being conducted - Maintain a caring, non-judgmental manner throughout all aspects of data collection - Assure adequate privacy for all interventions - Encourage victim to give details of assault - Specific nursing documentation is required but always use "Patient/client reports" rather than "patient alleges" - **Sexual violence: Evaluation questions** - Has the individual been reassured of his or her safety? - Is this evidenced by a decrease in panic anxiety? - Have wounds been properly cared for and provisions made for follow-up care? - Have emotional needs been attended to? - Trust established with at least one person to whom the client feels comfortable relating the abusive incident? - Have available support systems been identified and notified? - Have options for immediate circumstances been presented? - Is the individual able to conduct activities of daily living satisfactorily? - Have physical wounds healed properly? - Is the client appropriately progressing through the behaviors of grieving? - Free of sleep disturbances; psychosomatic symptoms; regressive behaviors; psychosexual disturbances? - Is the individual free from problems with interpersonal relationships? - Has the individual considered the alternatives for change in his or her personal life? - Has a decision been made relative to the choices available? - Is he or she satisfied with the decision that has been made? - **Sexual violence: forensic nursing, pg. 714** - Sexual Assault Nurse Examiner (SANE) Nurses - Specialized nursing to provide care, evaluation, and advocacy for victims of crimes in a variety of settings (ex: primary care facilities, hospitals, and correctional institutions) - Investigate wounds & reports - Evidence collection & preservation - May collect clothing, bullets, gunshot powder, bloodstains, hairs, fibers, grass, and other debris - Testify in court - **Trauma-informed care (TIC), pg. 718** - **Trauma-informed care is foundational to all treatment modalities when responding to survivors of abuse and neglect.** - Not a set of specific interventions but a framework for developing interventions to incorporate into care - Understanding that everyone's response to trauma is different and rooted in "fight or flight" (autonomic nervous system) response - This response impacts & disrupts the function of body systems; most notably is memory & emotional regulation - Goal is to accommodate the vulnerabilities of trauma survivors by adapting services to avoid inadvertent **re-traumatization** and facilitating consumer empowerment in health care. - **Four R's of TIC:** - **Realize** the widespread impact of trauma - Screen for trauma history - Understand potential paths for recovery - **Recognize** the signs & symptoms of trauma in patients, families, staff, & others involved - **Respond** by fully integrating knowledge about trauma into policies, procedures, & practices - **Resist** re-traumatization - Behaviors include trustworthiness, transparency, assuring patient safety, collaboration, & empowerment - **Treatment modalities:** - **Crisis Interventions** - Goal: help survivors return to previous lifestyle as quickly as possible - Patient should be involved in all planning of interventions and aftercare - Sense of competency, validation of personal worth, & begins recovery process - Usually, time limited 6-8 weeks - Referral to long-term psychotherapy - Focus on coping strategies - **Safe House or Shelter** - Where victims can reside temporarily in an environment that assures physical protection for them - **Family-Based interventions** - The focus of therapy with families who experience violence is to help them develop democratic (respectful, interactive) ways of solving problems. - Changing family functional/interactional patterns -