Survivors of Abuse or Neglect - Survivors of Abuse or Neglect

Survivors of Abuse or Neglect

1. Copyright ©2018 F.A. Davis Company
Survivors of Abuse or Neglect
Chapter 35

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Introduction
Abuse is the maltreatment of one person
by another.
More injuries are attributed to intimate partner
violence than to all rapes, muggings, and
automobile accidents combined.
An increase in the incidence of child abuse has
been documented.
Rape is thought to be vastly underreported.

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Introduction (cont’d)
Abuse affects all populations equally.
Abuse affects all races, religions, economic classes,
ages, and educational backgrounds.
The phenomenon is cyclical as many abusers were
themselves victims of abuse as children.
Laws now exist to protect children and the elderly.

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Predisposing Factors
Biological theories
•Neurophysiological influences
‒Temporal lobe
‒Limbic system
‒Amygdaloid nucleus
•Biochemical influences
‒Norepinephrine
‒Serotonin
‒Dopamine

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Predisposing Factors (cont’d)
Biological theories (cont’d)
•Genetic influences
‒Possible hereditary factor
‒Genetic karyotype XYY has been implicated
•Disorders of the brain
‒Organic brain syndromes
‒Brain tumors/trauma
‒Encephalitis
‒Temporal lobe epilepsy

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Predisposing Factors (cont’d)
Psychological theories
•Psychodynamic theory
‒Unmet needs for satisfaction and security result in an
underdeveloped ego and a poor self-concept
‒Aggression and violence supply the individual with a dose
of power and prestige that increases self-esteem

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Predisposing Factors (cont’d)
Psychological theories (cont’d)
•Learning theory
‒Children learn to behave by imitating their role models
‒Individuals who were abused as children or whose parents
disciplined with physical punishment are more likely to
behave in an abusive manner as adults

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Predisposing Factors (cont’d)
Sociocultural theories
•Societal influences
‒Aggressive behavior is primarily a product of one’s culture
and social structure.
‒American culture was founded on a general acceptance of
violence as a means of solving problems.
‒Societal influences also contribute to violence when
individuals realize that their needs and desires are not
being met relative to other people.

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a)Unmet needs for security resulting in an
underdeveloped ego and a weak super ego
b)Imitation of individuals who have a
predisposition toward aggressive behavior
c)Various levels of norepinephrine, dopamine,
and serotonin
d)The influence of culture and social structure
1. From a biological theory perspective, which
of the following predisposes individuals to
be abusive?
Predisposing Factors (cont’d)

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Predisposing Factors (cont’d)
•Various components of the neurological
system in both humans and animals have been
implicated in both the facilitation and the
inhibition of aggressive impulses.
•One biological theory suggests that
norepinephrine, dopamine, and serotonin may
play a role in aggressive behavior.
Correct answer: C

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Assessment
Battering
•A pattern of coercive control founded on and supported
by physical and/or sexual violence or threat of violence
toward an intimate partner
Intimate partner violence
•Various terms describe the pattern of violence between
intimate partners, including intimate partner violence
(IPV), domestic violence, and battering.
•Physical abuse between domestic partners may be
known as spousal abuse, domestic or family violence,
wife or husband battering, or IPV.

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Assessment (cont’d)
Intimate partner violence (cont’d)
•Profile of the victim
‒Battered women represent all age, racial, religious, cultural,
educational, and socioeconomic groups
‒Low self-esteem
‒Inadequate support systems
‒Some grew up in abusive homes

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Assessment (cont’d)
Intimate partner violence (cont’d)
•Profile of the victimizer
‒Low self-esteem
‒Pathologically jealous
‒“Dual personality”
‒Limited coping ability
‒Severe stress reactions
‒Views spouse as a personal possession

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Assessment (cont’d)
Intimate partner violence (cont’d)
•Cycle of battering
‒Three distinct phases
Phase I: Tension-building phase
Phase II: Acute battering incident
Phase III: Calm, loving, respite (honeymoon) phase

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Assessment (cont’d)
Intimate partner violence (cont’d)
•Why do they stay?
‒Fear for their lives or the lives of their children
‒Fear of retaliation by the partner
‒Fear of losing custody of their children
‒Lack of financial resources
‒Lack of a support network
‒Cultural/religious reasons
‒Hopefulness
‒Lack of attention to the danger

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Child Abuse
Child maltreatment typically includes physical or
emotional injury, physical or emotional neglect, or
sexual acts inflicted upon a child by a caregiver.
Signs of physical abuse
•Unexplained injuries
•Fading bruises or other marks
•Child is frightened of adults
•Shrinks at approach of adults
•Child reports injury by parent or caregiver
•Abuses animals or pets

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Child Abuse (cont’d)
Physical abuse may be suspected when the parent
or other adult caregiver
•Offers conflicting, unconvincing, or no explanation for the
child’s injury
•Describes the child as “evil,” or in some other very
negative way
•Uses harsh physical discipline with the child
•Has a history of abuse as a child
•Has a history of abusing animals or pets

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Child Abuse (cont’d)
Emotional abuse involves a pattern of behavior on
the part of the parent or caretaker that results in
serious impairment of the child’s social, emotional,
or intellectual functioning.
Indicators of abuse
•Extremes of behavior
•Inappropriately adult or infantile behavior
•Delays in physical or emotional development
•Suicide attempts
•Lack of attachment to the parent

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Child Abuse (cont’d)
Emotional abuse may be suspected when the
parent or other adult caregiver
•Constantly blames, belittles, or berates the child
•Is unconcerned about the child and refuses to consider
offers of help for the child’s problems
•Overtly rejects the child

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Child Abuse (cont’d)
Physical neglect of a child
•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
•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

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Indicators of Neglect
Behavioral indicators of neglect
•Is frequently absent from school
•Begs or steals food or money
•Lacks needed medical or dental care, immunizations,
or glasses
•Is consistently dirty and has severe body odor
•Lacks sufficient clothing for the weather
•Abuses alcohol or other drugs
•States that there is no one at home to provide care

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Indicators of Neglect (cont’d)
The possibility of neglect may be considered when
the parent or other adult caregiver
•Appears to be indifferent to the child
•Seems apathetic or depressed
•Behaves irrationally or in a bizarre manner
•Is abusing alcohol or other drugs

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Sexual Abuse of a Child
Sexual exploitation of a child
•A child is induced or coerced into engaging in sexually
explicit conduct for the purpose of promoting any
performance, and child sexual abuse, in which a child is
being used for the sexual pleasure of an adult
Incest
•Occurrence of sexual contacts or interaction between, or
sexual exploitation of, close relatives, or between
participants who are related to each other by a kinship
bond that is regarded as a prohibition to sexual relations

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Indicators of Sexual Abuse
Indicators of sexual abuse
•Has difficulty walking or sitting
•Suddenly refuses to change for gym or to participate in
physical activities
•Reports nightmares or bedwetting
•Experiences a sudden change in appetite
•Bizarre, sophisticated, or unusual sexual behavior
•Becomes pregnant or contracts a STD
•Runs away
•Reports sexual abuse
•Attaches quickly to strangers

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Indicators of Sexual Abuse (cont’d)
Sexual abuse may be considered a possibility when
the parent or other adult caregiver
•Is unduly protective of the child or severely limits the
child’s contact with other children, especially of the
opposite sex
•Is secretive and isolated
•Is jealous or controlling with family members

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Indicators of Sexual Abuse (cont’d)
Characteristics of the child abuser
•Parents who abuse their children were often victims of
abuse in their own early lives and have impaired
attachment with their child
•Substance use disorders increase the risk of child abuse
and neglect

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Indicators of Sexual Abuse (cont’d)
Additional characteristics associated with an
abusive parent
•Isolated with little support from family and friends
•Expects that the child should fulfill their emotional needs
•Prone to depression
•Frequent outbursts, anger and rage
•Low frustration tolerance

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Indicators of Sexual Abuse (cont’d)
The incestuous relationship
•Often there is an impaired spousal relationship
•Father
‒Domineering, impulsive, physically abusive
•Mother
‒Passive, submissive, and denigrates her role of wife
and mother
‒Often aware of the incestuous relationship, but uses denial
or keeps quiet out of fear of being abused by her husband

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Indicators of Sexual Abuse (cont’d)
The adult survivor of incest
•Common characteristics
‒A fundamental lack of trust that arises out of an
unsatisfactory parent-child relationship
‒Low self-esteem and a poor sense of identity
‒Absence of pleasure with sexual activity
‒Promiscuity

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a)Sexual abuse
b)Emotional neglect
c)Physical neglect
d)Emotional abuse
2. A 12-year-old girl suddenly refuses to change for
gym, participate in physical activities, has difficulty
walking and sitting, and will not eat her food at
lunchtime. What should the school nurse consider
when assessing this child’s symptoms?
Indicators of Sexual Abuse (cont’d)

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Indicators of Sexual Abuse (cont’d)
•Sexual abuse of a child may be considered a possibility
when the child
•Has difficulty walking or sitting; suddenly refuses to change
for gym or to participate in physical activities; reports
nightmares or bedwetting; experiences a sudden change in
appetite; demonstrates bizarre, sophisticated, or unusual
sexual knowledge; becomes pregnant or contracts a venereal
disease; runs away; or reports sexual abuse by a parent or
another adult caregiver.
•After assessing the data, the school nurse should
further investigate this child’s unexplained symptoms,
and if warranted, report findings to authorities.
Correct answer: A

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Sexual Violence
Sexual violence is often equated with rape, but
that is only one type of sexual assault.
Healthcare providers must be aware sexual
violence includes any act of sexual coercion
including penetration, unwanted sexual contact,
and noncontact unwanted sexual experiences.

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Sexual Violence (cont’d)
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.
Sexual assault is any type of sexual act in which an
individual is threatened or coerced, or forced to
submit against his or her will.
Rape is an act of aggression, not passion.

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Sexual Violence (cont’d)
Rape, a type of sexual assault, occurs over a broad
spectrum of experiences ranging from the surprise
attack by a stranger to insistence on sexual
intercourse by an acquaintance or spouse.
•Acquaintance rape
•Marital rape
•Statutory rape

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Sexual Violence (cont’d)
Profile of the victimizer
•It is difficult to profile a rapist
•Saddock and others identify four groups
‒Sexual sadists
‒Exploitative predators
‒Inadequate men
‒Those displacing anger

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Sexual Violence (cont’d)
The victim
•Rape can occur at any age
•Highest-risk age group is females younger than age 34,
those with lower income, and those living in rural areas
•Most victims are single women, and the attack often
occurs near their own neighborhoods

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Sexual Violence (cont’d)
Rape survivors
•Those who present themselves for care shortly after the
crime occurred likely are experiencing an overwhelming
sense of violation and helplessness that began with the
powerlessness and intimidation experienced.
•The long-term effects of sexual assault depend largely on
the individual’s ego strength, social support system, and
the way he or she was treated as a victim.

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Sexual Violence (cont’d)
Rape trauma syndrome has two emotional patterns
of response that may occur within hours after a
rape and with which healthcare workers may be
confronted in the emergency department or rape
crisis center.
1.Expressed response pattern: the survivor expresses
feelings of fear, anger, and anxiety through such
behaviors as crying, sobbing, restlessness, and tension
2.Controlled response pattern: feelings are masked or
hidden, and a calm, composed, or subdued affect is seen

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Sexual Violence (cont’d)
The following manifestations may be evident in the
days and weeks after the attack.
•Contusions and abrasions about various parts of the body
•Headaches, fatigue, sleep pattern disturbances
•Stomach pains, nausea and vomiting
•Vaginal discharge and itching, burning upon urination,
rectal bleeding and pain
•Rage, humiliation, embarrassment, desire for revenge,
and self-blame
•Fear of physical violence and death

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Sexual Violence (cont’d)
Victim responses
•Expressed response pattern
•Controlled response pattern
•Compounded rape reaction
•Silent rape reaction

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Diagnosis/Outcome Identification
Nursing diagnoses for the client who has been
abused may include
•Rape-trauma syndrome
•Powerlessness
•Risk for delayed development
Outcome criteria are identified for measuring the
effectiveness of nursing care

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Planning/Implementation
Nursing intervention for the victim of abuse or
neglect is to provide shelter and promote
reassurance of his or her safety.

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Planning/Implementation (cont’d)
Other nursing concerns include
•Tending to physical injuries
•Staying with the client to provide security
•Assisting the client to recognize options
•Promoting trust
•Reporting to authorities when there
is reason to suspect child abuse
or neglect
Concept care mapping

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a)“Research shows that men who batter get worse
rather than improve.”
b)“Aren’t you concerned about your children?”
c)“You really should not return home to that
violent situation.”
d)“Let’s develop a safety plan in case he becomes
violent in the future.”
3. A young mother in a severely abusive relationship is
admitted to the psychiatric unit after an attempted
suicide. The client tells the nurse, “I’m sure things will
be better between us once I go home.” Which is the
most appropriate nursing response?
Planning/Implementation (cont’d)

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Planning/Implementation (cont’d)
•It is critical to stress to the client the importance of
safety.
•The client must be made aware of the variety of
resources that are available to her.
•Most major cities in the United States now have safe
houses or shelters where women can go to be assured
of protection for them and their children.
•Helping the client develop a safety strategy will
increase her sense of control and decrease her sense
of powerlessness.
Correct answer: D

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a)Information on available community resources
b)The names and phone numbers of local
attorneys who defend rape victims
c)When to return to the ED for follow-up care
d)The phone number of the battered women’s
shelter or safe house
4.After an examination and treatment for rape,
the nurse prepares to discharge a client from the
emergency department (ED). Which discharge
teaching should the nurse provide?
Planning/Implementation (cont’d)

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Planning/Implementation (cont’d)
•The client must be made aware of the variety
of resources that are available to her.
•These may include crisis hotlines, community
groups for women who have been abused, and
counseling services.
•Knowledge of available community resources
decreases the victim’s sense of powerlessness.
Correct answer: A

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Evaluation
Evaluation is based on accomplishment of
previously established outcome criteria.
Evaluation of nursing actions to assist survivors of
abuse must be considered on both a short-and a
long-term basis.

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Treatment Modalities
Crisis intervention
•The focus of the initial interview and follow-up with the
client who has been sexually assaulted is on the rape
incident alone.
Safe house or shelter
•Most major U.S. cities have safe houses or shelters where
women assured of protection for them and their
children.
Family therapy
•Helps families who use violence to develop democratic
ways of solving problems