Child, Older adult, and intimate partner violence

• violence and abuse is the fastest growing public health problems of today

• it cuts across all demographics, ages, races, cultures, and religion groups

• _________ are often involved

• victims may present with injuries or health problems

• often ER departments come in contact with victims

• mandatory reporting laws require nurses report suspected cases of abuse in all states, there are civil and criminal penalties for failing to report

drugs and ETOH

list the types of abuse

▪ Family Violence – “domestic violence”

▪ Physical abuse

▪ Sexual abuse

▪ Emotional abuse

▪ Neglect

▪ Economic abuse

explain child abuse:

• acts of commission-deliberate and intentional, physical, sexual,

emotional abuse

▪ Acts of omission – neglect, basic physical, emotional or educational

needs are not met or a child is not protected from harm, can be

medical and dental needs, inadequate supervision and exposure to

violence

▪ Intimate partner violence – physical violence, rape, stalking,

psychological aggression by a current or former intimate partner

▪ Older adult abuse – intentional actions that cause harm or creates a

risk of harm to an older person, can be neglect, physical, sexual or

financial abuse

__________: situation that puts stress on a family with violent member. Anyone will be at risk for abuse during a crisis situation

what is a perpertrator

• any member of the household who is violent toward another member

• consider their own needs to be more important than anyone elses and look toward others to meet their needs

what is a vulnerable person

▪ Family member upon whom abuse is perpetrated

▪ Other terms: victim, survivor, or victim/survivor

▪ Survivor: recognizes recovery and healing process

______- of all americans have experienced violence in their family

half

most perpetrators of child abuse are the victims _______

parents

secondary comorbidities of violence and abuse

anxiety

PTSD

depression

suicidal ideation

▪ ____________ exhibit more pathopsychological changes, poorer coping and social skills, higher incidence of DID, & poorer impulse control

▪ Women victims of prolonged childhood sexual abuse are more likely to develop major psychiatric distress 

Abused adolescents

risk factors for child abuse

▪ Younger than 4 years (go to school and others see it

▪ Child is seen as different (easy tarzget)

▪ Child is seen as fragile (easy target)

▪ Having different temperament traits, congenital abnormalities

▪ Child reminds parent of someone they dislike

▪ Child does not live up to parents’ fantasy

▪ Child is the result of unwanted pregnancy

▪ Child whose emotional bonding was interrupted due to

prematurity or prolonged illness (initial bonding didnt happen)

individual risk factors for perpetrating abuse:

▪ Alcohol or substance misuse

▪ Psychiatric conditions such as major depressive disorder

▪ Low education, income, age, and lack of understanding about children’s needs

▪ Using spanking and other forms of physical punishment

▪ Accepting of or justifying violence or aggression

▪ A history of being abused as a child

▪ Single parenting, many children; or non-biological parents

▪ High levels of family stress or economic stress

▪ Consider their own needs more important than the needs of others

▪ Poor social skills

▪ May control family finances

▪ Involvement in a crisis situation, poor coping skills

▪ Violent temper outburst, poor impulse control, low tolerance for frustration

risk factors for intimate partner violence

▪ Male perpetrators

▪ May believe in male dominance; need to be in charge

▪ Belief that physical aggression lends power

▪ Pathological jealousy (want complete attention of family member)

▪ Substance or alcohol use disorder

▪ Resentment toward pregnancy or baby

▪ Violence may escalate when the woman attempts more independence

or attempts to leave (being able to provide for themselves)

explain the cycle of violence

• tension- building stage

• acute battering stage

• honeymoon stage

• repeat. periods of calm and safety diminish over time and repetition

explain the tension building stage in the cycle of violence

• abuser has minor explosions, may become verbally abusive, minor hitting, slapping, and other incidents begin

  • victim feels tense and afraid, walking on eggshells, feels helpless, becomes compliant and accepts blame

explain the serious battering phase of the cycle of violence

• the tension becomes unbearable ,victim may provoke an incident to get it over with

• serious battering incident

• the victim may try to cover up the injury or may look for help

explain the honeymoon phase of the cycle of violence

• abuser has loving behavior, gifts, flowers, doing special things for the victim

• contrite, sorry, makes promises to change

• victim: trusting, hoping for change, wants to beleive partner promises

types of older adult abuse

▪ Mistreatment

- Failure to provide basic needs

- Failure to protect

▪ Physical or sexual abuse

▪ Financial abuse

▪ Epidemiology

-Family

-Custodial/care personnel

_______: failure to provide needs, bills unpaid, spouse may be denied education or job resulting in dependence

economic abuse

risk factors for older adult abuse

▪ Poor mental or physical health

▪ Disruptive due to a disorder (Alzheimer’s)

▪ Dependent on perpetrator

▪ Female, older than 75 years, white, living with a relative

while impaired

▪ Elderly parents cared for by children or spouses they

abused earlier in life

▪ Elderly woman cared for by a husband who has abused

her in the past

assessment for violence and abuse should be completed with the victim _________ and in a _______

alone and in a private setting

what to assess for in a general assessment for violence and abuse

symptoms may be very vague, pain, insomnia, anxiety, gynecological problems

• does the explanation match injury

• is the patient minimizing the seriousness of injury

▪ Violence indicators, signs & symptoms – box 28.2

▪ Level of anxiety and coping responses – agitation and anxiety/panic

are often present, living in terror

▪ Family coping patterns

▪ Support systems – the victim is usually in a dependent position,

relying on the perpetrator for basic needs

▪ Suicide and/or homicide potential – may feel desperate to leave yet

be trapped in an abusive relationship, suicide is very common

amongst all of abuse victims

▪ Drug and alcohol use – common to self medicate to help escape an

intolerable situation, the abused are commonly prescribed anxiety

and depression drugs

▪ Post trauma syndromes

interview process for assessment of a violence and abuse patient:

▪ Establish TRUST – crucial for patient to be able to selfdisclose,

avoid words like “abuse” or “violence”

▪ Non-threatening and supportive manner

▪ Ask about ways of solving disagreements or disciplining

▪ Use the term “partner” when asking about the relationship

▪ Do not interrupt the story

▪ Reassure the patient that they did nothing wrong

▪ Observe the patients non-verbal responses when asking

questions

list red flags of abuse and violence

▪ Bruising on infants younger than 6 months- not walking

▪ Shaken baby syndrome – respiratory problems, bulging fontanels,

retinal hemorrhages, CNS damage such as seizures, vomiting and

coma

▪ Inconsistent explanations- story changing

▪ Vague explanations

▪ Hesitation to answer questions

▪ Lack of eye contact when answering questions- SA

▪ Younger children having precocious sexual knowledge- SA

▪ Children acting out sexually, masturbation

▪ Nightmares, disturbed sleep, somatic complaints

▪ Decreased socialization with peers- shameful

▪ Injuries & bruising in various stages of healing

▪ Unexplained bruising or injury

▪ Friction burns

▪ Facial, spiral, shaft or multiple fractures

▪ Facial lacerations and abrasions (you protect face when u fall)

▪ Human bite marks

▪ Intracranial, subdural, intraventricular & intraocular hemorrhaging

▪ Self-mutilations, running away, delinquent behavior,

malnourishment, poor hygiene, low self esteem, poor peer

relationships, regressive behaviors, bed wetting etc (regression)

signs of sexual abuse in children

▪ Sexualized behavior

▪ Precocious sexual knowledge/ explicit talk or

images/demonstration of sexual aggression

▪ Acting out sexual interactions

▪ Masturbation

▪ Sexual promiscuity in older children

▪ PTSD symptoms

▪ Somatic complaints

▪ Feelings of guilt

_________: low self esteem, reported feelings of inadequacy, anxiety, and withdrawal, learning difficulties, and poor impulse control

emotional abuse

____________: Appear undernourished, dirty, and poorly clothed; inadequate medical care such as lack of immunizations and untreated medical or dental conditions 

neglect

what are some questions you should ask when suspecting abuse or violence

▪ Ask the child directly, but in a nonthreatening manner, if someone

close to him or her has caused the injury.

• “Tell me about what happened to you.”

• “What happens when you do something wrong?”

▪ Then ask specific questions, such as:

• “When was the last time it happened?”

• “How often does it happen?”

• “In what ways are you hurt?”

outcomes identification for abuse and violence

▪ Abuse protection

▪ Abuse recovery

▪ Decreased suicide risk

▪ Improved self-esteem

▪ Improved coping

▪ Reduced anxiety

the _______ is often the first point of contact for ppl experiencing abuse and an ideal position to contribute to prevention, detection, and effective tx

nurse

what does the joint commission guidelines require for abuse and violence tx planning:

Staff education in family violence and abuse (do u feel safe at home)

Development of standards of care to guide clinical practice

Protocol for Planning

▪ Patient’s safety first

▪ Discuss with patient if possible; child removed to safe place

▪ Consider needs of abusers as well if they are motivated

implementation/ interventions for abuse and violence patients

▪ Provide treatment and meds for injuries

▪ Encourage patient to discuss fears

▪ Reassure the victim that they are not to blame

▪ Use community resources for referrals

▪ Educate the parents/caregivers-health teaching and health

promotion

▪ Help develop a Safety Plan for families with intimate partner

violence

you cant force someone to leave relationship, just give resources

what important documentation is needed in abuse/ violence situations:

▪ Verbatim statements of who caused the injury and when it occurred

▪ A body map to indicate the size, color, shape, areas, and types of

injuries, with explanations

▪ Physical evidence of sexual abuse, when possible

▪ ___________ – legally mandated to report suspected or actual

cases of child and vulnerable adult abuse or any assault with a

weapon

Reporting abuse

___________- personalized safety plan/guide (Box 28.4), rapid plan

for escape (include destination and transportation –Code Word

▪ Crisis intervention measures, support the victim, facilitate access to

other resources, shelters for safe houses

Counseling

____________ -

▪ ID high risk children, relationships and elderly

▪ Mothers with h/o late or no prenatal care, have had another child

removed from the home, a child with unexplained injuries,

Case management

what topics should be covered when dealing with abuse and violence

Reducing stress

Reducing the influence of risk factors

Increasing social support

Increasing coping skills

Increasing self-esteem

explain primary prevention of abuse

▪ Measures taken to prevent the occurrence of abuse, the activity that stops the problem before it occurs, strengthening family coping, asking about violence, or controlling behaviors, etc

explain secondary prevention of abuse:

▪ Early intervention in abusive situations to minimize their disabling or longterm effects, (read vignettes), ending the cycle, calling protective services, involving hospital social workers etc.

explain tertiary prevention of abuse:

▪ Facilitating the healing and rehabilitative process

▪ Providing support

▪ Assisting survivors of violence to achieve their optimal level of safety, health,and well-being

treatment modalities for abuse and violence

▪ Individual psychotherapy

▪ Family psychotherapy (dont put back with family if not safe)

▪ Group psychotherapy

explain a self assessment before dealing with abused or violent patients

▪ Intense and overwhelming feelings

▪ Strong negative feelings may cloud judgment and interfere

with objective assessment and intervention

▪ Common responses of healthcare professionals to violence